Monthly Archives: May 2021

Pantoea Agglomerans Bacteremia: A Real Pathogen? A Case Report and Review of the Literature

DOI: 10.31038/PEP.2021223

Introduction

Pantoea agglomerans is a facultative anaerobic Gram-negative bacillus that can rarely cause opportunistic infections in humans, mainly due to wound infection with plant material or to hospital-acquired infections mostly in immune-compromised individuals. The clinical findings are extremely variable and reports of such an infection have been published mainly in premature infants or in oncologic individuals [1,2]. Its role as real human pathogen is still controversial due to infrequent reports of spontaneously occurring Pantoea agglomerans infections and uncertain in taxonomic identification [3,4]. We report here a case of Pantoea agglomerans bacteriemia in a subject with a Buerger’s disease.

Case presentation

A 66 years-old man was admitted to our emergency department for fever up to 40°C after administration of intravenous prostaglandin analogs as therapy for Buerger’s disease. He was carrier of a peripherally inserted catheter central (PICC) and affected by diabetes mellitus and chronic kidney failure. Serum level of CRP was 8,40 mg/dl (normal value < 2 mg/dL) and procalcitonine was 31 ng/ml (normal value < 0,5 ng/ml). White blood cells were moderate augmented (12000/mmc, normal values 4000-11000/mmc); renal and liver tests were normal, except for creatinine that was slightly increased (1,4 mg/dL, normale values < 1,2 mg/dL). Chest X-ray was normal, as were two nasopharyngeal swabs for COVID-19 infection in two consecutive days. Blood cultures were promptly done and empiric antibiotic treatment with vancomycin was started due to the high risk of bacteremia due to meticillin-resistant Staphylococcus aureus. PICC was removed at the first day of hospitalization, supposing to be the possible source of infection. The patients had only a partial clinical and biochemical improvement after initial antibiotic treatment, with CRP 6,3 mg/dL at the second day of hospitalization. Abdomen ultrasound was normal and echocardiogram did not show findings compatible with endocarditis. On the third day after hospitalization, blood cultures resulted positive for Pantoea agglomerans; based on antibiogram, vancomycin was substituted with levofloxacin 750 mg. After further questioning, the patient revealed that he had recently done some garden works and had minor injuries to the legs that were not considered at the time of admission. Fever disappeared after 24 hours, and inflammatory parameters normalized after 72 hours. Patient was discharged after additional 5 days with a prescription of oral levofloxacin; levofloxacin was continued for a total of 14 days. After 2 months of follow-up no other febrile episodes recurred, and the patient maintains asymptomatic.

Discussion

Pantoea agglomerans, previously named Enterobacter agglomerans or Erwinia herbicola, is a non-capsulated, non-spore-forming anaerobic Gram-negative bacillus, usually associated with plants but rarely affecting humans and vertebrate animals. Approximately 20 species belong to this group of bacteria, and Pantoea agglomerans is the most prominent species in humans [5]. Clinical findings of patients infected by Pantoea agglomerans are very different, including bone and joints infections, osteomyelitis and synovitis [6]; uncommon presentation included endocarditis and endophtalmitis [7, 8]. Usually, cutaneous infections occur as a wound super-infection, with the bacteria entering the skin when penetrating trauma occurs. From the skin, the infection can subsequently extend deep into the bones, causing septic arthritis, spondylodiscitis or osteomyelitis, theoretically leading to peritonitis or sepsis [9]. Other than wound infection with plant material, also exposure to contaminated fluids or medical equipment may lead to infection outbreaks [10, 11]. However, sporadically  Pantoea agglomerans can cause spontaneous bacteremia. The association between this finding and the gastroesophageal reflux disease or the receipt of antacids has been hypothesized, maybe due to gastrointestinal translocation following ingestion of bacteria with vegetables or fruits [12]. Finally, bloodstream infections by Pantoea agglomerans have been associated with occupational exposure to organic dust [13]. Overall, spontaneous bacteremia has been associated with several underlying pathologies like active malignancies, diabetes mellitus, chronic viral hepatitis, congestive heart failure, autoimmune or connettive diseases, cerebrovascular accidents, chronic pulmonary obstructive diseases and end-stage kidney diseases. The diagnosis of Pantoea agglomerans infection is usually made with positive cultures from different specimens including blood, pus, urine or tracheal aspirate. Regarding the effective antibiotic treatment, antimicrobial susceptibility was studied in a cohort of adult individuals developing a spontaneous bacteremia due to Pantoea agglomerans [12]. All the isolates were susceptible to ciprofloxacin, gentamicin, amikacin, piperacillin/tazobactam, cefotaxime, ceftazidime and imipenem; 61% were susceptible to cefazolin, 56% to ampicillin and 33% to fosfomycin. In our patient, levofloxacin treatment showed to be highly effective in a very short time, leading to a rapid recovery. As a consequence, the use of appropriate antibiotic treatment, driven by the susceptibility tests in vitro, also in immune-compromised individuals, is usually associated with a therapeutic success.

The possible cause of Pantoea agglomerans bacteremia in our patient was a wound superinfection; further he had several underlying clinical conditions such as a vasculitis like Buerger’s disease, diabetes mellitus and chronic kidney failure that overall can have exacerbate the symptoms, contributing to the development of spontaneous bacteremia. However, the clinical course was well controlled by antibiotic treatment and no complications were observed in a medium-time.

References

  1. Bergman KA, Arends JP, Scholvinck EH et al. (2007) Pantoea agglomerans septicemia in three newborn infants. Pediatr Infect Dis J 26(5):453-4. [cross-ref]
  2. Yablon BR, Dantes R, Tsai V, et al. (2012-2013 & 2017) Outbreak of Pantoea agglomerans bloodstream infections at an Oncology Clinic – Illinois. Infect Control Hosp Epidemiol 38(3):314-19. [cross-ref]
  3. Rezzonico F, Smits TH, Montesinos E, et al.(2009) Genotypic comparison of Pantoea agglomerans plant and clinical strain. BMC Microbiol 9:204. [cross-ref]
  4. Volksch B, Thon S, Jacobsen ID, et al. (2009) Polyphasic study of plant and clinic-associated Pantoea agglomerans strains reveals indistinguishable virulence potential. Infect Genet Evol 9:1381-91. [cross-ref]
  5. Walterson AM, Stavrinides J. (2015) Pantoea: insights into a highly versatile and diverse genus within the enterobacteriaceae. FEMS Microbiology Reviews 39(6):968-984. [cross-ref]
  6. Flatauer FE. (1978) Septic arthritis caused by Enterobacter agglomerans. Arch Int Med 138(5):788. [cross-ref]
  7. Williams AJK, Scott RJD, Lightfoot NF. (1986) Erwinia herbicola as a cause of bacterial endocarditis. J Infect 12(1):71-73. [cross-ref]
  8. Mason GI, Bottone EJ, Podos SM. (1976) Traumatic endophtalmitis caused by an Erwinia Am J Ophtalmol 82(5):709-13. [cross-ref]
  9. Okwundu N, Mercer J. (2019) Pantoea agglomerans cutaneous infection. J Derm and Dermatologic Surg 23(1):41.
  10. Habsah H, Zeehaida M, Van Rostenberghe H, et al.(2005) An outbreak of Pantoea species in a neonatal intensive care unit secondary to contaminated parenteral nutrition. J Hosp Infect 61(3):213-18.
  11. Rasmussen SW, Koczulab B. (1992) Transfusion associated bacteremia and septic shock due to Erwinia herbicola. Scand J Infect Dis 24(2):241-43. [cross-ref]
  12. Cheng A, Liu CY, Tsai HY, et al. (2000-2010 & 2013) Bacteremia caused by Pantoea agglomerans at a medical center in Taiwan, J Microbiol, Immunol and Infect 46(3):187-94. [cross-ref]
  13. Dutkiewicz J, Mackiewicz B, Lemieszek M, et al. (2015) Pantoea agglomerans: a marvelous bacterium of evil and good. Part I. Deleterious effects:dust-borne endotoxins and allergens-focus on cotton dust. Ann Agricol Environ Med 22(4):576-88. [cross-ref]

Direct-to-Consumer-Tests and the Patient-Doctor Relationship. A Survey amongst Users, Non-Users, and Physicians

DOI: 10.31038/PEP.2021222

Abstract

In highly developed countries we see an increased uptake of predictive tests that can be accessed without the intervention of a physician. We performed surveys among 1,345 people in order to gauge the experiences and views of users and non-users. Since one of our foci was the impact of taking such tests on patient-doctor relationships, we also interviewed 15 physicians about their views on DTC-test and about their experiences with patients who saw their doctor prior to, or after, taking these tests.

We found that 5.6% of respondents used DTC-tests, particularly health checks and total body scans, with a tendency to increased use and thus possibly a growth potential. Uptake of DTC-tests was significantly correlated with having a positive attitude towards DTC-tests, male gender, and younger age in our main analysis, and with a positive attitude in our most representative subgroup analysis. In accordance with other studies, we found little evidence of a positive impact of DTC-participation that could not have been reached by other means. Generally, DTC-tests had a neutral to positive influence on patient-doctor relationships. GPs and consumers agree that that participation in DTC-tests, irrespective of physicians’ views on their value, should not inhibit existing patient-doctor relationships. This means that GPs may need an upgrade in their knowledge of DTC-tests.

Keywords

Health checks, Predictive tests, Direct to Consumer tests, DTC-tests, Screening, Patient-doctor relationship, ethics, Netherlands.

Introduction

Predictive medicine aims at early detection of disease or at identifying persons who are at risk of developing a disease, preferably in presymptomatic and well-treatable stages. It signifies a shift from a predominantly reactive to a more proactive medicine [1-3]. It particularly aims at various types of cancer and cardiovascular conditions, which often encompass several stages of disease: from asymptomatic to overtly symptomatic [4]. Due to an increase in knowledge of (asymptomatic) stages of disease and a widening range of tests–including blood tests for markers of disease, radiological imaging such as CT- or MRI-screening [5-7], genetic tests, and measurement of physical parameters such as blood pressure––the uptake of predictive medicine can be expected to rise in coming decades. In the Netherlands, predictive tests need governmental approval when they involve potentially harmful means (i.e. radiation) or when they target non-preventable and non-treatable diseases (e.g. Huntington’s disease). Screening criteria formulated by Wilson and Jungner play an important role in the approval procedure [4]. All DTC-tests are subject to general legal requirements with regard to safety, transparency, and informed consent.

In the Netherlands, some predictive tests that fulfil these criteria are offered as governmental screening programs for pre-defined high-risk groups, depending on their cost-benefit analysis. Currently, there are governmentally offered blood and ultrasound tests during pregnancy; blood and hearing checks for neonates; and screening programs for breast-, cervix-, and bowel cancer in adults. These tests assume an abstract relationship between institutions and individuals at risk, who are invited to undergo a particular test if they fall within a particular risk group. Other predictive tests are part of the diagnostic apparatus of the regular healthcare system [8,9]. Here, they presuppose a patient-doctor relationship, starting with a patient addressing their professional with a health-related question. In liaison with the patient, the healthcare professional will refer the patient for further medical investigations if indicated according to clinical guidelines, expert opinion, or for other reasons. In the Dutch context this is often a general practitioner (GP), often also known as ‘family doctor’ with whom there is a long-standing patient-doctor relationship. Both governmental screening programs and tests within the regular healthcare system involve a third-party (government or physician) that selects potential participants.

In contrast to the above, some tests do not involve a third-party selecting individuals for inclusion: tests that have become publicly available through insurance companies, pharmacies, NGOs, employers, and sport clubs [10,11]. We refer to these tests as direct-to-consumer (DTC) tests. Medically and ethically, DTC-tests are interesting for several reasons. First, they may influence a patient’s wellbeing: they may reduce anxiety and fear for the unknown, provide knowledge of treatable and preventable diseases, and encourage healthier lifestyles [7]. They may also cause harm, either due to the test itself, but also secondary as a consequence of additional and sometimes unnecessary investigations or treatments. DTC-tests may also increase anxiety and fear due to uncertain or false-positive test results [6, 12]. Second, DTC-tests may have positive consequences for the accessibility and fair distribution of healthcare. Early detection and appropriate treatment may reduce the need for expensive medical treatment at later stages of disease, possibly reducing the strain on publicly funded healthcare systems. However, they may also negatively influence accessibility and fair distribution of healthcare, as they may involve unnecessary tests and therapies and cause a health gap between those who can and who cannot afford testing. Third, DTC-tests fit into a pattern of an increased emphasis on patient autonomy, shifting from paternalistic to patient-oriented approaches of medicine [13].

Although interesting medically and ethically, there are several knowledge gaps. First, there is scarce data on the uptake of DTC-tests in general, characteristics of users of DTC-tests, and reasons for participation in DTC-tests. Further, to our knowledge there is no literature on the implications of DTC-tests for patient-doctor relationships. The research presented here addresses these voids. We will first map the incidence of the use of DTC-tests amongst respondents, explore the characteristics of users and non-users of DTC-tests, and investigate reasons for (non)participation. We then concentrate on the impact of DTC-tests on the patient-doctor relationship. Here, we focus on the involvement of physicians prior to and after a patient undergoes a DTC-test; on the view of DTC-tests held by users, non-users, and GPs; on the response of physicians when a patient did undergo a DTC-test; and on how this response was perceived by users. Further, we explore the follow-up of a DTC-test, and the morally relevant consequences testing may have on the patient-doctor relationship.

The normative hypothesis of this research is that participation in DTC-tests enhances patient autonomy and challenges existing patient-doctor relationships by bypassing the need for a physician’s expertise and referral.

Methods

Study design and population

This study has a cross-sectional survey design, with online, structured questionnaires among users and non-users of DTC-tests, and semi-structured interviews among GPs. The results were discussed in a focus group of users, non-users, and GPs.

The questionnaires

Three ethical frameworks were used to identify morally relevant aspects of DTC-tests and their potential impact on patient-doctor relationships: Beauchamp and Childress’ principalist approach in biomedical ethics [14], Wilson and Jungner’s principles of screening [4], and Emanuel and Emanuel’s models of the patient-doctor relationship. The first contains the principles of autonomy, beneficence, non-maleficence, and justice. Wilson and Jungner’s principles weigh the effectiveness of a particular test considering a disease’s prevalence, severity, and treatability, and a test’s effectivity, necessity, acceptability, and cost-benefit analysis. Values that underlie their principles are non-maleficence, beneficence, and justice. Finally, Emanuel and Emanuel’s four models of the patient-doctor relationship help us to understand the interactions of patient autonomy and the physician’s responsibility [13]. In the traditional or paternalistic model the physician has a leading role in promoting wellbeing with patient autonomy playing a marginal role. In the informative model, patient autonomy is leading. The other models are situated between these extremes, allowing room for shared decision-making: the interpretative model resembles the informative model but stresses the physician’s role in helping the patient interpret their underlying beliefs and values without influencing the process of deliberation; in the deliberative model the physician not only helps interpreting but also engages in a process of critical deliberation with the patient.

From the exploration of these normative aspects, we proceeded towards composing research questionnaires. Questions about respondents’ attitudes towards and uptake of DTC-tests are mainly based on the value of autonomy. Questions on their reasons for (not) participating and reasons for (not) consulting a physician involve all four principles of biomedical ethics. Beneficence and non-maleficence were the point of focus of questions about the effects of participation on the health and relationships of DTC-users. How respondents view and value their patient-doctor relationship was explored in questions about whether users informed their physician before or after testing, their reasons for (not) consulting, and their experiences if they did consult their physician. Further, all four ethical principles and the typology of the patient-doctor relationship underlie a number of statements that were presented to users and non-users.

Data collection methods and sampling techniques

Our survey of users and non-users was performed among two research groups: members from the Nederlandse Patiënten Vereniging (NPV), the largest patient association in the Netherlands, which has a predominantly Protestant Christian background; and members of research agent Direct Research (DR), forming a more general representation of the Dutch population.

Questionnaires received from 1345 users and non-users focused on their participation in and attitude towards DTC-tests. Non-users where asked about the reasons for not participating, users about the reasons to participate, the type of DTC-tests they underwent (total body scan, genetic testing, or other health checks), the consequences of participation for themselves or their relatives, whether they informed their relatives about the results, whether they consulted a physician before or after testing and the reasons for (not) consulting, how they experienced different aspects of their doctor’s involvement, how participation influenced their patient-doctor relationship, and if they would advise DTC-tests to others. All respondents were presented statements concerning their physician’s knowledge of and attitude to DTC-tests, the influence of testing on patient-doctor and family relations, their willingness to undergo testing in the future, and whether DTC-tests should be encouraged, with options ranging from ‘totally disagree’ to ‘totally agree.’

General physicians were recruited through the researchers’ networks, the network of the study’s supervisory board, and social media. They were interviewed with the use of semi-structured questionnaires matching the content of the questionnaires sent to users and non-users. After 13 interviews, saturation [15] was reached. In total, 15 GPs were interviewed.

For our discussion section, we used the results of a focus group discussion consisting of two DTC-users (one of which was a medical specialist), one non-user, and two GPs. A fictitious case of a DTC-user who underwent a total body scan and visits his GP, worried about the results of the scan, was presented to members of the focus group.

Data analysis

Data of baseline characteristics and outcomes are presented as absolute numbers and proportions. Characteristics of NPV- and DR-respondents, and users and non-users, were compared using Pearson’s chi-squared test or Fisher’s exact test. For variables with more than 2 categories, additional pairwise comparisons were done for each category if the overall chi-squared or Fisher’s exact test was significant.

Next, univariate and multivariate logistic regression analyses between predictor variables (baseline characteristics) and the outcome variable, uptake of DTC-tests, were performed for all participants, and separately for NPV- and DR-participants. Data are presented as adjusted Odds Ratios (aORs) with their respective confidence intervals (CIs) and related significance. To enhance comparability, for each variable similar reference groups were used. For our multivariate analyses, we included only significant predictor variables of univariate logistic regression. To prevent overfitting, for each predictor variable at least 10 events–DTC-users–were required. Interactions between predictor variables were tested using interaction terms. Multicollinearity was tested by calculating Variable Inflation Factors (VIFs). If VIF>10, multicollinearity between predictor variables was assumed and consequently, variables were removed from multivariate analysis. Further, Box-Tidwell models were used to check the linearity assumption.

For all survey analyses, initial significance levels were set at an alpha-level of 0.05. In case of multiple pairwise comparisons, Bonferroni-corrections were applied to adjust alpha-levels. Our surveys among GPs had qualitative and heuristic purposes. Therefore, no statistical analyses were performed.

Results

Survey amongst users and non-users

Baseline characteristics

Baseline characteristics and uptake of DTC-tests of NPV-participants (N = 1029; 76.5% of total participants) compared to DR-participants (N = 316; 23.5%) can be found in table 1a; baseline characteristics of users (N = 75; 5.6% of total participants) compared to non-users (N = 1270; 94.4%) can be found in table 1b. Two participants who assumed themselves users participating in governmental screening programs, were reclassified as non-users as these do not qualify as DTC-tests. Therefore, data of 2 non-users are partly missing.

Table 1a: Baseline characteristics Comparing research groups

table 1a

Table 1b: Baseline characteristics Comparing users and non-users

table 1b

Comparing NPV- to DR-groups, participants of the NPV-group were significantly more likely to be male, of older age, and of a higher educational background. Further, as expected, they were more likely to be Protestant Christians, and less likely to be Roman Catholic, Humanistic, or non-religious. Regarding DTC-tests, NPV-participants were less likely to have a positive or mixed attitude and more likely to be negative. Further, NPV-participants were less likely to have undergone DTC-tests. Looking at the type of DTC-test among users, NPV-participants were less likely to have had total body scans. There were no significant differences in the uptake of genome testing or other health checks between DTC-users in NPV- and DR-groups.

Comparing users to non-users, users were more likely to be male, of younger age, and non-religious. Comparing attitudes, users were more likely to be positive and less likely to be negative towards predictive medical tests.

Outcomes of users

Table 2 shows outcomes of users regarding the type and timing of DTC-testing, reasons for participation, information regarding consultation of one’s physician, and consequences of testing for users and their relatives. In total, 75 individuals underwent DTC-tests, of whom most within the last 5 years (N = 52, 69.3%). Of users, 18 underwent a total body scan (24.0%), 3 underwent genetic testing (4.0%), and 54 underwent another health check (72.0%), such as periodic occupational health tests (N = 15), blood tests for several blood markers such as cholesterol and blood glucose (N = 8), musculoskeletal tests (N = 5), tests for cardiac disease (N = 2), and general preventive health tests not further explicated (N = 11). Reasons for participation were an offer by their employer (29.3%), out of curiosity (25.3%), presence of symptoms (21.3%), family medical history (16.0%), and out of concern (10.7%).

Table 2: Outcomes of users

table 2

Before testing, 14 users (18.7%) consulted their physician. Nine of these found their doctor to have a positive attitude towards testing (64.3%), and six were informed by their physician on the pros and cons of testing (42.9%). Only one user found their physician to be dissuading (7.1%). Sixty-one users (81.3%) did not consult their general physician before testing, the majority stating they did not need their physician to decide on testing (N = 38, 62.3%). Two users (3.3%) assumed their physician would oppose testing. After testing, 21 users (28.0%) consulted their physician, with main reasons being that they needed medical follow-up (42.9%), reassurance (33.3%), or wanted to inform their doctor (23.8%). Fifty-four users (72.0%) did not consult their physician after testing, mostly because no medical follow-up was needed (53.7%) or they did not need their physician (35.2%). Two of 54 (3.7%) did not consult their doctor because they thought their physician would oppose testing.

Main consequences of testing for users were better insight in health risks (42.7%), lifestyle changes (36.0%), and reassurance about one’s health (26.7%). Five users needed further examining (6.7%) and 8 received medical treatments (10.7%). One user became more concerned about their health (1.3%). Sixty users informed their relatives on the results (80.0%), of which 6 noticed consequences for their relatives, mainly lifestyle changes and better insight in their health risks.

Responding to a number of statements (table 6), most users would participate again or recommend testing to others. Further, most users were neutral to positive about their physician’s knowledge of DTC-tests, respectfulness towards their choices, and willingness to refer and assist in lifestyle changes. When asked about the test’s influence on the patient-doctor or family relationships, the majority of responding users were neutral. Responses to the statement that doctors should more often point out positive aspects of DTC-tests or that the government should stimulate testing show less consensus.

Table 6: Statements (users) about their doctor

table 6

Outcomes of non-users

Reasons for not undergoing medical testing for non-users can be found in table 3. A large proportion of non-users stated that they would undergo predictive testing if recommended by their physician (35.7%) or if they would have symptoms (29.3%). Reasons for not undergoing testing were that non-users thought testing was too commercialised, that they lacked knowledge of the tests, lacked symptoms, or that the costs were too high. Non-users in the DR-group were significantly more likely to not undergo testing because they found it too costly, too commercialised, unreliable, or because they lacked knowledge or symptoms. In comparison, non-users from the NPV-group were more likely to not participate in DTC-tests because of emotional or principal objections. The non-users of this group were more likely to consider testing if they have symptoms or if their physician would recommend it.

Table 3: Outcomes of non-users

table 3

Responding to our statements (table 7), most non-users stand neutral to positive to participating in future predictive tests and the level of knowledge of their physician. As with users, non-users had mixed responses to whether physicians should point out positive aspects of DTC-tests and whether the government should stimulate uptake of DTC-tests.

Table 7: Statements (non-users)

table 7

Uni- and multivariate logistic regression analyses

Univariate logistic regression analyses were performed for all participants (main analysis) and for NPV- and DR-groups separately. Results can be found in tables 4 and 5. In univariate analyses, included predictor variables were gender, age by category, level of education, religion, attitude toward testing, and for our main analysis the variable of belonging to NPV- or DR-groups.

Table 4: Univariate Logistic Regression

table 4

Table 5: Multivariate Logistic Regression

table 5

Multivariate logistic regression analyses were performed for all participants (main analysis) and for the NPV-group separately. Since the DR-group had only one significant predictor variable from univariate analysis no multivariate analysis was performed. For the main analysis, we included gender, age by category, religion, attitude, and belonging to NPV- or DR-groups as predictor variables. For the NPV-group, only gender and attitude were included. There was no relevant multicollinearity with all VIFs under 10. Box-Tidwell models showed that for all variables in multivariate analyses the linearity assumption was met. There was one significant interaction between predictor variables, namely between gender and attitude. Further exploration of this interaction showed that female participants were significantly less likely to opt for testing than male participants if they had a mixed attitude. There were no significant gender differences if participants had a positive or negative attitude towards testing.

In our main analysis and for the NPV-group, male gender and having a positive attitude towards testing remained significantly associated with opting for testing. Further, there was a significant correlation between being aged 20-39 years and uptake of DTC-tests in our main analysis.

Survey amongst GPs

Baseline characteristics

In total, 15 GPs aged 30 to 60 years were interviewed. Nine were male, 6 were non-religious, 9 were Christians, and they lived and practiced in a variety of environments (both urban and rural). On average, GPs are consulted weekly to monthly by patients who made use of health checks and are consulted about 3 times annually by patients who underwent a total body scan. Two GPs had been consulted by one or more patients who underwent genetic testing. With regards to their attitude towards DTC-tests, 9 GPs had a mixed or neutral attitude, 2 were mainly positive, and 4 were mainly negative.

User-related outcomes of GPs

If GPs were consulted pre-testing, patients did so mainly to explore their opinion of a DTC-test, to gain information, to prepare for testing, or to seek consent. During pre-testing consultation, 13 GPs informed patients on the pros and cons of a test, 8 generally discouraged testing, and 1 specifically explored the patient’s motives for testing. Regarding reasons for not having been consulted before testing, 9 GPs suggested that patients do not seem to need their help before testing and 8 mentioned that patients expect a negative and critical response. Most GPs would prefer patients to consult them pre-testing to engage in a deliberative process or to refer to a particular test.

After testing, most patients consulting their GP did so to get advice about further medical investigations, to seek reassurance, to inform their GP, or for advice. Based on their experiences, the interviewed GPs identified three groups of people who undergo DTC-tests: (1) those without health problems who want to prevent misfortune, (2) patients with worries about their health because of physical complaints or because of their family history, (3) those having experience in healthcare systems in which predictive medical tests are more commonplace, i.e. immigrants.

GPs noticed several consequences of DTC-tests, such as a felt need for referral for further medical care, an increased sense of responsibility for the wellbeing of oneself or one’s family, lifestyle changes, fewer worries about oneself or one’s family, and better insight in health risks. One GP mentioned a patient receiving an early diagnosis of cancer due to a total body scan.

Regarding the patient-doctor relationship, 11 GPs affirmed that testing did not influence the patient-doctor relationship, 3 thought testing positively influenced the relationship as they felt patients became more aware of their autonomy and responsibility for their health, and 1 said it had a negative effect on the relationship. All the interviewed GPs affirm that doctors ought to be respectful and should try to understand a patient’s motivation for testing, emphasising deliberative, interpretative, and informative models of the patient-doctor relationship. None of the GPs prefers a paternalistic model.

Test-related outcomes of GPs

On the level of the individual user, most GPs stated that many DTC-users have only partial knowledge of the value of a DTC-test and its results. They conclude that users should have received more in-depth information to help them contextualise a test’s results. More explicitly, GPs mentioned that DTC-tests tend to focus on one aspect of health and overlook the importance of other determinants of health, such as a patient’s history and social context. Further, 8 GPs said that DTC-test providers give only scarce instructions on how to proceed if further medical follow-up may be indicated. Hereby, DTC-tests saddle the doctor with the intricate task of guiding DTC-users in how to interpret the results and to determine what medical follow-up is needed. Some GPs stated that results of DTC-tests seem to be intentionally vague or inconclusive so as to instigate further medical tests to affirm or disprove their findings. Information on the risks, side effects, and costs was also reported to be lacking.

Asked about societal aspects, the interviewed GPs mentioned that DTC-tests burden existing healthcare systems with possibly unnecessary follow-up medical investigations and treatments. Some GPs indicated that the availability of DTC-tests leads to an increased medicalisation focusing on potential health hazards. Finally, some GPs expressed doubts whether DTC-tests really benefit patient autonomy. Given their commercial nature aimed at inviting people to participate, and given the limited information about the advantages and disadvantages, DTC-tests may even inhibit a well-informed, autonomous choice. All interviewed GPs asked for governmental regulation of DTC-tests, preventing the marketing of tests with limited clinical validity and utility, and of tests carrying significant risk of harm or discomfort. Further, available DTC-tests should be monitored to guarantee a continuous evaluation of their benefits and harms. Reflecting on their own role, GPs think that physicians should emphasise 1) the possibility of performing health checks themselves, and 2) their potential as interlocutors and sources of information to help patients balance the advantages and disadvantages of testing before deciding whether to participate, emphasising deliberative, interpretative, and informative models of the patient-doctor relationship.

Focus group discussion

Our focus group included two GPs, both counselling several patients yearly about the results of health checks, two DTC-users (one having had 2 total body scans and one having had a genetic test), and one interested non-user. In their discussion the participants, despite some different views, affirmed several findings from our surveys. Most importantly, they valued an open and respectful patient-doctor relationship, irrespective of the patient’s and the physician’s convictions. Participants agreed on the value of (1) a physician being open to discuss DTC-tests and willing to inform about their different medical characteristics, (2) shared decision-making, (3) recognition of the importance of a patient’s responsibility in exploring health risks and preventing illness, (4) openness to find ways to reach these objectives by less invasive means, and (5) recognition of the fact that some tests may cause unnecessary concerns.

Discussion

DTC-tests

We found that 75 of 1,345 respondents (5.6%) underwent a DTC-test, mainly health checks and total body scans, of which most within the last 5 years. Multivariate logistic regression analysis showed that, for our total research group, male gender, younger age (20-39 years), and having a positive attitude towards DTC-tests were significantly correlated with the uptake of DTC-tests. Focusing on the DR-group, univariate logistic regression analysis showed that only having a positive attitude towards DTC-tests significantly correlated with the uptake of DTC-tests. If we extrapolate our results to the Dutch population, counting 17.4 million in 2020, approximately 900,000 people will have participated in DTC-tests, with more than 200,000 people having had a total body scan. Given the positive attitude towards future testing that we found amongst users and non-users, combined with the importance of lifestyle, prevention, and patient autonomy, we can expect these numbers to rise in the coming decades. Based on our results, the rise of DTC-users can be expected to be greatest among those with a positive attitude towards these tests and possibly greater among younger, non-religious men.

Some of this stands in contrast to earlier research of Hoebel et al and Dryden et al, who found that participants of adult health checks generally were of older age [16,17] and more likely to be female [17]. However, these studies do not focus on DTC-tests, but include predictive tests offered by regular healthcare systems. Tests offered through healthcare schemes are more likely to invite the elderly, as they are at increased risk for (chronic) disease. Moreover, our results may indicate that younger, male respondents prefer to decide for themselves whether to partake in health checks or are more likely to be offered DTC-tests through work, sport clubs, etc. As reviewed by Dryden, many studies show that people of lower socioeconomic status are less likely to use health checks. This is a finding we could not reproduce with our data (level of education) when correcting for other factors. We did not focus on employment, height of income, marital status, or ethnicity.

Main reasons for participation in DTC-tests were the availability through one’s employer, presence of symptoms, curiosity, and concern. Of 1,268 non-users a large proportion responded they would undergo DTC-tests either upon recommendation by their physician or in case of symptoms. These findings are in accordance with existing literature, as reviewed by Dryden et al [17] and Stol et al. [18] Studies included in these reviews show that people participate in health checks for health related and non-health related reasons. Among the first are the goals of informing on and monitoring of one’s health status, reassurance, preventing (advanced stages of) disease, and health improvement. This included testing out of concern or due to symptoms or family history. Examples of non-health related reasons include preferential circumstances lowering the threshold for testing, such as availability during a workday and an invitation from colleagues or family members. In contrast to these studies, we did not find that the intention to establish contact with a physician was a reason for testing.

In our study, main reasons for not participating in DTC-tests were the absence of symptoms, their commercial nature, a lack of knowledge of DTC-tests, expected costs, or principal objections. Likewise, Stol et al found that reasons for people not to use health checks were the absence of physical complaints, distrust of tests, the conviction that health checks are unfit in a presymptomatic stage, busy schedules, lack of knowledge, and related costs. In contrast to our study, both reviews mention that people also refrain from testing because they already had a health check, do not want to burden health systems, put low priority on healthcare or their health, were less self-sufficient, felt less in control of their health, or had problems with accessibility or transport. We did not include these options in our structured questionnaire but they may also have been reasons for non-usage.

From our results, it cannot be concluded whether or not DTC-tests offer direct health benefits. A systematic review by Krogsbøll et al [19], which included 14 randomised controlled trials with 182,880 participants, attempted to compare benefits of health checks in adult populations. Aggregating the evidence of these trials did not show a decrease in morbidity, total mortality (11 trials), cardiovascular mortality (8 trials), or cancer mortality (8 trials). Two trials found an increase in new diagnoses per participant in screened populations, mainly hypertension and hypercholesterolemia. Further, two trials reported an increase in the prescription of antihypertensive drugs in screened populations [19]. A similar review by Si et al [20] looked at surrogate outcomes such as cholesterol and blood pressure levels. They did so stating most studies of health checks are too short to validly measure differences in morbidity and mortality rates. Their review shows that health checks offered by GPs significantly improve these surrogate outcomes [20]. Therefore, DTC-tests may lead to long-term health benefits.

DTC-tests may also enhance health through an increased awareness of one’s health status and of the need for a healthy lifestyle, as was found in our study. Other studies found that health checks for cardiovascular disease led to an improvement in self-reported physical activity [21], a more healthy diet behaviour [21], a decline in self-reported alcohol consumption [22], and positive dietary changes [22]. However, these effects could in principle be realised without DTC-tests, for example through public awareness campaigns. Further, some studies did not find a lasting improvement towards a healthier lifestyle after using DTC-tests [23], questioning their long-term effects. Moreover, these benefits should be balanced against the possibility that DTC-tests may lead to unnecessary concern, over-medicalisation, and over-responsibilisation [8]. The latter refers to the idea that we are personally responsible for our health, blaming the ill for much of their health status.

Finally, DTC-tests carry a risk of overdiagnosis and overtreatment. After all, inconclusive or abnormal results may prompt further medical investigations and treatment which in hindsight may turn out to have been unnecessary. In our study, a small proportion of DTC-users underwent additional investigations (6.7%), or received medical treatment (10.7%). It is unknown to us what the indications were and whether this led to health benefits or caused harm. Given the risks of DTC-tests, all our interviewed GPs stressed the importance of governmental regulation and monitoring of DTC-tests to ensure their quality and health benefits.

Patient-doctor relationship

Most DTC-users and all but one of the interviewed GPs stated that DTC-tests had a neutral to positive impact on patient-doctor relationships. Users were neutral to positive about their physician’s knowledge of DTC-tests, respectfulness towards their choices, and willingness to refer or assist in lifestyle changes. GPs emphasised the importance of non-paternalistic models of the patient-doctor relationship, mainly the deliberative and interpretative models, guiding a patient in deciding on the uptake of a DTC-test or referring for a particular test themselves. However, most DTC-users did not consult their physician before or after testing, the main reasons being that they needed no extra expertise (this underscores the value of autonomy) and that there was no indication for medical follow-up. This might show that DTC-users either think of DTC-tests as being of little importance, not worth mentioning to their GP, or value their patient-doctor relationship less highly than GPs do. We assume that the first is more likely. We conclude this from the fact that normal (i.e., negative) test results were separately mentioned as a major reason for not consulting one’s physician.

Among interviewed GPs, over half expected the prospect of an opposing attitude to be a major reason for their patients not to consult their physician. In our patient survey, however, we found that this was a reason for only a small minority of users: whilst only 1 of 14 DTC-users who had consulted their doctor before testing stated to have received a discouraging reaction, 8 of 15 GPs said to have been discouraging. This might imply a perceived difference between how physicians reflect on themselves compared to how a patient reflects on their physician.

To maintain their role as interlocutor or source of information, physicians should ensure adequate knowledge of DTC-tests and show that they are willing to be involved prior to and after testing. Doctor and patient alike could benefit from the effects of this openness for their relationship. However, this requires clear information regarding DTC-tests and their characteristics, benefits, harms and costs.

Limitations

One limitation of our research is that about 75% of respondents were recruited from the Dutch Patient Association NPV, whose members have a predominantly Protestant Christian background. For compensation we performed and compared separate analyses of NPV- and DR-research groups, assuming our DR-group to better represent the Dutch population. A second limitation is the relatively small group of DTC-users: although a number of 75 users (5.6% of our research population) does provide valuable material, research with a larger group of users is commendable. A third limitation is our use of semi-structured questionnaires, thereby limiting the options for respondents to choose and possibly missing unique insights. This limitation was mitigated by the fact that almost all questions included an ‘other’-option. A fourth limitation of our study is its cross-sectional design, which impedes follow-up and thus evaluation of possible benefits and harms of DTC-tests, and risks recall bias as it depends on the memory of respondents. Therefore, further research into DTC-tests should preferably include prospective study designs or randomised controlled trials.

Conclusion

We found that 5.6% of respondents have used DTC-tests, particularly health checks and total body scans, with a tendency to increased use and an apparent growth potential. Uptake of DTC-tests was significantly correlated with having a positive attitude towards DTC-tests, male gender, and younger age in our main analysis, and with a positive attitude in our most representative subgroup analysis. Generally, DTC-tests had a neutral to positive influence on patient-doctor relationships. However, regarding this relationship there were discrepancies between responses of DTC-users and GPs. In particular, most DTC-users saw no need to consult their physician either before or after testing, whilst GPs stressed the importance of consultation for guidance or referral. Therefore, DTC-tests seem to challenge patient-doctor relationships by enabling patients to undergo medical tests without interference by their physician. Patient autonomy thus continues to gain importance within the medical field.

Funding and organisation

The study was funded by The Netherlands Organisation for Health Research and Development (ZonMw), an independent governmental research platform, and supervised by an interdisciplinary, independent board of scientists, GPs, and patients. The project was initiated by the Prof.dr. G.A. Lindeboom Instituut (PLI) for Medical Ethics.

Impact statement

We certify that this research is novel. The raw research results can be accessed in a VU-University database. A preliminary report of this research, without the analyses conducted here, was published as Boer TA, Einerhand SMH, De Haas‐de Vries JA, Van Rijswijk MN. Komt een test bij de dokter. Amsterdam: Buijten & Schipperheijn; 2018.

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Review on Pregnancy Toxemia in Sheep with Observation of Resolution Using ReaShure (Protected Choline)

DOI: 10.31038/IJVB.2021522

Abstract

Pregnancy toxemia is a metabolic disorder in sheep and goats which usually develops during late gestation and which is always associated with hyperketonemia and hypoglycemia. Ewes of certain breeds, mainly when bearing two or three lambs, are more susceptible than ewes only one fetus [1]. The economic significance of the disease is determined by reduced milk yields and body weight loss, poor feed conversion, increased culling and mortality rates of offspring and affected animals [2].

Compared to dry ewes, ewes in late pregnancy require about 50 percent more feed if bearing a single lamb and about 75 percent more feed if carrying twins. This amount of feed may exceed their intake capacity unless grain is substituted for part of the ration [3]. Ovine pregnancy toxemia or “twin-lamb” disease occurs in the latter part of pregnancy in sheep, typically in ewes with multiple fetuses, and is characterized by anorexia and neurologic signs of motor weakness, amaurosis, and mental dullness. It may occur spontaneously or may be induced by dietary deficiency. The disease is associated with the high calorific requirements of pregnant sheep.

Pregnancy toxemia may occur following a relative deficiency of available carbohydrate that leads to a drain on oxaloacetate and its precursors in an effort to maintain blood glucose concentration. Toxemia can usually be prevented by adequate supplementary feeding in late pregnancy. Clinical pathologic studies show consistent elevation of blood ketones and glucocorticoids and, in the early part of the disease, decreased blood glucose. Subclinical ketosis is defined as elevated concentration of circulating ketone bodies in the absence of clinical signs [4].

There are four categories of disease according to [5]: 1) Primary pregnancy toxemia caused by inadequate nutrition (poor quality feed, period of fasting) 2) Fat ewe/doe pregnancy toxemia seen in over-conditioned ewes/does in early gestation (suffer a nutritional decline in late gestation, possibly from smaller rumen capacity) 3) Starvation pregnancy toxemia seen in severely under-conditioned ewes/does (lack of feed after drought, heavy snow or flood) and 4) Secondary pregnancy toxemia due to concurrent disease such as parasites, poor dentition, or lameness.

Hyperketonaemia is defined as an abnormally high concentration of circulating ketone bodies during the postpartum period. The gold standard diagnostic test for Hyperketonaemia is the test for hyperketonaemia is the measurement of hydroxybutyric acid (BHBA) in serum or plasma by a laboratory process [6]. The most commonly used level of serum BHB to identify ketosis is a concentration ≥1400 mol/l (14.4 mg/dl) [7].

An alternative to the laboratory method is blood BHBA measurement that can be used as on – farm cow side test for hyperketonaemia with a near perfect accuracy (Precision Xtra; sensitivity 96%, specificity 97%). More recently, cow side tests for ketosis have focused on measuring BHBA level. One test is Keto Test (Sanwa Kagaku Kenkyusho Co Ltd, Nagoya, Japan; distributed by ELANCO Animal Health, Greenfield, IN). This test measures BHBA in milk and consists of test strips on which a reagent converts BHBA in the milk sample to AcAc. Using a provided colour scale, the strip may be used to semi-quantitatively measure BHBA concentration s in the milk sample based on intensity of the colour change observed on test strip [8,9]. A new blood strip test for BHBA and glucose was developed and manufactured by DFI CO., Ltd (South Korea). Recently a new test BHBCheck Plus (blood ketone & glucose test system) manufactured by PortaCheck, Inc, USA. Laboratory findings in individual animals may include hypoglycemia (often <2 mmol/L), elevated urine ketone levels, elevated BHBA levels (normal <0.8 mmol L, subclinical ketosis >0.8 mmol L and clinical disease >3.0 mmol /L) and frequently hypocalcemia and hyperkalemia due to severe ketoacidosis [10].

Blood glucose concentration between 40 and 65 mg/dl are common in pregnancy toxemia, although comatose animals may show terminal hyperglycemia, especially associated with fetal death [11]. To prevent ketosis in sheep, goats, it is important to identify the animals carrying twins or triple, separate them and provide them with a diet that will meet their energy demand. Successful treatment of pregnancy toxemia requires early detection and steps to quickly meet the energy (glucose) needs of the affected ewe. The most common treatment is to drench ewes with 2 to 3 ounces of propylene glycol 2 to 3 times daily. Propylene glycol, which is mainly absorbed intact directly from the rumen at a rate of 40% per hour and reaches its maximum blood level within 30 min of administration and maximum blood glucose conversion at about 4 h after administration. Propylene glycol transformation in glucose probably occurs via conversion to pyruvate [12].

Reashure microencapsulated choline, a recent technological breakthrough, protects choline on its journey rough-and -tumble rumen and releases it in the small intestine. Lipid (fat) layers, applied using a proprietary process, encapsulate (coat) the choline. At the time of calving and during negative energy balance, feeding ReaShure increases fat export out of the liver which prevents fatty liver and reduces the amount of fatty acids converted to ketones by the liver [13,14].

Feeding ReaShure also reduced the incidence of mastitis (P = 0.06) and all postpartum diseases combined (P = 0.001). Clearly, cows fed ReaShure were healthier and produced more milk [15]. The impact of feeding of ReaShure to sheep is obvious in reducing the incidence of ketosis in sheep (pregnancy toxemia). Sheep fed ReaShure are healthier compared to those not fed Rea Shure. Also, it reduced the incidence of abortion [16].

Keywords

Pregnancy toxaemia-Ketosis Beta-hydroxybutyrate (BHB)-, Hypoglycemic-hyperglycemic-hyperketonemia-propylene glycol-protected choline (ReaShure)-acetone or acetoacetate (AcAc), BHB check plus (blood ketone & glucose test system), Qucare Vet Meter – Qucare Vet strips – mmol/l-Subclinical Ketosis-Abortion

References

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  14. Zom R, Baal J van, de Veth MJ, Goselink RMA, Widjaja- Greefkes HCA, et al. (2010) Effect of rumen -protected Choline on performance and hepatic fat metabolism in periparturient dairy cattle and hepatic fat metabolism in periparturient. J Dairy Sci 93: 781
  15. Santos JP, Lima FS (2009) Feeding rumen-protected choline to transition dairy cows. Page 149 in Proceedings of the Florida Ruminant Nutrition. Univ.Florida, Gainesville.
  16. Hameid OA, Abu-Zeid TESA, Mustafa Taha MK, Vandoni S (2019) Studying The Effects of supplementing ( Reashure ) to pregnant sheep on incidence of ketosis Health status Pre and after lambing. J Anim Sci livest Prod 3: 20

Intralesional Therapy in Oncology: A New Vision of a Classic Treatment

DOI: 10.31038/CST.2021621

Abstract

Intralesional therapy has been used in oncology for over a century. The former empirical observations on local control were followed by trials with administration of different substances and/or destructive treatments with the aim of controlling cancer growth. Chemotherapy, molecular target therapy, radiotherapy and other physical therapies were initially viewed as a strategy that mainly affected tumor cells, but accumulating evidence in recent years indicates that can also affect the immune system and the tumor microenvironment to contribute to tumor regression. In the light of the recent and relevant findings in immunotherapy, a new point of view that integrates the current knowledge in the topic is presented, with the aim of stimulating further research that might help to optimize the use of new drugs, making them affordable, more effective and less toxic.

Keywords

Intralesional therapy, Immunotherapy, Cancer

Introduction

Intralesional therapy has been used in oncology for over a century, since the initial observations of Coley about tumor remissions in patients treated with bacterial extracts [1]. The former empirical observations on local control were followed by trials with different substances and/or destructive treatments that induced a local acute trauma at the tumor site, with the aim of controlling cancer growth [2,3]. Later on, new reports on distant disease remissions after local injection or Spontaneous Tumor Regression (STR) following infectious episodes and/or surgery caused a progressive shift in the paradigm in parallel with the evolution of knowledge in oncology [4,5].

Everson and Cole defined STR as “the partial or complete disappearance of a malignant tumor in the absence of all treatment, or in the presence of therapy which is considered inadequate to exert significant influence on neoplastic disease” [4]. They also stated in 1966, in a key work in the field, “in many of the collected cases it must be acknowledged that the factors or mechanisms responsible for spontaneous regression are obscure or unknown in the light of present knowledge. However, in some of the cases, available knowledge permits one to infer that hormonal influences probably were important. In other cases, the protocols strongly suggest that an immune mechanism was responsible” [4]. According to many reviews describing STR, Renal Cell Carcinoma (RCC) is one of the most frequent types of malignant neoplasm related to this phenomenon. The rate of STR of RCC, around 1%, is frequently associated with nephrectomy [6]. Many reports of STR have implicated surgery or operative trauma as an element that can increase immunological resistance to tumor growth. A number of cases in whom surgery on the primary tumor or the metastases has led to regression in the remaining tumor mass have been reported. The removal of a portion of the tumor burden presumably allows the host immune system to destroy the remaining tumor [7].

Initially conceived as an isolated entity growing independently of homeostatic mechanisms of the host, current knowledge of cancer biology has uncovered behind the neoplasia a more complex evolutionary process. Hirata and Shai pointed out this evolutionary nature of cancer, with the Tumor Microenvironment (TME), a complex mixture of non-transformed cell types and extracellular matrix, playing a key role in both the development of tumors and their response to therapy [8]. TME is not merely a physical framework but an interactive structure that conditions tumor development in several ways. In addition, tumors are heterogeneous entities, with strong differences between subpopulations inside the tumor, between primary tumor and metastases and between metastases. Part of this heterogeneity is caused by the presence of Cancer Stem Cells (CSC), characterized by particular phenotypic traits that distinguish them from non-CSC tumor cells. The activation of Epithelial to Mesenchymal Transition (EMT) program has been postulated as the main cause of the epigenetic changes observed in non-CSC to CSC transition. EMT can also activate the possibility of metastatic spread [9]. This plasticity makes possible for carcinoma cells to interconvert between multiple alternative states characterized by different degrees of mesenchymal features [9].

The possible contribution of intralesional therapy to the destruction of all the residual carcinoma cells and the subsequent increased cure rate of different solid tumors can be inferred from the fact that most of cells surviving after various types of therapy commonly display signs of EMT activation. To target cancer cells that have activated portions of the EMT programme constitutes one of the promising ways in development to improve the efficiency of commonly used anticancer therapeutic modalities [9].

In a work analyzing the application of Chimeric Antigen Receptor T (CAR-T) cell therapies to solid tumors, Scarfò and Maus described the identification of proper tumor associated antigens, the limited trafficking of adoptively transferred cells to tumor sites and the immunosuppressive effect of TME as the three main circumstances conditioning its efficacy. TME constitutes a physical barrier decreasing the penetration of modified T-cells into the tumor parenchyma and actively upregulates inhibitory signals. As has been previously suggested, a complete and effective antitumoral strategy has to include all the tumor cells in their different biological situations and the TME elements [10].

Chemotherapy, molecular target therapy, radiotherapy and other physical therapies (electrochemotherapy, cryotherapy, radiofrequency ablation, etc.) were initially conceived as a strategy to destroy tumor cells, but accumulating evidence in recent years indicates that cytotoxic drugs also affect the immune system and TME to contribute to tumor regression. Local irradiation of a single tumor site can reduce the size of non-irradiated metastases that are located at a distant site, a phenomenon known as abscopal effect, mediated by the immune system. Neoadjuvant radiochemotherapy may be immunologically more relevant than adjuvant therapies [11]. Several anticancer therapies have “yin-yang” characteristics with respect to the tumor, being able to attack tumor cells but to cause immunosuppression as well, with the response to the treatment depending on the balance between both aspects. It has been postulated that there is no cancer cure without inducing effective antitumor immunity, independently of the therapeutic modalities employed to treat the patient [11].

From an immunological point of view, tumors are classified as “hot” (T cell-infiltrated), “excluded” (inflamed but non-infiltrated), “immunosuppressed” (low infiltration in tumor and margins) and “cold” (non-inflamed) [12]. According to the previous postulates, physical therapies can cause tumor response by direct destruction of tumor cells, induction of immunogenic cell death with the release of danger associated molecular patterns, and tumor associated antigens that are key to initiate an innate immune response, targeting both the treated lesion as well as distinct lesions. These physical therapies can be combined with classical treatment modalities (chemotherapy, radiotherapy) and/or intralesional immunomodulating factors (BCG, IL2, IFNα, oncolytic viruses, etc), with the aim to enhance anti-tumor immune responses2 rendering hot an initially described as cold or altered tumor.

Some systemic immunotherapies have a benefit limited to a minority of patients, might cause immune-related adverse events and imply long-lasting treatments with the risk of financial toxicity. Intratumoral immunotherapy can address these issues by providing a better priming of the antitumor immune response, avoiding off-target toxicities and requiring a lower amount of medication per patient [13]. Disruption of physical barriers, local activation of immune effectors, inactivation of immunosuppressant cellular populations (myeloid derived suppressor cells, Tregs, tumor associated macrophages) and counteraction of soluble immunosuppressant factors can be better attained by direct action on the tumor mass, with a more selective and less toxic effect, with the possibility of expanding combinations of complementary agents (probably not feasible by systemic route) and at a much lower cost. The most exciting modality in this field has been the intratumoral administration of oncolytic viruses. Talimogene laherparepvec, the first approved by FDA, is a genetically engineered herpes virus with two genes removed-one that shuts down an individual cell’s defenses, and another that helps the virus evade the immune system-and the one that codes for human GM-CSF added. Initial results in patients with previously resistant metastatic melanoma have been encouraging.

In recent years, several other attempts have been made in order to induce local secretion of immunomodulating molecules as IL12 or GM-CSF in the tumor area through genetic engineering of somatic and/or tumor cells, with the aim of obtaining a clinical response. They have paved an exciting way, but at this moment, in general, results have not been conclusive enough and the question if it represents an improvement over direct intralesional administration of the substances is not resolved. In summary, intralesional route in cancer therapy has evolved from an empirical concept to a more defined one, with exciting possibilities strongly related with the development of modern immunotherapy and a future open to new combinations. Further studies to better delineate this field are warranted.

Declarations

  1. Funding: This work has no funding sources.
  2. Conflicts of interest/Competing interests: The authors declare no conflicts of interest.
  3. Ethics approval: N/A.
  4. Consent to participate (include appropriate statements) N/A.
  5. Consent for publication (include appropriate statements) N/A.
  6. Availability of data and material (data transparency) N/A.
  7. Code availability (software application or custom code) N/A.
  8. Authors’ contributions: MS conceptualization, formal analysis, supervision, writing original draft, writing review & editing; VEO conceptualization, formal analysis, writing review & editing; EMN data curation, investigation, visualization, writing review & editing; JR data curation, investigation, writing review & editing.

References

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fig 1

Postmarketing Analysis of Osteoporosis Patient Adverse Event Reports Reveals Stronger Association of Alendronate and Risedronate Use with Jaw Osteonecrosis and Atypical Femur Fracture

DOI: 10.31038/IJOT.2021413

Abstract

In the United States, there are over ten million adults diagnosed with osteoporosis and many more are at risk of developing the condition. Osteoporosis affects both males and females, mostly post-menopausal. Bisphosphonates and denosumab have been widely used globally to treat the condition. The use of bisphosphonates and denosumab had been associated with rare adverse effects including osteonecrosis of the jaw, ONJ, and atypical femur fracture, AFF. However, it remained unclear whether those side effects were class-wide or drug-specific. By analyzing over 230,000 osteoporosis patient reports from the FDA adverse event reporting system, FAERS, we confirmed the association of bisphosphonates and denosumab use with AFF and ONJ.

Additionally, comparing each of the four frequently used bisphosphonates with denosumab-treated patients used as a control, we identified: (i) varying significance of association with ONJ and AFF for alendronate, risedronate, ibandronate and zoledronic acid, (ii) over two fold increase in risk of both side effects in alendronate patients, particularly in females, (iii) over a six-fold increase in AFF risk in both males and females taking risedronate, and (iv) lower risk of both AFF and ONJ, for zoledronic acid patients compared to denosumab.

Keywords

Fracture, Osteonecrosis, Bisphosphonates

Introduction

The National Osteoporosis Foundation reports that 10.2 million adults age fifty and older had osteoporosis in the U.S in 2013, and 43.4 million adults were at risk of developing the disease, giving a total of about 54 million U.S. adults with osteoporosis or low bone mass [1]. It was projected that this total number will grow to 64.4 million by 2020 and to 71.2 million by 2030 [1]. Moreover, the study showed that more women than men had osteoporosis (8.2 million vs. 2.0 million) and low bone mass (27.3 million vs. 16.1 million) [1]. Osteoporosis causes a reduction of bone mass and strength due to multiple pathogenic mechanisms, leading to increased bone fragility and susceptibility to breakage [2,3].

Three main types of drugs are recommended for the treatment of osteoporosis, including bisphosphonates (alendronate, risedronate, ibandronate, and zoledronic acid), denosumab and teriparatide [4]. Bisphosphonates are small molecules that bind to hydroxyapatite in bone, leading to the inhibition of osteoclastic bone resorption, [5,6] denosumab is a fully humanized monoclonal antibody to RANKL [7], and teriparatide is a synthetic version of the human parathyroid hormone which works by activating osteoblasts [8,9].

Common adverse effects of oral bisphosphonates (alendronate, risedronate, ibandronate) include, but not limited to, upper gastrointestinal side effects (acid reflux, esophagitis, ulcers) due to local effects on esophagus and/or gastric mucosa [10-12]. Intravenous (IV) bisphosphonates (ibandronate, zoledronic acid) are associated with injection-related reactions, such as, flu-like symptoms (fever, myalgias, arthralgias) [12,13]. Musculoskeletal pain is common to both oral and IV formulations [10-13]. Denosumab, administered as a subcutaneous injection, is associated with fatigue/asthenia, hypophosphatemia, nausea, and back pain [14]. Common side effects of teriparatide include injection-site pain, nausea, headaches, leg cramps, and dizziness [15].

While these adverse effects are expected and can be managed, there are two counterintuitive and troubling adverse effects, unique to bisphosphonates and denosumab, that directly damage the bone instead of preventing bone loss: 1) Osteonecrosis of the Jaw (ONJ), and 2) Atypical Femur Fracture (AFF) [16].

AFF is referred to as “atypical” due to the location of the fracture. AFF occurs in the subtrochanteric or diaphyseal region of the femur with simple transverse or oblique pattern [16]. The pathophysiology of AFF is not well understood. However, it is suggested that since bisphosphonates inhibit the activity of osteoclasts, they cause suppression of bone turnover rate, resulting in the effects that contribute to AFF, such as accumulation of microdamage in the bone [16]. Similarly, denosumab provokes the disruption of the targeted remodeling process, which is needed to replace microcracks with new bone tissue, leading to accumulation of bone microdamage [17]. A study done by Black and colleagues reviewed 284 records of hip or femur fractures associated with bisphosphonates use among 14,195 women in these trials [18]. The study showed no significant increase in the risk of AFF for alendronate use (Relative Risk (RR) 1.03, 95% Confidence Interval (CI) [0.06-16.46]) and for zoledronic acid use (RR 1.50, 95% CI [0.25-9.00]) compared to placebo [18]. However, many case reports and small-scale studies have shown the association of bisphosphonate use with AFF for alendronate, ibandronate, risedronate, zoledronic acid, and denosumab [19-27].

ONJ is a severe disease that affects the jaw, and it is defined as exposed, necrotic bone in the maxillary and mandibular regions [28]. There are multiple factors that play a role in the pathophysiology of ONJ, putting the oral cavity at a higher risk [29]. Oral structures can be subjected to various types of stresses such as mastication, dental procedures, periodontal disease, caries, poor oral hygiene and effects of chemotherapy [29]. Combination of these factors can lead to bone exposure and demand higher rates of bone remodeling [29]. It is advised for all patients to undergo dental examination prior to initiating treatment with bisphosphonates or denosumab, as well as, maintaining good oral hygiene throughout the treatment [30].

A literature review of eleven publications reporting 26 cases of ONJ was performed by Pazianas and colleagues to clarify the association between bisphosphonate use and the development of such adverse event [31]. The study showed that the relative prevalence of ONJ was low and more often associated with a dental procedure; however, the authors did not draw any conclusion related to the differences between the drugs due to the scarcity of the reports [31]. There have been a few case reports and small-scale studies on the ONJ adverse drug reaction in patients taking alendronate, ibandronate, risedronate, zoledronic acid, and denosumab [32-37].

To further quantify the drug-specific associations those treatments with AFF and ONJ and expand on current evidence we analyzed over twelve million post-marketing adverse drug reaction reports. Initially, we illustrated the association of ONJ and AFF with bisphosphonates and denosumab in relation to teriparatide. Teriparatide was chosen due to its unique mechanism of action and adverse event profile [38-40]. Additionally, we evaluated the Reporting Odds Ratios (RORs) of AFF and ONJ in patients with osteoporosis for each of four bisphosphonates using denosumab as a control and evaluated the co-occurrence of these adverse events. The magnitude of the effects, and their 95% Confidence Intervals (CIs) were also evaluated for each bisphosphonate in both male and female patients to quantify additional risk factors.

Methods

FAERS/AERS contains reports of medication-related adverse effects submitted to the FDA voluntarily by patients, healthcare providers, and legal representatives through MedWatch, [41] the FDA Safety Information and Adverse Event Reporting System. FAERS reports were utilized to conduct a retrospective analysis on patients with osteoporosis, taking either bisphosphonates, denosumab, or teriparatide to compare the frequency of rare adverse events, AFF and ONJ, associated with the use of these drugs.

Data sets are available to the public online at:

shorturl.at/lsK36

Normalizing and Combining the Data

Each quarterly report set was then downloaded in a (.txt) format and modified to produce a standardized table field structure. Some data sets contained missing columns, and blank columns were added with no values to homogenize the reports [42,43]. The final data set contained over twelve million reports. Reports were submitted mostly from the United States, however, many reports were submitted from around the world with their country-specific formats. International brand and generic names were translated into a single generic form using online drug databases [42,43].

Choosing the Cohorts

The FAERS system was queried based on the adverse events reported between January of 2004 and March of 2019. A total of 12,004,552 FAERS adverse reaction reports were collected. Reports of patients with osteoporosis were selected into the osteoporosis cohort if the “indication” field in the FAERS reports had the term osteoporosis exclusively. Approximately 0.04% of FAERS reports are duplicates. These are follow-up reports with the same case numbers. In our case selection, the duplicate reports were excluded. Additionally, reports by lawyers were also excluded due to potential bias.

Guidelines and position statements from the following organizations and societies were used to identify the first-line recommended therapeutics for osteoporosis prevention and treatment: The American Association of Clinical Endocrinologists [44], the Endocrine Society [45], the American Academy of Family Physicians [46], the National Osteoporosis Foundation  [47], and the North American Menopause Society [48]. Alendronate, ibandronate, risedronate, zoledronic acid, and denosumab were all recommended as a first-line line therapeutic option.

From 232,512 osteoporosis reports, a total of 133,089 osteoporosis monotherapy reports were selected. Out of the latter osteoporosis group, reports where denosumab was used for the treatment of osteoporosis, excluding bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid) and other drugs associated with ONJ such as m-TOR inhibitors (sirolimus, everolimus, temsirolimus), and antiangiogenic drugs (bevacizumab, sunitinib, sorafenib, pazopanib, axitinib), were selected into the denosumab cohort (n=18,336). Reports where bisphosphonates were used, excluding denosumab, m-TOR inhibitors, and antiangiogenic drugs, were selected into the bisphosphonates cohort (n=36,527). Out of the osteoporosis reports, reports where teriparatide were used for the treatment of osteoporosis, excluding denosumab, bisphosphonates, m-TOR inhibitors, and antiangiogenic drugs, were selected into the teriparatide cohort (n=66,173). The bisphosphonate cohort was further split into alendronate (n=14,682), ibandronate (n=6,065), risedronate (n=2,309), and zoledronic acid (n=13,471) sub-cohorts (Figure 1). Demographic analysis was also performed (Tables 1 and 2).

fig 1

Figure 1: Cohort selection.

Table 1: Patient demographics in bisphosphonates and denosumab cohorts.

Sex

Bisphosphonates

(n=36,527)

Frequency (%) Denosumab (n=18,336)) Frequency (%)

% Difference

Female

30,154

82.55 15,146 82.60

0.05

Male

3,303

9.04 2,009 10.96

1.92

Unknown

3,070

8.40 1,181 6.44

1.96

Table 2: Age difference in patients with osteoporosis taking bisphosphonates vs. denosumab.

 

Bisphosphonates

Denosumab

Mean Age, Years (Standard Deviation)

69.10 (12.22)

73.01 (11.52)

Median Age, Years

69.40

67.60

Unknown (%)

32.60

25.98

Cohort selection for adverse event rate comparison between bisphosphonates, denosumab and teriparatide as a class, and between individual bisphosphonates and denosumab.

Statistical Analysis

Descriptive statistics

Reporting frequencies for ONJ and AFF adverse drug reactions were calculated by the equation:

Frequency = (Number of reports with adverse drug reaction of interest)/(Number of total adverse drug reaction reports)∗100                                        (1)

Comparative Statistics

The analysis was performed and presented according to established guidelines of pharmacovigilance research established by the FDA and the scientific community. Disproportionality analysis term Reporting Odds Ratio (ROR) was used to differentiate the study from other observational epidemiological studies [49-51].

Adverse drug reaction report rates were compared via the ROR analysis for Figures 1-6 using the following equations:

ROR= (a/b)/(c/d)                                             (2)

Where:

a: ONJ/AFF cases in exposed group with an adverse event

b: ONJ/AFF cases in exposed group with no adverse event

c: ONJ/AFF cases in control group with the adverse event

d: ONJ/AFF cases in control group with no adverse event

LnROR= Ln(ROR)                               (3)

Standard Error (SE) of Log Reporting Odds Ratio;

SELnROR= √ (1/a+1/b+1/c+1/d)                                  (4)

95% Confidence Interval;

95%CI= [exp(LnROR−1.96×SELnROR) , exp(LnROR+1.96×SELnROR)]                   (5)

Results

Osteonecrosis of the Jaw (ONJ)

Patients with osteoporosis-only indication who used bisphosphonates or denosumab had an about hundred-fold higher frequency of ONJ when compared to teriparatide, (reporting odds ratio, ROR, 128.68, 95% Confidence Interval (CI) [84.45, 196.06]) and (108.74 [71.07, 166.39]) respectively (Figure 2a and 2b).

ONJ Adverse Events in Bisphosphonates, Denosumab and Teriparatide Cohorts

Frequencies of ONJ for patients in FAERS who took bisphosphonates as a class (n=36,527), denosumab (n=18,336) or teriparatide (n=66,173) (Figure 2a). Figure 2b reporting odds ratios were calculated comparing adverse event frequencies of bisphosphonates, denosumab and teriparatide patients. Ranges represent 95% Confidence Intervals (95% CI) (see Methods). X-axis is presented in log scale.

fig 2

Figure 2: Frequencies and Reporting Odds Ratios (RORs) of osteonecrosis of the jaw. Abbreviations: ONJ – Osteonecrosis of Jaw, ROR – Reporting Odds Ratio.

While in comparison with teriparatide the 95%CI ROR ranges of denosumab and bisphosphonate-class overlapped, bisphosphonates as a class, when compared directly with denosumab, had a significantly higher risk of ONJ (1.18 [1.08, 1.30]) (Figure 3a and 3b). However individual bisphosphonate drugs varied in the ONJ RORs vs denosumab. Interestingly, the alendronate cohort had a two-fold increase in risk of ONJ when compared to denosumab (2.00 [1.84, 2.26]) (Figure 3a and 3b). On the other hand, ibandronate and zoledronic acid cohorts had significantly lower frequencies of ONJ when compared to denosumab, (0.52 [0.43, 0.65]) and (0.61 [0.53, 0.70]) respectively (Figure 3a and 3b). The difference in the frequency of ONJ in patients with osteoporosis taking risedronate did not meet the significance criteria when compared to denosumab (1.06 [0.84, 1.33]) (Figure 3a and 3b).

Frequencies of ONJ for patients in FAERS who took bisphosphonates as a class (n=36,527), individual bisphosphonates: alendronate (n=14,682), ibandronate (n=6,065), risedronate (n=2,309), zoledronic acid (n=13,471), or denosumab (n=18,336) (Figure 3a). Figure 3b reporting odds ratios were calculated comparing adverse event frequencies of bisphosphonates and denosumab patients. Ranges represent 95% Confidence Intervals (95% CI) (see Methods). X-axis is presented in log scale.

fig 3

Figure 3: Frequencies and Reporting Odds Ratios (RORs) of Osteonecrosis of the Jaw (ONJ) adverse events in patients with osteoporosis taking bisphosphonates or denosumab. Abbreviations: ONJ – Osteonecrosis of Jaw, ROR – Reporting Odds Ratio.

Females who used bisphosphonates as a class or alendronate, as an individual bisphosphonate, had a significant increase in the relative reporting odds ratio of ONJ when compared to denosumab (1.20 [1.10, 1.33]) and (2.10 [1.84, 2.30 respectively (Figure 4a and 4b). The ibandronate and zoledronic acid cohorts had significantly lower risk of ONJ compared to denosumab (0.55 [0.44, 0.67]) and (0.66 [0.57, 0.76]) respectively (Figure 4a and 4b).

Males who used bisphosphonates as a class, ibandronate, risedronate or zoledronic acid had no significant difference in the reporting frequency of ONJ when compared to denosumab (1.28 [0.92, 1.76]), (0.42 [0.14, 1.15]), (1.48 [0.66, 3.30]) and (0.80 [0.53, 1.23]) respectively (Figure 4c and 4d). Similar to females, alendronate male cohort had a significantly higher occurrence and related odds ratio of ONJ when compared to denosumab (2.13 [1.50, 3.04]) (Figure 4c and 4d).

Frequencies of ONJ for female patients in FAERS who took bisphosphonates as a class (n=31,834), alendronate (n=12,614), ibandronate (n=5,614), risedronate (n=2,016), zoledronic acid (n=11,590) or denosumab (n=15,690) (Figure 4a). Figure 4b reporting odds ratios were calculated comparing adverse event frequencies females taking bisphosphonates or denosumab. Frequencies of ONJ for male patients in FAERS who took bisphosphonates as a class (n=3,303), alendronate (n=1,229), ibandronate (n=334), risedronate (n=169), zoledronic acid (n=1,571) or denosumab (n=2,009) (Figure 4c). Figure 4d reporting odds ratios were calculated comparing adverse event frequencies females taking bisphosphonates or denosumab. Ranges represent 95% confidence intervals (95% CI) (see Methods). X-axis is presented in log scale.

fig 4

Figure 4: Frequencies and Reporting Odds Ratios (RORs) of Osteonecrosis of the Jaw (ONJ) in female and male patients with osteoporosis taking bisphosphonates or denosumab. Abbreviations: ONJ – Osteonecrosis of Jaw, ROR – Reporting Odds Ratio.

Atypical Femur Fracture (AFF)

Patients who used bisphosphonates or denosumab had a significantly higher frequency of AFF when compared to teriparatide. The reporting odds ratio, ROR, for bisphosphonates was 97.16, with 95% confidence interval, CI, [43.32, 217.92]), and for denosumab it was 51.97 [22.71, 118.91] (Figure 5a and 5b).

Frequencies of ONJ for patients in FAERS who took bisphosphonates as a class (n=36,527), denosumab (n=18,336) or teriparatide (n=66,173) (Figure 5a). Figure 5b reporting odds ratios were calculated comparing adverse event frequencies of bisphosphonates, denosumab and teriparatide patients. Ranges represent 95% confidence intervals (95% CI) (see Methods). X-axis is presented in log scale.

fig 5

Figure 5: Frequencies and Reporting Odds Ratios (RORs) of Atypical Femur Fracture (AFF) adverse events in bisphosphonates, denosumab and teriparatide cohorts. Abbreviations: AFF – Atypical Femur Fracture, ROR – Reporting Odds Ratio.

When compared to denosumab, patients taking bisphosphonates had a significant increase in the frequency of AFF (1.87 [1.47, 2.37]) (Figure 6a and 6b). However, the adverse effects between the four bisphosphonates under study differed significantly. The risedronate and alendronate cohorts had significantly higher ROR values of AFF than that of denosumab (6.63 [4.82, 9.12]) and (3.03 [2.36, 3.91]) respectively (Figure 6a and 6b). The zoledronic acid cohort had a significantly lower AFF RORs when compared to denosumab, (0.29 [0.18, 0.49]) (Figure 6a and 6b). There was no significant difference in the reported frequencies of AFF in patients taking ibandronate when compared to denosumab (ROR = 0.80 [0.51, 1.28]) (Figure 6a and 6b).

Frequencies of ONJ for patients in FAERS who took bisphosphonates as a class (n=36,527), individual bisphosphonates: alendronate (n=14,682), ibandronate (n=6,065), risedronate (n=2,309), zoledronic acid (n=13,471), or denosumab (n=18,336) (Figure 6a). Figure 6b reporting odds ratios were calculated comparing adverse event frequencies of bisphosphonates and denosumab patients. Ranges represent 95% confidence intervals (95% CI) (see Methods). X-axis is presented in log scale.

fig 6

Figure 6: Frequencies and Reporting Odds Ratios (RORs) of Atypical Femur Fracture (AFF) adverse events in patients with osteoporosis taking bisphosphonates or denosumab. Abbreviations: AFF – Atypical Femur Fracture, ROR – Reporting Odds Ratio.

Females who used bisphosphonates as a class, alendronate, or risedronate had a significant increase in the frequency of AFF when compared to denosumab (1.83 [1.47, 2.44]), (3.11 [2.38, 4.10]) and (6.58 [4.70, 9.21]) respectively (Figure 7a and 7b). The zoledronic acid cohort had a significantly lower frequency of AFF when compared to denosumab (ROR=0.28 [0.17, 0.49]) (Figure 7a and 7b). The ROR value of AFF in female ibandronate patients did not meet the significance criteria when compared to denosumab since the range covered the value of 1 (0.84 [0.53, 1.35]) (Figure 7a and 7b).

Males who used bisphosphonates as a class, alendronate, or zoledronic acid had no significant difference in the AFF RORs when compared to denosumab (1.13 [0.48, 2.68]), (1.43 [0.52, 3.96]), and (0.47 [0.13, 1.81]) respectively (Figure 7c and 7d). The risedronate cohort had a significantly higher AFF ROR when compared to denosumab (6.63 [4.82, 9.12]) (Figure 7c and 7d). There were no reports of AFF in male patients taking ibandronate for osteoporosis.

Frequencies of AFF for female patients in FAERS who took bisphosphonates as a class (n=31,879), alendronate (n=12,614), ibandronate (n=5,614), risedronate (2,016), zoledronic acid (n=11,590) or denosumab (n=15,690) (Figure 7a). RORs were calculated comparing adverse event frequencies in females taking bisphosphonates or denosumab (Figure 7b). Frequencies of AFF for male patients in FAERS who took bisphosphonates as a class (n=3,303), alendronate (n=1,229), ibandronate (n=334), risedronate (n=169), zoledronic acid (n=1,571) or denosumab (n=2,009) (Figure 7c). RORs were calculated comparing adverse event frequencies males taking bisphosphonates or denosumab. Ranges represent 95% confidence intervals (95% CI) (see Methods). X-axis is presented in log scale (Figure 7d).

fig 7

Figure 7: Frequencies and Reporting Odds Ratios (RORs) of Atypical Femur Fracture (AFF) in female and male patients with osteoporosis taking bisphosphonates or denosumab. Abbreviations: AFF – Atypical Femur Fracture, ROR – Reporting Odds Ratio.

In a separate analysis we investigated the most common adverse events reported alongside AFF and ONJ and observed that: 1) AFF and ONJ co-occurrence was extremely rare and was reported only in 3 out of 18,336 denosumab reports (Supplement Table S1); 2) ONJ co-occurred primarily with dental health and procedure complications, and; 3) AFF most often co-occurred with falls and bone health related adverse events (Supplement Table S2).

Discussion

In this study we quantified the association between individual bisphosphonate use and AFF and ONJ adverse events. We also confirmed the association between bisphosphonates and denosumab exposure and the increased risk of these effects. To our knowledge this is the first study that used over 12 million reports including 230 thousand osteoporosis reports from the FDA FAERS data (between 2004 and 2019) to evaluate and compare the frequency of rare adverse events associated with the use of three common osteoporosis drug types for the treatment and prevention of osteoporosis.

The risk of ONJ was significantly higher with for both bisphosphonates as a class, and denosumab when compared to teriparatide. However, the adverse effects risk related to each of individual bisphosphonate varied dramatically. Alendronate had the highest frequency of ONJ, and ibandronate had the lowest frequency. Our findings were consistent with those from the study conducted by Zhang and colleagues [52], where they used FAERS reports from the first quarter of 2010 to the first quarter of 2014 and assessed only ibandronate and risedronate. In our study we utilized a much broader data set (2004-2019) and performed a direct pairwise comparison between alendronate, risedronate, ibandronate, zoledronic acid, and denosumab. When analyzed separately, male and female reports yielded similar results with alendronate exhibiting a nearly two-fold increase in risk of AFF.

Osteoporosis patients using bisphosphonates as a class, had higher frequency of AFF when compared to denosumab, and around a hundred-fold higher value when compared to teriparatide. However, similar to the ONJ adverse effect, this difference was not preserved when individual bisphosphonates were analyzed. Patients taking risedronate and alendronate had the highest risk of AFF, while zoledronic acid had the lowest. Our study confirmed the findings of Edwards and colleagues and other studies that showed AFF risk with bisphosphonates [53-55]. There was a significantly higher risk of AFF in females taking alendronate and risedronate, while in male patients only risedronate exhibited significant risk.

Interestingly, we observed a tentative inverse relationship of ONJ and AFF risk with frequency of administration of bisphosphonates: zoledronic acid (once a year), ibandronate (once every three months [IV], or once a month [oral]), risedronate (once a week to once a month), alendronate (once a week) [10-13]. For both side effects the trend in reporting odds ratios was similar for females and males, although in males the association was not always significant due to smaller numbers of reports.

Conclusion

In our study we observed various levels of risk of ONJ and AFF adverse effects in FAERS reports of individual bisphosphonates with respect to denosumab reports. It may be beneficial to choose zoledronic acid treatment for female patients who are at risk of AFF. In patients at risk of developing ONJ, zoledronic acid may also be the safer option. However, this consideration was restricted to only two adverse effects, further research and controlled trials are needed, and health care providers should use their professional judgment and weigh all the risks and benefits to determine the best treatment option for each specific patient.

Study Limitations

The FAERS reporting system is voluntary indicating that the number of reports available do not represent the number of actual cases and that adverse drug reaction frequencies do not represent actual population incidences. A study done by Alatawi and colleagues using FAERS to found a significant underreporting of adverse events [56]. Additionally, overreporting due to newsworthiness and legal reasons may add noise to the analysis [57,58]. Absence of comprehensive medical records and demographic variables further limits the extent of our analysis. By using the indication section in the data set, potential comorbidities were excluded, however, due to incomplete reporting, some comorbidities and concurrent medication records may be missing. Although only monotherapy reports were selected for the analysis, some concurrent and over-the-counter medications might have been underreported. That could potentially have introduced error in frequencies and reported odds ratios calculations. As with any association study, causation cannot be established based on RORs. However, analysis of over 230,000 reports provides large scale evidence for rare side effects that may go unnoticed in clinical trials or can be difficult to quantify in smaller observational studies. Despite the limitations, FAERS/AERS remains to be a unique source of population scale data used to identify and quantify rare adverse events that can affect patient safety [59].

Declarations

Funding

This work was supported by University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests

The authors have read the journal’s policy and have declared that no competing interests exist.

Ethics Approval

The study used publicly available de-identified data. Institutional Review Board requirements do not apply.

Availability of Data and Material

Data were obtained from the FDA Adverse Event Reporting System and can be accessed at https://urlzs.com/tXUaP

The authors confirm that they did not have any special access privileges to these data.

Code Availability

Standard Unix code was used for $ separated .txt file analysis.

Acknowledgement

We thank Da Shi for contributions to processing the FAERS/AERS data files, demographic analysis, and supporting the computer environment.

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fig 4

Countering Expect Despair after Release from Prison: A Mind Genomics Cartography from the ‘Outside In’

DOI: 10.31038/PSYJ.2021322

Abstract

Respondents were introduced to a hypothetical situation of an individual being released from prison. The test stimuli were vignettes comprising information about WHO the released prisoner is, WHAT the person did in prison, WHAT kind of people were in prison with the released individual, and WHAT efforts were made in prison to help the prisoner adjust after release. Respondents projected their impression of the described former prisoners, using an anchored 9-point scale, from 1=feeling hopeful to 9=feeling suicidal. When viewing the scale from the point of view of “Suicide,” two mind-sets emerged: MS1, responding to lack of preparation for release, and MS2, someone who is middle class with nothing to do in prison, surrounded by drug addicts. When viewing the scale from the point of “Hopefulness,” two other mind-sets emerge: MS3, hopeful after release and when in prison had daily schedule, and MS4, hopeful when took preparatory courses in prison. The experimental design allows the creation of a PVI, personal viewpoint identifier, to assign a person to one of each mind-set.

Background

Increasingly, we come to hear of the difficulties faced by people who, having served their sentences, are released from prison, only to find a wall of obstacles in front of them as they try to reconstruct their lives. The anguish is great, and occasionally one reads of the despair, which may lead to the use of drugs and often to suicide. The suicides are among otherwise decent people who, having served their time, are attempting to re-enter society [1-3]. We read these stories, feel saddened by them, and, at the same time, we are often fascinated by these individuals and by why they committed suicide. It is a bit of what in German might be called Schadenfreude, the interest of others in a person’s misfortune. The great sociologist, Emil Durkheim, talked about suicides, finding from his statistical analysis of the frequency of suicide, that those with a structured religious life (e.g., Catholics) showed fewer suicides than those with a less well-structured religious life (e.g., Protestants) [4].

The notion of understanding the situation which might lead to suicide prompted a discussion among the two senior authors, Ari Zoldan and Howard Moskowitz, and a separate discussion with author Arthur Kover. The issue was whether there was a “wisdom of the masses” which could inform about what details of a situation might likely be the cause for a released prisoner to commit suicide. The answers were not clear, and so the discussion led to a small Mind Genomics cartography, an attempt to understand the conditions leading to suicide (viz., despair) versus hopefulness, albeit from the ‘outside-in,’ from the response of the general population to presentation of material about released prisoners. This is called a Mind-Cart ‘cartography’.

The literature dealing with the emotions of released prisoner is extensive. Most of the literature is descriptive, dealing with the measurement of recidivism and even suicide. Issues include WHO the released prisoner is (viz., [5-7]. Other topics include the prison environment [8], the other prisoners with whom the individual socialized in prison, including violence which occurred [9,10] and the prisoner’s thoughts and preparations for release while in prison [11-16]. Finally, the literature deals with the follow-up situation and activities of the released prisoner [17], and ongoing efforts to maintain contact with the released prison to integrate the prisoner into society [18].

The literature is primarily sociological in nature, looking at the situation which exists. We propose a ‘next step,’ namely looking into how people feel about the nature of the feeling of the released prisoner, one year after release. This first paper deals with the ‘wisdom of crowds’ [19], using external respondents to read vignettes about the released prisoner, and based upon the vignette, estimate the feeling that the individual will have one year after release.

How Mind Genomics and the ‘Wisdom of the Masses’ Combine Approach the Problem?

We use the newly emerging science of Mind Genomics, a branch of experimental psychology, to understand why “suicide.” The approach, a version of “wisdom of masses,” presents the respondent with combinations of messages, descriptions of the “case,” and instructs the respondents to rate the likely outcome, adjustment to suicide. The science of Mind Genomics is appropriate to study how people think about these topics.

Mind Genomics emerged from the desire to study the experience of the “every day,” using the techniques of experimental psychology (actual experiments, conducted with the aid of computers), consumer research (focusing on the real world of experience, rather than on a situation distorted in the interests of the experiment), and experimental design (focusing on so-called within-subjects design). The topics of Mind Genomics already studied range from disease and recovery, internal war and peace, law, education, food, social distancing in time of COVID-19 , and a host of others [20,21]. The worldview of all these studies is the same: study how people make decisions with the ordinary information to which they are exposed, information known to everyone. It is the focus on the daily life, on the situations to which one pays conscious attention, the absolute ordinary, which constitutes the hallmark of Mind Genomics.

Mind Genomics follows a series of well-defined steps, starting with choice of topic, elucidation of different “granular aspects” of the topic, how people respond, and concluding with the discovery of underlying mind-sets, mental genomes, viz., fundamentally different ways that people think about the same aspects of the topic [22,23]. The later applications of Mind Genomics have been presented by [20,21].

Step 1: Select Raw Materials (Topic, Four Questions, Four Answers to Each Question)

The basis of Mind Genomics is the deconstruction of responses to mixtures of ideas, these ideas representing answers to relevant questions. Figure 1 shows the templated version. The researcher is given the form, which is structured, and comprises several screens. All the respondent must do is type in the topic at the start of the study, then type in the four questions (Figure 1, left panel), and then the four answers to each question (Figure 1, right panel).

fig 1

Figure 1: The set up-template for the Mind Genomics study, showing the input form for the four questions, and the input form for the four answers from question #2.

Table 1 shows the raw material created for the topic of feeling after being released from prison. The four questions are not engraved in stone. Rather, they are “first guesses,” aspects that can be fine-tuned or even discarded in subsequent easy and affordable iterations. The Mind Genomics experiment can be modified quickly, after the initial data have been collected, and executed once again, virtually immediately after the study materials have been updated.

Table 1: The four questions and the four answers for each question.

Question A: What kind of person is this?
A1 WHO: young inner city black woman
A2 WHO: white middle age for theft
A3 WHO: 21-year-old, second conviction for drugs
A4 WHO: 54-year-old woman convicted for drugs
Question B: What does the person do on a daily basis?
B1 ACTIVITIES: boring stay, little to do
B2 ACTIVITIES: machine shop license plates
B3 ACTIVITIES: 4 hours of forced library
B4 ACTIVITIES: rehabilitation and reeducation
Question C: what kind of people are in the prison?
C1 SITUATION IN PRISON: lower and upper middle class
C2 SITUATION: camaraderie
C3 SITUATION IN PRISON: drug addicts
C4 SITUATION IN PRISON: invisible status
Question D: What kind of links are there for a future after prison?
D1 RELEASE PREPARATION: optional courses to prepare for jobs
D2 RELEASE PREPARATION: out you go
D3 RELEASE PREPARATION: no support
D4 RELEASE PREPARATION: simply re-enter life

Step 2: Select a Rating Scale

The rating scale dictates the nature of the experiment. The rating scale is shown below. The scale deals with the likelihood of what will happen 12 months after the person is discharged from prison.

Rating question: What will happen in 12 months?

Low Anchor: Rating question 1=hopeful

High Anchor: Rating question 9=suicidal

Figure 2 two other tempates. The left panel in Figure 2 shows the orientation page. The right panel show the rating scale, including number of scale points (9), and the anchors for each scale point.

fig 2

Figure 2: The templates, for respondent instructions (left panel), and for rating scale (right panel).

Step 3: Create the Vignettes, Combinations of Elements to be Tested

The vignette, a combination of 24 elements, becomes the “stimulus” that the researcher presents, and the respondent responds by following a rating scale introduced in Step 2. The vignettes are created according to a systematically designed set of combinations, “the experimental design” [24]. The underlying experimental design for this so-called 4×4 design of Mind Genomics (4 questions, 4 answers/question) prescribes exactly 24 combinations. The combinations are of three types: combinations with one element from two questions (2-element vignette), one element from three questions (3-question vignette), or one element from four questions (4-question vignette). By design each question can contribute at most one element, but often no elements. Furthermore, each respondent evaluates a different set of combinations, permutations of the main design [25].

The rationales for the design and the permutations follow:

a. The experimental design ensures that each respondent evaluates the appropriate vignettes, designed for OLS (ordinary least squares) regression. OLS regression builds a model or an equation, of the form: Dependent Variable = k0 + k1(A1) + k2(A2) … k16(D4)

b. The systematic permutation of the design ensures that the structure of the combinations is the same for all respondents, but each respondent tests different combinations. In effect, the permuted design ensures that the Mind Genomics experiment covers many of the possible combinations. The approach of testing many combinations, each with “noise,” rather than testing a limited number of combinations with the noise averaged out through replication, represents a dramatic departure from conventional statistics and design. Conventional design suppresses noise or averages out the noise. Permuted designs accept the noise at each point but cover most of the design space, thereby allowing the underlying pattern to emerge. The best metaphor is the difference between a high resolution X- ray of a single area, with a single X- ray impression, versus the MRI, magnetic resonance imaging, which takes many pictures of the tissue from different angles, and combines the different pictures later on. Metaphorically speaking, Mind Genomics is an “MRI of the mind.”

c. In order for the rating scale to work, it must be applied to the description of a person. Only with combinations of elements is there a real, albeit sparse, description of a person and situation. The rating scale will not be meaningful when applied to each of the 16 elements, in a one-by-one fashion. There is no context in the format which presents one element at a time, despite the attractiveness of doing so. By presenting the test elements in a one-by-one fashion, one allows the respondent to alter the criterion for judgment to fit the nature of the test element being evaluated. The experimental design combines elements, forcing the respondent to maintain one criterion, and preventing “gaming” the interview.

Step 4: Define the Dependent Variables

The raw data from Mind Genomics are the ratings on the anchored 9-point scale (see Step 2), and the response time. The response time is defined as the number of seconds between the presentation of the test vignette and the rating assigned by the respondent. The response time is easily measured by the underlying computer program.

The original ratings on the 9-point scale are hard for managers to understand, despite their seeming simplicity. The typical question encountered is: “What does <rating X> mean?” “Rating X” could be a 3, a 7, or any of the numbers on the scale. As simple as the scale is, the reality in practice is that the scale has no intrinsic meaning to the manager, except at the very top or bottom.

The convention in traditional consumer research has been to divide the scale into two points, to denote NO versus YES. For these data we divide the scale two ways:

Top3: The scale is divided so that ratings of 7-9 are transformed to 100 to denote “suicide YES” (whether thoughts or expected action), and ratings of 1-6 are transformed to 0 to denote “hopefulness YES”). A small random number is added to the transformed ratings to introduce minute variability, a statistical requirement for OLS (ordinary least-squares) regression analysis. The small random number, assigned to each transformed number, ensures the necessary but vanishingly low variability in the dependent variable.

Bot3: The scale is divided so that ratings of 1-3 are transformed to 100 to denote “hopefulness YES,” and ratings of 4-9 are transformed to 0 to denote “hopefulness NO.” A random number is once again added to each transformed rating.

The Mind Genomics program, BimiLeap, measures the response time, defined as the time between the appearance of the vignette and the time that the rating is assigned. The response time is also treated as a dependent variable, but not transformed. For the analysis, the response times from vignettes 13-24 will be the only ones used for analysis. The use of data from the second half of the vignettes for response time, but the use of data from all 24 vignettes for the binary transformed variables (Top3 and Bot3), comes from the striking observation in Figure 3. The average response time drops as the respondent becomes more acquainted with the task, and more practiced. In contrast, the average rating on the 9-point scale does not change. Figure 3 shows the average values by each of the 24 positions in the experiment for the four prospective dependent variables, respectively. It is clear that there is no order dependency for the average rating, a clear decreasing function for response time, and a very “noisy,” but possibly decreasing function for both Top3 and Bot3.

fig 3

Figure 3: Average value of the four dependent variables for each of the 24 positions (test order) in the Mind Genomics experiment. Position 1 is the vignette tested in the first position, position 10, for example, is the vignette tested in the 10th position.

Step 5: Build the Model (Equation) Relating the Presence/Absence of Elements

It is the contribution of the elements to the response which constitutes the key information afforded by the Mind Genomics experiment. That contribution is provided by the coefficient of the model, relating the presence/absence of the 16 elements to the dependent variable.

The equation is estimated using the well accepted method of OLS (ordinary least-squares) regression, or so-called “curve fitting.” The analysis focused on three equations, relating to Top3, Bot3, and response time. The equation for the rating was not calculated because it is contained within the analysis of Top3 (Suicide) and Bot3 (Hopeful).

The basic equation is expressed as an additive constant (k0) and 16 coefficients (k1-k16), respectively.

Top3 = k0 + k1(A1) + k2(A2) … k16(D4)

Bot3 = k0 + k1(A1) + k2(A2) … k16(D4)

RT (Response Time ) = k1(A1) + k2(A2) … k16(D4)

The additive constant is the estimated value of the dependent variable (e.g., Top3 or Bot3) in the absence of elements. The experimental design ensured that each vignette would be comprised of 2-4 elements, meaning that the additive constant is a purely estimated parameter. The additive constant can be thought of as the baseline value of Top3 or Bot3. If the metaphor is a statue, then the additive constant is the base, viz., not part of the statue itself, but a basic, fixed contribution to the height.

Above the baseline or additive constant will be the separate contributions of the elements, given by the coefficients. The coefficients are positive (the element contributes to the the value of Top3 or Bot3), zero (no effect), or negative (the element takes away from the value of Top3 or Bot3). For the sake of clarity and to allow the patterns emerge, we will estimate the coefficients, but only show the positive or non-zero coefficients. It is the pattern of these positive coefficients which tell the “story.”

Step 6 – Results from the Total Panel

The total panel comprises all the vignettes from all the respondents. Keep in mind that the analysis generated two models, one looking at suicide (not further defined; Top3), the other looking at hopefulness (not further defined; Bot3). Again, keep in mind that we are dealing with the wisdom of the masses, viz, a guess about the behavior based upon the vignette. Yet, we surmise that an average judgment, given by many people, may provide a good sense of what people believe regarding how a recently released prisoner might feel after 12 months. Table 2 shows the positive coefficients driving either suicide/despair (Top3) or hopefulness (Bot3).

The additive constant represents the expected feeling of the person described, in the absence of any additional information. The expected proportion of responses “suicide”(ratings 7-9) in the absence of information is 24. Of course, all vignettes by design comprised 2-4 elements, so the addiive constant is a purely estimated parameter. Nonetheless, we get a sense that about a quarter of the responses will be that the person described will contemplate suicide. In contrast, for feelings of hopefulness, Table 2 suggests that 44% of the time, i.e., almost half of the responses, the person described will feel hopeful.

Table 2: Parameters of the models relating the presence/absence of the 16 elements to the thought of suicide (Top3) or hopefulness(Bot3). Strong performing elements (8 or higher) are shown in shaded cells. Only positive coefficients are shown, to reveal the patterns.

table 2

It is in the elements that we see some situations which drive the feeling of suicide. The only elements we show are positive ones because we are interested in what drives the feelings of suicide, rather than what does not drive the feeling of suicide. The two strongest elements are having been in prison with SITUATION IN PRISON: drug addicts, and an element described as RELEASE PREPARATION: no support in prison. Both of these elements have high coefficients of 11, meaning that when they are included in the description of the released person, an additional 11% of responses are that the person will fee “suicidal” (ratings 9, 8, 7). If the person leaving is a 21-year old, with a second conviction for drugs, an additional 7% feel there could be suicide behavior.

The data suggest that two strong elements are thought to drive a feel of hopefulness: RELEASE PREPARATION: optional courses to prepare for jobs, and ACTIVITIES: 4 hours of forced library. There is a sense that forcing the prisoner to do things to improve the mind should help.

Step 7: Response Time (Reflection of Degree of Engagement of Responder) as a Dependent Variable

The response time, defined as the time between the presentation of the vignette and the rating, may represent time needed to process the information. Response time is not directly under the cognitive control of an individual, who is simply reading the vignette (if that), and assigning a rating.

Figure 3 above shows the systematic decrease in the average response time. The average response time in the aggregate, by test position (postion 1 to position 24), shows a dramatic pattern which makes sense. As respondents get increasingly experienced with the task, even without feedback, their average time to read and rate the vignette decreases, at first dramatically. The response time eventually stabilizes near the end of the experiment.

Graphs similar to these appear in virtually any study, leading to the introduction of a “practice first vignette,” the response to which is discarded. In this study we discard that first vignette, which is not part of the design, measure the response times for the 24 vignettes, and build models for the total set of 24 vignettes, followed by models for the first half of th vignettes vs the second half (vignette 1-12 vs 13-24).

The deconstruction of the response time for the total vignette into the component response times is done using the same type of regression equation , but without the additive constant. The rationale for this analysis, called “forcing the model through the origin” comes from the recognition that in the absence of elements there is no response at all.

Response Time = k1(A1) + k(A2) … k16(D4) (Note: no additive constant)

Table 3 shows the coefficients for response time, first for the total set of vignettes (Vig 1-24), then for the first 12 vignettes (Vig 1-12) and finally for the last 12 vignettes (Vig. 13-24). The final column (Sec-First) shows the change in estimated response time (seconds) by element, for the total panel. The important thing to notice is the changes are not the same. There is a dramatic range.

Table 3: Response times for the 16 elements, showing the response time for the total panel over 8 second for all 24.

table 3

The response times are not highly correlated, but they are positively correlated, all except one being shorter for the second half of the 24 vignettes, and being longer for the first half of the vignettes. That element, B3, ‘ACTIVITIES: 4 hours of forced library’ is important because it becomes more engaging as the respondents are exposed to it. It may be that the message becomes increasingly meaningful with repeat exposures. It may be these types of elements which are most important to recognize. Their meaning may “sink in” over time, rather than become diluted (Figure 4).

fig 4

Figure 4: Relation between the coefficients for response time for the first vs the second half of the set.

Step 8: Create New Groups of Respondents (Mind-sets), based Upon the Patterns of Their Coefficients

A continuing hallmark finding of Mind Genomics is that people differ in the way they think. The finding is not surprising and often glossed over as a characteristic of “subjective data,” such as ratings of opinions, and certainly ratings of opinions of the Mind Genomics vignettes.

Mind Genomics studies often reveal that what seems to be a “flat” data set with few strong elements is stronger than one might believe at first glance. The mind-sets can be thought of as different patterns of interesting elements. When one group of people is interested in a set of elements, but another group is not, often the result is flat and noisy when the coefficients of the elements are plotted against each other. The plot is “noisy,” with the coefficients darting about with no pattern emerging. Such is the general problem in research when one deals with groups of people with radically different points of view towards the same topic. What could be rich veins of information, rich patterns of “color” are discarded because at first glance the general impression is a boring monochrome. Only when one looks more closely do the intricate patterns reveal themselves, patterns which otherwise intertwine, interdigitate, and produce a dull gray.

The process to uncover the mind-sets comprises simple steps, described elsewhere [26]. Here is a list of the steps:

a. Create a model for each respondent. This is possible because of the underlying experimental design, used to create the vignettes for each respondent.

b. Cluster the respondents based upon the pattern of their coefficients.

c. For clustering, use the metric (1-Pearson Correlation) as the measure of “distance” or “dissimilarity” between pairs of respondents.

d. Extract two and then three clusters, the mind-sets.

e. Create the models for all respondents in a specific cluster or mind-set. Thus the analysis creates two new models for the two-mind set solution, three new modesl for the three mind-set solution.

f. Inspect the models for interpretability, viz., do the data “tell a coherent story?”

The clustering program was run twice, first for the models for Top3 (suicide), and second for the individual models for Bot3 (hopefulness). The analysis, run twice, allows us to look at these two feelings separately, viz. treating the data anew, once from the viewpoint of feelings about suicide and once, and entirely separately, from the point of view of feelings about hopefulness.

Table 4 shows the results of two sets of cluster analyses: MS1 and MS2, based on suicide (Top3); MS3 and MS4, based on hopefulness (Bot3). Table 4 shows only the positive coefficients for each, in the interests of readability and to detect the underlying patterns. The strongest performing elements are shown in shaded cells. The “names” for the mind-sets are shown in the second row. These names were assigned by the researchers based upon the “story” which the strong performing elements appeared to provide.

Table 4: The two pairs of mind-sets, based upon clustering coefficients for suicide (Top3, left two columns) and coefficients for hopefulness (Bot3, right two columns).

table 4

Pairwise Interactions – What Situation Drives a Rating of “Suicide”

The underlying exoerimental design using Mind Genomics ensures that all of the elements are statistically independent of each other. Yet, despite that, some combinations naturally “enhance each other,” when they appear together, despite being statistically independent. The permuted design used here (Gofman & Moskowitz, 2010) allows us to discover these synergistic combinations, or more correctly, to discover how a set of elements performs when one of the elements is held constant with different options. This analysis shows the change in the performance of a set of elements when we systematically “cycle through” the elements in one question.

In order to discover these synergistic combinations we simpy divide the data for any question (e.g, WHO the person is, question A) into the five levels or strata (A=0 viz., A does not appear in the vignette; A=1 in the vignette, A=2 in the vignette, A=3 in the vignette, and A=4 in the vignette, respectively). The vignettes in each strata comprise an experimental design that can be analyzed. The value of A is held constant in the stratum. Thus, A no longer acts as a source of four independent variables (A1-A4). We are now left with 12 independent variables, B1-B4, C1-C4, and D1-D4, respectively.

Table 5 shows the coefficients which are very strong for independnt variables B1-D4, when A is “cycled through,” viz., A0 (A absent), A1, A2, A3 and A4, respectively. Only the very strong performing coefficients appear in Table 5. The analysis was done for suicide (Top3) as the dependent variable. It is clear that there are synergies between WHO the person is and the situation in prison. Of course, these are inferred by the respondent. We are relying on the ‘‘wisdom of the masses” to give us a sense of the pattern Nonetheless, the data suggest some patterns, such as the perceived synergy between a middle class released prisoner and an experience with drug addicts in prison.

Table 5: Synergistic combinations in which the coefficient for the situation is very strong. The dependent variable is Top3 (suicide).

table 5

Finding these Individuals in the Population

A key output of most Mind Genomics studies is the continuing discovery that the mind-sets do not vary in a straightforward way with the typical geo-demographics that fill the databases of people. We know a lot about the behavior of people. However, despite being able to measure their behaviors at many touchpoints and in many situations, we cannot say that we know the attitude of a person in a granular way for any topic which arises. Everyday experience suggests that people differ. Although we might hazard a guess about the way people make decisions regarding issues in a specific topic, these are guesses, not facts. Indeed, just a bit of thinking will reveal that people dramatically differ, often to the surprise of those who question them and believe they know the answer before it is given. The reason for the surprise is that how a person thinks is not related to, except in the most obvious cases, who the person is.

Table 6 below shows the distribution of mind-sets for both Top3 (suicidal) and Bot3 (hopeful). There were two mind-sets extracted for each. There is no clear relation between mind-sets in either case analysis to gender or age. Indeed, there is no clear relation between membership in segments created for suicidal vs segments created for hopeful, even though the people were the same, the ingoing data were the same, and all that differed was the way the data in the scale were treated.

Table 6: Distribution of mind-sets for Suicidal (Top3) and for Hopeful (Bot3).

 

 

MS1 (Top3) Feel worst when just sent out after finishing sentence with no contact after release

MS2 (Top3) Feel worst when recalling time in prison was spent being bored, surrounded by addicts, etc.

Total

42

19

23

Male

19 9

10

Female

23

10

13

Age 18-29

13

7

6

Age30-Plus

29

12

17

 
 

Total

MS3: (Bot) Feel hopeful when recall that prison experience was ok, fellow prisoners were middle class, time was boring but did some work

MS4 (Bot) Feel hopeful when recalling prison prepared for exit, and provided something to do to keep busy

Total

42

22

20

Male

19

9

10

Female

23

13

10

Age18-29

13

6

7

Age30-Plus

29

16

13

 
 

Total

Bot 3 MS Seg3

Bot 3 MS Seg4

Total

42

22

20

Top 3 MS1

19

12

7

Top 3 MS2

23

10

13

Unable to generalize the discoveries of Mind Genomics, our ability to understand what the mind-sets mean in terms of behavior and how they relate to mind-sets of other studies is limited. The mind-sets here can be used to understand how one thinks of the feelings of released prisoners. The results would be far stronger if the study could be administered to prisoners a year after their release or to prisoners from different socio-economic classes with the objective to assign a new individual (ex-prisoner) to one of the two mind-sets.

Recently, authors Gere and Moskowitz developed an approach to assign new people to the mind-sets discovered through Mind Genomics. The approach, called the PVI (Personal Viewpoint Identifier), uses a combination of Monte Carlo Simulation with added variability, and Decision Tree analysis. The PVI creates a set of six questions, using the elements and coefficients shown in the left part of Table 4 (mind-sets created from Top3, viz., Suicide). The table, comprising both positive and negative coefficients, is “perturbed” by added, random variability. The PVI then identifies the optimal set of six elements, taken directly from the study, the patterns of response which best reproduce the original mind-sets. The elements are presented to the new person on a 2-point scale. The pattern of responses to these six questions, based on the elements, assigns the new person to one of the two (or three) mind-sets, empirically uncovered by the study.

It should be kept in mind that the PVI works with granular data, with data used to create the vignettes in the first place. Thus, the PVI does not need to be “interpreted” by experts, who take macro segmentation of an entire topic and change the focus to a micro-topic. The PVI works automatically, without training, and is set up in minutes based upon the proper input from the study.

Figure 5 shows the PVI. The first part of the PVI (left side) contains a section to obtain demographics, allowing the researcher to understand who the respondent IS, when the PVI is completed, and so forth. Many of these questions can be suppressed for a shorter interview. The second part comprises two PVI’s, one for Suicide, and the other for Hopefulness. The respondent simply answers the 12 questions. The data are stored in a database, showing the demographics, the mind-set for each PVI (suicide, hopefulness), and the original ratings. The PVI is set up for rapid, easy deployment, and for fast answers.

The PVI for the study, the left panel shows the demographics section. The right panel shows the two PVIs comprising six questions each, one for suicide (study 1), the other for hopefulness (study 2). The PVI structure allows the researcher to randomize the order of the studies, and within a study randomize the order of the questions. There is a third option to randomize all 12 questions so that questions of hopefulness may be mixed with questions of suicide (Figure 5).

The PVI showing two panels, the left panel obtains the demographics. The right panel presents two sets of six questions each, designed to assign a person separately to the one mind-set from the first pair of mind-sets (regarding suicide), and at the same time assign a person to one mind-set from the second pair of mindsets (regarding hopefulness) (Figure 5).

Discussion and Conclusion

fig 5

Figure 5: The PVI. The left panel shows the first part, which acquires the demographics. The right panel shows the two PVI questionnaires, for the two pairs of mind-sets.

With increased experience in applying the methods of Mind Genomics, the researcher can gain valuable insights into the minds of people. In contrast to the typical approach of science, which addresses “holes” in the literature, the Mind Genomics approach proceeds in a purely inductive, exploratory way. With a Mind Genomics experiment, there is no hypothesis to be tested and either corroborated or falsified in the classical manner of science as described by Karl Popper [27]. Rather, the science here is simply observing a situation and formalizing a way to understand the different aspects of that situation [28].

What is important in this paper is the discovery of the two mind-sets for suicide thoughts and the two mind-sets for hopeful thoughts. It should be noted that rather than interviewing recently released prisoners (viz., after a year), we began this project in the spirit of “wisdom of the masses” and engaged in a gedanken or “thought” experiment.

If the approach presented here is acceptable to the scientific community as a way of understanding our perception of others, then the Mind Genomics approach provides an interesting way to introduce new topics into the world of research, topics which are appropriate for specific groups but must be first explored with the world at large. Mind Genomics offers many benefits. The results can be directly integrated into a larger database. The data is self-evident. Patterns emerge from the data. Some are meaningful and some are not. By following many iterations and fine-tuning the questions and answers that received the most responses in an earlier iteration, the researcher arrives at the truth. This is the science of psychology in its most basic form: looking at all possibilities, sorting out the emerging patterns, searching for differing mind-sets, and predicting which mind-set someone new will belong to. By repeating this methodology for dealing with questions of economics or feelings or everyday occasions, the researcher will gather the data to formulate a “wiki of the mind” and understand how mind type and behavior are related.

Acknowledgement

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

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fig 1

Paying Fare and Playing Fair on a Commuter Bus: A Mind Genomics Cartography of Topics Appropriate for Ethics

DOI: 10.31038/PSYJ.2021321

Abstract

Respondents evaluate combinations of short phrases, rating each combination as either being relevant to ethics, or not relevant to ethics. The topic was the daily behavior of a local or a commuter bus, ranging from the nature of the bus ride, what was the person taking the ride either doing or feeling, how the fare was given to the bus driver, and what happened afterwards. The deconstruction of the responses revealed two clearly different groups of people having different ‘mind-sets’ about what ethics deals with in this ordinary, quotidian situation. One group felt that ethics pertains to the nature of the daily activity, the nature of the bus ride, and the feeling of the person described. The other mind-set felt that ethics pertained to the nature of how the rider handled the payment of a fare. The Mind Genomics approach provides a deep understanding of the nature of ethics, casting light on the nature of how one thinks about the topic of ethics, rather than immediately jumping into the ethical issues themselves.

Introduction

Traditionally, ethics have been studied in the context of problems which are often puzzling. These problems, like ‘who should one kill’ in a specific situation when faced with a two-alternative situation, are designed to make people think about the issues underlying ethics. The problems are often deep, have no clear answer, and are striking, unusual in their nature. The problems force deep thinking. It is no wonder that many of these are popular ‘ignition devices’ for a course on ethics. Mind Genomics is an emerging behavioral science, which deals in the simplest format with the way people make decisions in situations with different aspects. The underlying principle for Mind Genomics is that by mixing different features of a situation, creating alternative ‘realities,’ and observing the decision a person makes, one can identify the criteria used by the person.

Traditional uses of Mind Genomics begun with issues involving economics, usually issues involving consumer purchases [1-3]. The economics aspect moves from individual micro-economic decisions encountered in marketing, and onto more complex situations such as issues of public policy and what to do [4]. Over the years, the original uses of the approaches called conjoint measurement [5] evolved from the study of issues regarding finances to issues regarding social well-being [6] and even into law [7].

Mind Genomics Meets ‘Ethics’

The study reported here, a ‘cartography’ in the language of Mind Genomics, resulted from a discussion by author HRM with a group of students in Israel. The question was ‘how do we know what is ethical in the world of everyday?’ The question was framed as an inquiry into how one goes about establishing ethics in the world of the everyday experience. People know that it is unethical to murder, and so forth. There is the sense of ethics, whether that sense is innate from natural law, or emerging from convention, and internalized through education to become normative, both in action and in thought. The issue was not those topics, but rather the nature of right and wrong in the small actions of the everyday, actions where one might say are minor ‘peccadillos’ rather than ethical issues [8,9]. In an excellent summary article ‘ethical feelings’ for behavior, including the ‘ordinary can be introduced by the simple set of paragraphs:

So, What is Ethics?

Ethics is the manner by which humans regulate individual behavior in civilized society. One might say that humans regulate behavior by laws, which is true. But laws cannot apply in every instance, and all the time. So, ethics is how we train people to behave, or teach them how they ought to behave, even if no laws apply in some circumstance (source: https://www.oocities.org/athens/acropolis/1628/A53ethic.htm). A deeper look into the world of ethics and how it could involve Mind Genomics would move from a simple research paper to books. The literature on ethics is vast, with roots stretching back to antiquity. A simple search in Google Scholar® for ‘What is relevant for ethics?’ generated 2.95 million ‘hits.’ The need to know the difference between ‘right’ and ‘wrong’ remains an important issue, and the topic of inquiries reaching into academia and the teaching of ethics [10]. The need has been stated by philosophers, but manifests itself everywhere, from daily life to the machinations and strategies of corporations projecting themselves in a favorable light [11].

Mind Genomics as a science deals with studying and understanding human responses to outside stimuli, whereas it focuses on measuring deep structure of thinking, subconscious mechanisms that go on in the mind. Since we deal with the mind processes that originate on a cellular level, a direct relationship with the genome indicates that there is genetic participation in determining a response. Being a sort of an antenna, on a molecular level DNA acts both as a receiver of information and initiator of a response [12]. Therefore, when we apply Mind Genomics to research the topic of ethics, we gain insight to the inner workings of how we differ from one another and what we perceive as relevant to ethics. The study shows two distinct mindsets that differ in the way they respond to the sixteen elements, which shall be considered as sixteen commuter bus riding situations. The beauty of this science is that it enables us to study deep mind processes by creating a simple matrix and combing textual elements.

Investigating Some ‘Ethics’ Aspects of an Everyday Behavior-paying the Fare on a Bus

We demonstrate the application of Mind Genomics cartography to the simple problem of behavior on a commuter bus, and the issue of where the incident takes place, the payment situation, and the response of the driver, and finally who the person is. The underlying notion is to look at the nature of the behavior, and to decide whether the specific behavior should be a topic for ethics or not. The results reveal a strategy by which to understand the ethics of the every-day, where the behavior is the quotidian, almost automatic behavior which only occasionally involves what we would call ‘ethics.

The focus of the Mind Genomics cartography is the nature of what a respondent considers to be in the realm of ‘ethics’, and conversely not in the realm of ‘ethics.’ In contrast to the traditional studies of ethics, which deal with general problems, Mind Genomics deals at the level of the mundane, granular, everyday experience. When the topic is ethics, the Mind Genomics approach is to present vignettes, combinations which describe different facets of everyday behavior, instruct respondents to read these vignettes, rate them, and from the data thus obtained, understand the topic almost from the ‘bottom up. Applying Mind Genomics to ethics, and following the foregoing strategy, means that the researcher defines a topic (ethics), creates four questions (aka ‘silos’), and four answers to each question (aka as ‘elements.’). The topic is ethics, the questions pertain to aspects of behavior on a commuter bus, and then different specifics of each aspect of behavior.

The important things to note concern the nature of the experiment. When we think of a commuter bus, we may think of ethics, but anything having to do with ethics is probably at the low end of importance. The issues involving what is in the realm of ethics for the mundane commuter trip are certainly far from dramatic, and perhaps require a stretch of imagination to link these behaviors we hardly notice to a topic so essentially human as ethics. Nonetheless, it is precisely the contribution of Mind Genomics to ethics, when the study pulls out ethical issues from the ordinariness of the situation, the lack of drama, and the difficulty of finding a link. We deal with the topic of the commuter bus, following the Mind Genomics process, as illustrated below:

The Mind Genomics Process

Step 1: Define the Topic, and the Raw Materials

This first step sounds easy, and in fact it begins with simply the statement of a topic. The topic must be reasonable circumscribed, limited so that it can be further investigated using specific statements.

The raw materials comprise four questions, each of which is answered by four different statements, phrases presented in the declarative form. Table 1 shows an example of the four questions, and the four answers for each question. It is important to keep in mind that the Mind Genomics process is rapid, inexpensive, and iterative, so that one need not be ‘correct’ at the start. Thus, the questions and answers in Table 1 can always be modified, improved, and resubmitted to the Mind Genomics process. There is no need to be ‘right’ on the first or indeed any iteration.

Table 1: Raw materials (four questions, and four answers for each question).

Question A: what is the act?
A1 Getting on to a local bus in your neighborhood
A2 Getting on to a shared taxi in your neighborhood
A3 Getting on to a return bus from the city to your suburb
A4 Getting into a shared taxi from city to your suburb
Question B: How do you pay?
B1 You give in a fixed amount that may be less and say that’s all I have
B2 You ask the price and pay it
B3 You negotiate the price
B4 You give a deliberately higher amount and play dumb
Question C: What is the response?
C1 The money is taken, and correct change given
C2 The money is taken, and you pay less than you should
C3 They forget to take your money and you say nothing
C4 They forget to take your money and you remind them
Question D: What are the circumstances?
D1 You feel tired from a long day
D2 it’s the weekend and your happy to see your family
D3 You have been very sick and coming from hospital
D4 You are with your young child or grandchild

Step 2: Combine the Answers into Vignettes Using an Experimental Design

Mind Genomics works by presenting combinations of answers (elements) in a simple format, a set of elements and a rating scale. The respondent reads the introduction to the study, reads the combination of elements (the vignette), and rates the combination on the defined scale. Here the scale is a 9-point scale, anchored at the top (ethical) and at the bottom (non-ethical).

Most consumer research asks the respondent to rate one element or answer at a time, in order to maintain focus on the element. The practice of Mind Genomics is the opposite, namely, to simulate real-life and to prevent ‘gaming the system’ by having the respondent think of an appropriate answer for each element. By presenting combinations of vignettes, the combinations comprising 2-4 elements, Mind Genomics forces the respondent to sift through the vignette, doing so virtually automatically, without dee thinking, and without the ability to ‘game the system’ by providing the ‘right’ answer.

The experimental design itself comprises 24 combinations, vignettes. Each element from the set of 16 appears five times in the vignettes. A vignette can comprise at most one element from a question, viz., one answer for a question, ensuring that the vignette does not feature two different and possibly mutually contradictory ideas. The topic of experimental design in research has been dealt with extensively in various books. A good review is presented by [13]. The actual interview comprised a short introduction about age, gender, and a third question dealing attitude towards the law:

What do you consider yourself to be, given the following choices:

1=Most of the time obey the rules rigidly,

2=Don’t complain if you get an advantage and don’t hurt anyone,

3=5Pragmatic honest but not stupid,

4=Not applicable.

The self-profiling questionnaire followed by an introduction to the topic, and 24 vignettes. The introduction to the topic appeared on every vignette, at the top, with the respondent reading the vignette as a single ‘thought’. Here are some common situations with transportation. Each is a vignette of a common situation. Please read it and rate the degree of ethical behavior described in the whole vignette. Let 1=totally unethical … 9=totally ethical

Step 3: Invite Respondents to Participate

The interaction is an experiment but was positioned as a ‘study’ to make the respondents feel comfortable. The respondents were members of a large panel offered for use at a fee by Luc.id, a strategic partner of Mind Genomics Associates. The respondents were sent a link, began the study, and earned ‘points’ for their participation. The respondents did not know the purpose of the study nor could the respondents ‘game’ the study. The entire study took 3-5 minutes. The BimiLeap program recorded the specific combination, the rating on the 9-point scale, and the number of seconds from the appearance of the vignette on the screen to the rating. This latter time, recorded to the nearest tenth of a second, was called the response time.

Step 4: Transform the Rating

In the world of Mind Genomics, the objective is to relate the presence/absence of the elements (viz., the 16 answers) to the ratings assigned. Users of the Mind Genomics data prefer to view the results as ‘no/yes’, rather than as points along a graded Likert Scale, such the 9-points ethics scale. To make the results easy to understand, we transform the data twice, first to create a binary scale for ‘Ethical’ and then to create a binary scale for ‘Not Ethical’’

Transformation #1: Ethics: Ratings of 7-9 → 100, Ratings of 1-6 → 0

Transformation #2 Not Ethics: Rating of 1-3 → 100, Ratings of 4 -9 → 0

To each transformed number, whether 0 or 100, we add a small random number <10-5. This prophylactic measure ensures that when we use OLS (ordinary least-squares regression), even on the data of a single respondent, that there is guaranteed to be variation in the dependent variable. We also create a new variable, response time, which was defined above as the number of seconds, to the nearest tenth of second, elapsing between the presentation of the vignette and the response.

The data matrix emerging from the experiment and the transformation comprises the following:

  1. Each row corresponds to a respondent and a vignette.
  2. Each row corresponds to a particular variable, as follows:

a.  Respondent Identification Number

b.  Test order (1-24)

c.  16 columns, one column for each of the 16 elements or answers.

d.  A cell for the 16 elements is ‘0’ when the element does not appear in the vignette, and ‘1’ when the element appears in the vignette. By design each vignette comprises 2-4 elements, at most one element or answer for a question. Thus majority of numbers in a row for the 16 columns is 0, and the minority is 1.

e.  The actual rating originally assigned by the respondent.

f.  The actual response time.

g.  The Transformed value: For Ethics

h.  The transformed value: Not for Ethics

i.  A code showing the specific questions in the vignette. There are 11 different combinations of elements that can be made with 2-4 different sources or questions (Table 1). These range from AB (answer or element from question A, answer from question B), all the way to ABCD (one answer or element from questions A, B, C, D).

Step 4: Analyze the Data to Uncover Three Mind-sets, and Create the Four Models (Total, Mind-sets)

The matrix is now set up for OLS (ordinary least-squares) regression, both at the level of the individual respondent, and at the group level. OLS regression generates a simple equation of the form:

Rating or Transformed Rating = k0 + k1A1+ k2A2 … k16A16.

For the measurement of response time, the equation is almost the same, but without the additive constant, viz., Response Time = k1A1 + k2A2 … k16A16.

The equation allows us to trace the contribution of each element to either the rating, the response time, or the transformed rating. The regression analyses, for Total Panel or for individuals, will be done primarily for the dependent variable of ethical (ratings of 1-6 transformed to 0; ratings of 7-9 transformed to 100). The additive constant is the estimated value of the dependent variable (e.g., binary transform of Not Ethical), in the absence of any elements. The additive constant is a strictly estimated parameter but gives a sense of the predisposition of the respondent to assign the rating, Thus, for the transformed variable ‘Ethical’, an additive constant of 48 means that 48% of the ratings are be 7-9 in the absence of elements. The additive constant gauges the predisposition of a group to judge harshly (low additive constant for Ethical) or judge mildly (high additive constant for ethical).

The regression analysis can be done at the level of the individuals to general 103 individual equations. The vignettes for each respondent allow for the creation of a valid equation, because the vignettes were created by an experimental design, complete on an individual-by-individual basis. The design was permuted to create different combinations, but the same mathematical structure was maintained, underlying the specific permutation for each respondent [14]. One can imagine now a matrix of 17 columns, an additive constant and 16 coefficients. The matrix comprises 103 rows, one per respondent. A separate statistical analysis called the cluster analysis [15] divides the 103 respondents into either two or three groups, based upon the dissimilarity of the patterns of 16 coefficients.

For this study, the clustering generated three different groups, called mindsets MSA, MSB, and MSC, respectively. We do not know the names of these mind-sets. We just know that respondents in the same mind-set show similar patterns of the 16 coefficients. (The additive constant is discarded). Mind-sets A and B were similar to each other, sharing a number of strong performing elements, and were thus combined into one new mind-set, MS1. Mind-set C became MS2. The final analysis creates three equations, one for Total Panel, and one model each for the two mind-sets. It is important to keep in mind that often mind-sets of interest must first emerge, be kept separate, and the remaining mind-sets recombined. Thus Mind-Set 2 did not emerge when two mind-sets were extracted. Mind-Set 2 emerged only when three mind-sets are extracted.

Step 5: Post the Coefficients in a Way Which Allows the Mind-sets to Emerge

Table 2 shows the positive coefficients of the Total Panel and of the two mind-sets. The table is sorted to show which elements perform very strongly (shaded). A coefficient of +8 or higher corresponds to ay strong performing element with an expected value for the coefficient around 2.0 or higher. The coefficients of 0 or lower are not shown because they add no insight.

Table 2: Models for Ethics (viz., involves ethics) for Total Panel and two final mind-sets).

table 2

The additive constant for the Total Panel is 48, meaning that in the absence of any information, we expect 48% of the responses to be 7-9, defined as ‘Ethical’ in the mind of the respondent. MS2 is slightly more generous, with 53% of the ratings 7-9, whereas MS3 is less generous, with 40% of the ratings 7-9. Beyond the additive constant, it is the pattern of coefficients which tells us the difference between groups in terms of what they feel to be ‘Ethical’. MS1 feels that ethical behavior is the behavior of the ordinary, the routine activities of the every-day. Ethical behavior is what normal people do.

MS2 feels that ethical behavior is an interchange, a decision to do something. Ethical behavior has nothing to do with daily routine behavior, but rather has to do with volitional behavior, where there are gain and loss involved.

We can now look at the same data and mind-sets, but from the viewpoint of what constitutes ‘non ethical behavior.’ Not ethical behavior may either be ‘unethical behavior’, or more likely behavior that has nothing to do with ethics. Mind-Set 1 may feel that D2 is the only element which does not relate to ethics. Mind-Set 2 may feel that going somewhere is something which does not involve ethics. Recall that for them, ethics were involved in volitional behavior with money.

The important thing here is that the respondents have a sense of what they feel ‘involves ethics.’ Table 3 shows that they have an equivalent and complementary feeling of what does involve ethics.

Table 3: Models for Not Ethics (viz., does not involve ethics) for Total Panel and two mind-sets.

table 3

Step 6: Effect of Repeated Evaluations on Ratings

The permuted experimental design ensures that each respondent evaluates a unique set of vignettes. Thus, across the set of 103 respondents and 24 vignettes per respondent we have 2472 combinations. Often the issue is raised that during the evaluation the respondent may lose interest, and simply assign random numbers. If that is the case, we might see a decrease in the variation of average ratings as the respondent presses the same number to finish the task.

Figure 1 shows two sets of plots. The four left plots show the average response times, ratings, and transformed binary values for Mind-Set 1, the group which felt that the ‘everyday’ actions involved ethics. The four right plots show the average response times and ratings for Mind-Set 2, which felt that ethics are involved in the volitional handling of money. In this study both mind-sets MS1 and MS2 show similar patterns of decreasing response times through the entire evaluation of 24 vignettes.

fig 1

Figure 1: How the average response time, rating, and value for Ethical and Not Ethical change with repeated exposure in an experiment. Each point represents the average rating for all vignettes evaluated in the position. The left panel shows the patterns Mind-Set 1. The right panel shows the pattern for Mind-Set 2 the more stringent mind-set.

MS1 and MS2 differed in what they felt to be ethical. MS1 (ethics deals with the every-day) became more lenient as they proceeded, feeling more of the element were ‘ethical’ as they proceeded through the evaluation. In contrast, as the experiment proceeds, there is no effect on judgments of ‘ethical’ by MS2 (ethics deals with volitional situations with gain and loss).

Interactions among Variables

The data from the clustering suggests two mind-sets, MS1 focusing on ethics being relevant to the everyday activities, and MS2 focusing on ethics being relevant to the nature of financial transactions under a person’s control. The final issue for this paper is to determine the degree to which the involvement of ethics with the everyday (Mind Set 1) or with financial transactions (Mind Set 2) can be intensified or in contrast, can be attenuated, by specific external factors. We have already identified the mind-sets by the pattern of their coefficients. It is the pattern which defined the mind-sets.

Recent efforts by author Moskowitz have shown that the strategy of permuted design permits a deeper understand of the mind of the respondent by revealing the effect of one element on another, so-called scenario analysis [1]. That is, through stratification of the data, and subsequent OLS statistics, on a stratum-by-stratum basis, one can quickly see how on type of element can influence how you feel about the involvement of a topic in ethics. Put in simpler terms, Mind Genomics allows us to answer questions such as: ‘We know that you feel an everyday activity, such as A1, Getting on to a local bus in your neighborhood, is an elements where ethics is relevant. A new question is the degree to which other elements from other questions, such as D (what you are doing, how you are feeling) drive the involvement of ethics of element A1. That is, can one element affect the response to another element in the same vignette, or are the elements evaluated totally separately?

To answer the foregoing question, viz., interaction of pairs of elements, the analysis separates the full data set into a pair of datasets, each with five matching strata. The data are divided first by the mind-set to which the respondent has been assigned. This division creates two databases, that will be analyzed separately, but in parallel. For each of the two databases one per mind-set, we create five strata, each stratum defined by the value of the element from silo or question D (who the respondent is, or how the respondent feels). There are five values of D (D=0, absent …. D-4). We then run five OLS regression, with the independent variables being A1-C4 (12 predictor, not 16), and the dependent variable being Ethical (viz., appropriate for ethics). Tables 4 and 5 shows the summary data, viz., the additive constant, and the positive coefficients for elements A1-C4.

Interaction of Feelings (Silo D) with Remaining Elements among Mind-Set1 (Ethics = Daily Living)

We begin with the value of the additive constant across D=0 to D=5. Table 4 shows the coefficients for A1-C4. The columns are sorted by incremental value of the additive constant, the measure of basic relevance for ethics. When the specific circumstance of the situation is absent (D=0), the additive constant is high, 56. We should not be surprised. Mind-Set 1 reacts as if all behavior of whatever type is relevant for ethics.

Table 4: How the interaction of elements from Question D (circumstances) with other elements drive the perception of ‘ethical’ (viz., involves ethics) drives responses. Data from Mind-Set 1.

table 4

With element D3 as the constant (hospital), the basic relevance for ethics drops 40 points, from 56 to 16. Again, this makes sense because Mind-Set 1 focuses on the very ordinary, and D3 is an unusual, and not a daily occurrence. At the same time, elements A1-A4 reemerge as important, which is not surprising in light of the very low additive constant. With element D4 as the constant (grandchildren), the basic relevance increases from the low of 16 to the value 26. Having grandchildren is also not a daily occurrence. The elements from silo A, daily commuter activities, no longer are drivers of ethics.

With element D1 and D2, tired and weekend, the more normal events of oneself, the additive increases. The behavior is every-day, no excuses, and the focus goes back to the absolute ordinariness of life. It is clear that for Mind-Set 1, ethics concern the everyday. What is important is the ability for Mind Genomics to discover this organizing principle with a simple study, but a study whose data structure allows this discover through studies of interactions, of scenarios produced by holding one element constant.

Interaction of Feelings (Silo D) with Remaining Elements among Mind-Set2 (Ethics = Financial Behavior)

When we look at the same analysis, this time from the point of view of data provided by Mind-Set 2, with focus on ethics involving control over money, we see a similar pattern, but the numbers differ. The absence of circumstances (D=0) generates an additive constant of 34. This makes sense because for Mind-Set 2 ethics is about something under one’s control, not about the world of the everyday, with everything relevant for ethics, as it is for Mind-Set 1. It is when the elements involve money, elements B1-B4, that we see the feeling that the topic is relevant for ethics. Furthermore, the coefficients are extraordinarily high and most of them are focused on elements from both Question B and Question C, the two questions dealing with money.

Table 5: How the interaction of elements from Question D (circumstances) with other elements drive the perception of ‘ethical’ (viz., involves ethics) drives responses. Data from Mind-Set 2.

table 5

Practical Applications – Who is in these Mindsets, and How can They be Discovered?

We move now to the final analysis of the data, namely the discovery of who these people are, in terms of gender and age, and in terms of how they think of themselves. We finish with a way to discover these individuals in the population at large, viz., a way to begin to merge sociology, psychology, marketing, and ethics into what might be called the Mind Genomics of Ethical Inquiry, or some similar name. Table 6 shows the distribution of the 103 respondents into the two mind-sets. It is clear that the mind-sets transcend the common ways of describing oneself (gender, age), and a prima-facie way of describing one’s ethics attitude during daily life.

Table 6: Distribution of the total panel and the two ethics mind-sets by gender, age, and self-described ethics.

Total

MS1

Ethics=Every day

MS2

Ethics=Financial

Total

103

68

35

Gender
Male

47

33

14

Female

56

35

21

Age
Age 14-25

26

18

8

Age 26-59

56

37

19

Age 60+

18

11

7

How do you consider yourself?
1=Most of the time obey the rules rigidly

43

29

14

2=Don’t complain if you get an advantage and don’t hurt anyone,

20

14

6

3=Pragmatic, honest but not stupid,

34

20

14

4=Not applicable

6

5

1

The Personal Viewpoint Identifier (PVI) uses the created mind-sets and their coefficients. The aim of the PVI is to find those elements that have the highest discriminatory power on the mind-sets. This means that it looks for the elements that are the most different among the mind-sets. In order to do so, so-called distance metrics are used which calculate the mathematical distances between the mind-sets for each element. The six most discriminatory elements are then chosen for the PVI and presented to the participants. Based on the original coefficients, the PVI can classify newly recruited participants into existing mind-sets. This way new participants do not need to complete the whole BimiLeap® study but need to answer six short (binary) questions. That way assignment of new participants is fast and immediately done. The PVI is presented by Figure 2, and the mind-set feedback of the PVI is presented by Figure 3. After completing the questionnaire of Figure 2 the results is immediately presented to the participant. There is room for different videos or links, which can therefore be suggested based on the mind-set memberships.

fig 2

Figure 2: Personal viewpoint identifier created using the given study. Participants are asked to answer the binary scale as soon as they can.

fig 3

Figure 3: Mind-set feedback of the personal viewpoint identifier.

The PVI created for this specific study is available here:

https://www.pvi360.com/TypingToolPage.aspx?projectid=2292&userid=2008

Discussion and Conclusion

The literature of philosophy comprises an inordinate number of papers on problems touched by the issue of ethics. Scarcely any generation can be found which did not have philosophers who focused on ethics as part of the great questions. Attempting to locate this Mind Genomics cartography in the vast ocean of ethics and philosophy would be a meaningless exercise. Rather than that, this discussion might be a good place to consider the potential of a Mind Genomics effort to quantify ethics, at least in simple, everyday matters.

It is clear from the unexpected results, viz., that people judged the vignette in terms of relevance for ethics, that we are dealing with two different aspects in this Mind Genomics cartography. The first, the goal that was not achieved, is the effort to have people judge good versus bad. That failed, perhaps because in a vignette of good versus bad the story must be clearer. There must be something which has gone wrong and is to be put aright by justice. When that is missing, the obvious right versus wrong, it may be difficult to think about the fit of the topic into the world of ethics. There is nothing to link the daily, ordinary, quotidian to what the person thinks about ‘ethics.’ In such a case the respondents are left to their own devices. Those belonging to Mind-Set 1 perceive the entire situation as relevant for ethics. Those belonging to Mind-Set 2 revert to issues where there can be wrongdoing, viz., the payment of money by the passenger, where it is possible to ‘cheat’ the bus driver. It is that situation which calls forth the relevance of ethics, at least to Mind-Set 2.

What may be the most important contribution of this paper is the method of Mind Genomics, and specifically the ‘scenario analysis’ to reveal the deep structure of thinking. Mind Genomics already can lay claim to being able to metricize thought. These data suggest the next level, to quantify interactions, and by so doing clarify the underlying structure of thinking, through simple experiments, done anywhere, and dealing with virtually anything where decisions by people are relevant.

Acknowledgment

AG thanks the support of the Premium Postdoctoral Researcher Program.

References

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  15. Dubes R, Jain AK (1980) clustering methodologies in exploratory data analysis. Advances in Computers 19: 113-228.
fig 1

Nutrient Flow in an Integrated Rabbit–Fish–Rice System in Rwanda

DOI: 10.31038/AFS.2021324

Abstract

An analysis of nutrient flow, based on nitrogen (N) and phosphorous (P), was conducted on an integrated rabbit–fish–rice system (IRFR) system at the Rwasave Fish Farming Station (National University of Rwanda). Rabbits, stocked at 12 per are (1200 rabbits.ha-1) of pond, were reared over fishponds stocked with one and three male tilapia (Oreochromis niloticus) per m2 for pond treatments PT1 and PT2. Effluent fertilised by the rabbits was drawn away from the ponds by pipes installed at the bottom of the ponds to irrigate rice (Oryza sativa L., variety Yuni Yin4) fields. There were six 400 m2 ponds and nine 90 m2 rice fields; three of the latter were irrigated by canal water and fertilised by NPK (200 kg.ha-1.crop-1, 2 applications; 100 kg.ha-1.crop-1, one application).

The results showed that rabbit droppings supplied about 27% N and 79% P of the total N and P inputs, fertilising the ponds at a rate of 3.98 kg N and 1.94 kg P.ha-1.d-1. The fish recovered 18.5‑7.6% N and 16.9-34.3% P of the total nitrogen (TN) and total phosphorus (TP) inputs. All water quality variables remained within good limits for tilapia aquaculture and nutrient distribution was not dependent on fish density. Large amounts of N and P accumulated in the water, sediment, and effluent fertilised rice fields at a higher rate (118.5 kg N and 27.2 kg P.ha-1.d-1) than that of inorganic fertilizers, resulting in a slightly higher rice yield than that induced by NPK and urea.

Tilapia effluent was thus able to substitute inorganic fertilisers completely, allowing savings to the farmers, and showing its potential as a fertiliser for fish and crop production rather than waste to be discharged, polluting the environment by its solids and organic matter component. Further studies involving a thorough analysis of nutrients lost and diversified uses of the nutrient-rich effluent are needed.

Keywords

Integrated aquaculture-agriculture system, Nutrient-rich effluent, Rabbit-fish-rice system, Earthen ponds

Introduction

During recent years, aquaculture has developed worldwide for the purpose of addressing food insecurity and income generation. In aquaculture, ponds are dynamic ecological systems that continuously process and remove large quantities of nutrients and organic material [1]. This has led to large quantities of pond nutrients (total solids and organic matter) being discharged, generally into natural water bodies, where they constitute a major source of water pollution, especially in semi-intensive and intensive aquaculture systems in countries where farmers lack effluent management techniques.

Earlier aquaculture enterprises are either extensive or semi-intensive fish farms, integrated to agriculture (crop and/or livestock) or not (that is stand-alone enterprises). The later are intensive systems or recirculated aquaculture systems (RAS) which, when operating at larger scale, are risky ventures and are not suitable for resource-poor farmers in developing countries [2]. They require formulated fish feeds and operate using high level energy, and high investments. Subsequent to that, these systems cause high risks including water quality deterioration through accumulation of nutrients in water and pond bottom soil, diseases, low profit margin, and lead to impacts such as pollution, environmental destruction, and reliance on pelleted feeds [3]. Extensive and semi-intensives aquaculture rely on fertilsation and use crop by-products for supplements to fish feeds. These are often Integrated agriculture-aquaculture (IAA), less risky systems because they benefit from synegisms from constituent enterprises, have a diversity in produce and environmental soundness [4,5].

The nutrient budget of fish ponds in conventional aquaculture explains that only small portions of inputs are recovered in fish biomass and in water columns, with the largest amounts lost in pond bottom mud [6-8]. During fish harvest by the draining of the ponds, nutrients in the upper layer of mud are carried away in the effluent and released into rivers. The most important nutrient in fertilised fish ponds are N and P which, in key concentrations, are limiting for phytoplankton growth. N and P, in intensive aquaculture systems are also reported the two main pollutants of water [9,10].

The feeding and fertilisation of fish ponds, with fish feed and fertilisers always result in the accumulation of nutrients in the form of fish waste and other organic matter. In this regard, observations made of channel catfish (Ictalurus punctatus) and hybrid catfish (C. macrocephalus x C. gariepinus) ponds, reported an increase of most water quality variables, including nutrients, total solids, organic matter, and a high 5-day biochemical oxygen demand in the remaining 25% of effluent when fish ponds are being drained [11-13]. This last part of pond effluent is potentially harmful to the environment as it often contains more than 50% of the total load of nutrients [14], 35.5% TN and 10.4% TP [15].

However, the aquaculture wastewater, because of its load of nutrients, could be seen as a potential fertiliser for fish farming and agriculture production [16] more generally in integrated agriculture-aquaculture (IAA) systems [2,17] rather than a waste to be discharged and to pollute water bodies (that is, the environment) by solids and organic matter. According to [2,4,18], IAA-farming is characterized by the recycling of nutrients between the farm components and this system allows the intensification of production and income generation while reducing environmental impact [17]. Tropical integrated pond systems are reputed to retain nutrients to a high degree as the latter are re-used by primary and secondary producers, making the system a better nutrient converter than the recirculation aquaculture systems [19].

In the current study, nutrient-rich wastes were dropped directly into fishponds from grass-fed rabbits and pond wastewater (that is, fertilised effluent) was then used as fertiliser for irrigated rice. The flow of bio-resources and nutrients throughout the rabbit-tilapia (O. niloticus)-rice integrated system was investigated, with the rabbits as the major entry point for nutrients for the system [20]. The purpose of this study was to identify the flow of nutrient by quantifying the mass flow of N and P nutrients by using the mass balance approach, assuming that IAA farming allows the recycling of nutrients between farm components.

Materials and Methods

Site and Experimental Arrangement

The present study was carried out at the Rwasave Fish Culture Research Station (SPIR) of the National University of Rwanda (geographic co-ordinates 02° 36’ 10’’ S and 29° 45’ 25’’ E and elevation about 1,625 m above sea level). The University is at Butare in the Southern Province of the Republic of Rwanda.

Figure 1 is a detailed diagramme of the agriculture system implemented at the SPIR combined with an annotated photograph. The experiment used three different living organisms, namely rabbits (Oryctolagus sp.), fish (Oreochromis niloticus L.), and rice (Oryza sativa, var Yuni Yin4); these were all farmed as part of a full IAA system.

fig 1

Figure 1: A profile of the experimental rabbit-fish–rice integrated system at the Rwasave Fish Culture Research Station. The connections between the rabbit hutch, the fish pond, and the rice field are demonstrated. The pond is here viewed lengthwise.

Rabbit Housing

Rabbit hutches were built and placed over the fishponds to allow all rabbit droppings to fall straight into their respective fishponds. Each hutch was divided into four cages, each 0.7-1 m in height with a 1 m2 wire mesh floor. Three hutches were installed over each fish pond of 4 ares (400 m2). The rabbits were placed in their hutches one week before the ponds were stocked with fish and two weeks before the rice was transplanted into the adjoining fields. The rabbits were a local strain of the Oryctologus sp. genus.

(1200 rabbits per hectare) of pond. The mean live weight of each rabbit was 600-800 g. The rabbits were fed with cut grass, brought in from the pond dykes and the station surrounds. Rabbit health was attended to: the only disease that was frequently observed was rabbit gall, and this was treated by subcutaneous injections of ivermectin and sometimes by skin application of motor or crankcase oil.

Fish Ponds and Rice Fields

Before the experiment began, the fishponds were drained, dredged, and dried to minimise any possible effect of prior use. The inlet pipes were blocked by a fine mesh net to avoid wild aquatic species, such as frogs, molluscs, and wild fish, being carried into the pond by the flow of water in the canals that connected the ponds to the Rwabuye River.

Each fishpond was connected to a 90 m2 (9 m x 10 m) rice field by a PVC outlet pipe, installed about 10 cm from the bottom of the pond for the irrigation of the rice fields (Figure 1). Two small PVC pipes, perforated along their length (8 m), were installed at a depth of 40 cm in each of the rice fields to drain the pond water after it had seeped through the rice field soil.

The experiment commenced on 24 August 2009, on the day the rice was transplanted. This was two weeks after the rabbit hutches were stocked and the ponds filled with water. The experiment ended on 25 January 2010, the day the rice was harvested.

Experimental Management

The principle purpose of the experiment was to use rabbit droppings to fertilise fish ponds, thereby producing well-grown fish as well as fertilised pond water (effluent) that could then be used to irrigate rice fields; this would simultaneously reduce the discharge of nutrients from the fish culture ponds into the environment.

The experiment consisted of two treatments in a completely randomised design with three replicates [21]. Hand-sexed, monosexual juvenile male Nile tilapia (Oreochromis niloticus L.) were used for their grow-out phase. The six fishponds were each connected to their own rice field of 90 m2. The experiment was then conducted in six fish ponds of four ares (400 m2) each and in nine rice fields of 90 m2 (9 m x 10 m) each. The following treatments took place in the fishponds:

  • -Pond treatment 1 (PT1): three of the six fishponds were stocked with one fish per m2 and were fertilised with the droppings from 1,200 rabbits per hectare of pond.
  • Pond treatment 2 (PT2): three of the six fishponds were stocked with three fish per m2 and were also fertilised by dropping from 1,200 rabbits per hectare of pond.
  • With regard to the rice, the following three treatments took place:
  • Rice treatment 1 (RT1): three of the nine rice fields were fertilised by chemical fertilisers (NPK: 17:17:17 and urea 45%-N).
  • Rice treatment 2 (RT2): three of the nine rice fields were fertilised by the effluent of the fishponds stocked with 1 fish per m2 (see PT1).
  • Rice treatment 3 (RT3): three of the nine rice fields were fertilised by the effluent from the fishponds stocked with three fish per m2 (see PT2).

Dynamic of Nutrients in the Rabbit-Fish-Rice Integrated System

Composition of Rabbit Droppings and Rabbit Feed

Every two weeks, a 24-hour cycle collection of droppings (both rabbit dung and urine) was conducted. The dung, taken from under one cage lodging four rabbits, was collected twice a day, at 07 h and 16 h for night and day excreted amounts respectively. All overnight excretion, both dung and urine, was collected at 07 h. Urine excreted during the day was collected, and the volume recorded, every two hours during the day in order to minimise loss through evaporation; subsequently, it was poured back into the fishpond.

The biochemical composition of the droppings was determined by the laboratory of the Animal Science and Poultry Department, University of KwaZulu-Natal. The analysis determined the concentration of N, P, Ca, gross energy, fibres, fat, ash, and moisture using the ALASA method for feed and plants detailed [22]. The same analysis was carried out for the composition of the rabbit forage, the rabbit pellets, fish carcasses, and rice at harvest. N was determined on a LECO TruSpec Nitrogen Analyser according to Official Method 990-03 and expressed as percentage protein [22].

Water Quality in Fish Ponds

Water quality parameters, including dissolved oxygen, water temperature, pH, and electrical conductivity, were monitored on a daily basis, twice per day, using appropriate manual probes.

Chlorophyll a was determined after filtrating water on Whatman paper microfibre GF/C (retention: 1.2 µm; Ø47 mm) and was analysed using the acetone extraction method [23].

Pond water nutrients, including N and P forms, were analysed from a sample collected fortnightly. A one litre sub-sample was filtered through Whatman filter paper and kept in the fridge for later laboratory analysis. Another litre of non-filtered water was analysed for TN and TP. TN was analysed using the Kjeldhal method (Blume, 1966) and adapted by [24]; TP was determined after hydrolysis into ortho-phosphates by persulfate digestion [25], thereafter with the colorimetric method. Ortho-phosphate analysis was carried out on filtered water following the ascorbic acid method [23]. Inorganic N, NH4-N (mg/l) and NO2-N (mg/l), was determined by the colorimetric method, while NO3-N was analysed using the cadmium reduction method [26].

Water Seeping through Rice Field Soil

A one-litre sample of seepage water was collected at the drains (perforated PVC tubes) that had been installed at a depth of 50 cm under the rice field. The sample was a mixture of water collected from the two drains installed in each. One half of the sample (that is, 500 ml) was filtered for NH4-N, NO2-N, NO3-N, and PO4-P analysis; the second half was not filtered for TN and TP dosage. Nutrient analysis was done using the same procedures as described above for the pond water nutrients.

Nutrient Analysis in Soil Samples

The analysis parameters used for the soil samples that were collected at the start, the midterm (90 days after transplanting DAT), and the end (153 days DAT) of the experiment were TN, nitrates (NO3-N), ammonia (NH4-N), TP, and phosphates (PO4-P). The soil samples were collected using a soil auger along a “double S” trajectory in the fish pond and a “W” trajectory in the rice field. Samples were taken from a mixture of eight clumps of soil both for fishponds and rice fields.

Soil pH was measured by the electrometric method in a soil-solvent suspension, and cation exchange capacity (CEC) was analysed on a saturated soil as detailed in IITA (1975, adapted by [24]. The TN was analysed using the Kjeldahl method according to INEAC (1959), adapted by [24], and NO4-N ammonium and NO3-N nitrates from soil were determined according to the method detailed by McKeague (1978), adapted by [24]. The TP in the pond sediment and rice field soil was analysed using the spectrometric methods detailed [27], and the PO4-P was determined by extraction followed by the blue-colorimetric method set out [28].

Statistical Analysis

The mean values were compared using a two-way analysis of variance (ANOVA II) for parameters changing over time, especially for water and soil quality. Significant differences among the treatments as shown by ANOVA were further tested using the least significant differences of means at a 5% level (LSD0.05). Possible relationships between the parameters were highlighted through regressions and correlations analysis using GenStat statistical software (GenStat12.1 Ed®, 2009 – VSN International Ltd), which was also used for ANOVA.

Results

Rabbit Nutrition, Excretion of Droppings and Discharge of Nutrients

Rabbits were fed forage ad libitum but formulated pellets were supplied only during the first month to supplement the ration in order to help the rabbits adapt to the new environment. The bromatological composition of forage, as well as that for rabbit droppings (both for rabbit fed forages or formulated pellets, is detailed in Table 1.

Table 1: Chemical composition of the rabbit forage, droppings from rabbits fed forage and rabbits fed pellets, highlighting the contribution of the rabbits to the integrated rabbit-fish-rice system. (N: nitrogen, P: phosphorus, K: potassium, Prot: crude proteins, G.E: gross energy, Ca: Calcium).

Items

Amount

Chemical composition
N (%) P (%) K (%) Prot. (%) Fibre (%) Ash (%) Moist. (%) Fat (%) Ca (%)

 G.E(MJ.kg-1)

Rabbit forage (kg/12 rabbits/d)

5

2.4 0.22 1.94 14.97 21.73 12.67 8.17 2.85 1.24

17.01

Rabbit pellets (kg/12 rabbits/d)

6

2.91 0.86 18.19 13.11 9.81 10.05 9.15 0.88

15.45

Rabbit dung (fed forage) (kg/are of pond/d)

0.60±0.1

1.57 0.62 0.38 9.82 33.84 13.63 8.1 4.56 1.43

17.78

Rabbit dung (fed pellet)

 —

1.71 0.34  — 10.71 35.04 10.85 8.2 3.11 0.76

17.48

жRabbit urine (l/are of pond/d)

1.36±0.3

2.17 1.16

 —

Rice straw

1.48

0.31 9.23 28.22 15.21 1.43 0.36

15.45

Harvested rice grain

1.56

0.16 0.09

Havested Fish

9.79

4.35 1.04

 —

жChemical composition [29]; data not available.

The average amount of dung ranged from 0.44 to 0.85 kg.a-1.d-1, and the average amount of urine ranged from 0.86 to 1.69 l.a-1.d-1. These wastes fluctuated widely over the rearing time, and no significant difference was found between the amounts of droppings (P<0.001) of the various treatments being voided into the fish ponds. Rabbit dung was very rich in basic nutrients for plankton development (Table 1). Rabbit wastes were composed of 1.57 or 1.71% N and 0.62 or 0.34% P content when rabbits were fed grass or formulated pellets respectively. The rabbit urine might be an important source of nutrients in view of its composition: 2.17 % and 1.15 % N and P respectively. Rabbit waste was the major source of organic nutrient in the current IAA, providing about 505.10 kg TN and 245.87 kg TP to fish ponds during the 127 days of pond fertilisation monitoring. The largest amounts of TN (1365 kg) and of TP (65 kg) were sourced from the canal water used to refill the pond during the culture period. However, the waste weight increased significantly in time (P=0.02) with increasing rabbit weight.

The present study identified a good rabbit growth with a daily weight gain of 8.0 g/day while the mean weight changed from 821.03 to 1362.7 g with a survival rate of 85.4%.

Fish and Rice Yields

In treatments TP1 and TP2 (1 and 3 fish.m-2), total fish yield was 953 and 1939 kg.ha-1 respectively. Fish mean weight of 104.3 ± 4.2 and 70.7 ± 1.6 g.fish-1 was obtained in TP1 and TP2 respectively. Recorded rice yields were 5.79, 5.44, and 5.87 t.ha-1 in RT1, RT2, and RT3 respectively and rice straw biomass was 10.79, 9.97, and 9.70 t.ha-1. The fish and rice content in N and P nutrients is presented in Table 1.

Pond Water Quality

Table 2 presents the mean and standard error for listed water quality parameters and the major nutrients which characterised the pond water. The overall temperatures that were recorded ranged from 20.4 to 29.9°C and the pH ranged from 6.5 to 8.4. Total alkalinity ranged from 40 to 120 mg CaCO3 l-1 in the ponds undergoing the range of treatments. All the parameters of the water quality remained within acceptable limits for pond aquaculture throughout the duration of the experiment. The temperature, DO, pH, and total alkalinity values did not differ significantly between treatments, but the DO, the pH, and the temperature recorded had significantly higher values (P<0.05) in the afternoon than observed at dawn within the same treatment (Table 2).

Secchi disk transparency was significantly higher (P<0.05) in the ponds stocked with one fish/m2 than in those stocked with three fish/m2.

The daily primary productivity ranged from 0.7 to 2.9 g C/m2/d for PT1 and from 1.1 to 2.8 g C/m2/d for PT2, with no significant difference (P<0.05) between treatments, whereas the chlorophyll a concentrations were significantly higher in PT2 than those in PT1 (P = 0.002, Table 2). Regarding the nutrient concentrations in the pond water, there appeared to be no accumulation of inorganic N (ammonia, nitrites, and nitrates) as toxic levels were not reached in any of the treatments (Table 2). There was no significant difference between the treatments for all nutrients, except for the available P, for which the phosphate concentrations in PT2 were significantly higher than those in PT1 (P<0.05).

Table 2: Physico-chemical parameters characteristics of fish pond water in rabbit-fish-rice integration system [ponds stocked with one (PT1) and three (PT2) fish per m2 of pond].

Pond water parameters

Treatments

LSD0.05

P value

PT1

PT2

Temperature (°C) a.m.

 21.56 ± 0.22x

 21.75 ± 0.25x 0.18 (*)

0.021 tdt

Temperature (°C) p.m.

 25.11 ± 0.47ay

 25.98 ± 0.39bz

pH a.m.

 6.94 ± 0.09x

 6.90 ± 0.05x 0.25

0.017 dt

pH p.m.

 7.10 ± 0.44y

 7.11 ± 0.52y

Conductivity (µS.cm-1) a.m.

115.42 ± 5.32

118.54 ± 4.29

NS

Conductivity (µS.cm-1) p.m.

115.67 ± 5.64

117.71 ± 4.37

Dissolved oxygen (mg.l-1) a.m.

 1.90 ± 0.34x

 1.69 ± 0.85x 2.23

<0.001 ddt

Dissolved oxygen (mg.l-1) p.m.

 9.64 ± 0.41y

 10.10 ± 0.88y

Secchi transparency (cm)

 28.88 ± 1.37a

 26.63 ± 1.63b 1.8 (*)

0.017 t

Total alkalinity (mg CaCO3.l-1)

87.9 ± 8.73a

 85.00 ± 5.71a 8.98

NS

Chlorophyll-a (µg.l-1)

 41.07 ± 5.69a

 71.45 ±14.69b 30.11 (*)

0.002

Primary productivity (g C.m-2.d-1)

 1.69 ± 0.27a

 1.77 ± 0.26a

TN (mg.l-1)

 3.16 ± 0.28

 3.00 ± 0.17 1.03 NS

<0.001 t

NH4-N (mg.l-1)

 0.12 ± 0.04

 0.16 ± 0.06

NS

NO2-N (mg.l-1)

 0.13 ± 0.00

 0.12 ± 0.00

NS

NO3-N (mg.l-1)

 3.31 ± 0.01

 2.72 ± 0.00

NS

TP (mg.l-1)

 0.55 ± 0.02

 0.66 ± 0.01 0.49 NS

<0.001 t

PO4-P (mg.l-1)

 0.35 ± 0.07a

 0.47 ± 0.09b 0.113 (*)

0.012 

The values presented above are means ± SE of mean. Data with different superscript letters (that is, a and b) in the same row and letters (that is, x, y, and z) in the same column for the same parameter were significantly different (P < 0.05). NS refers to no significant difference, whereas the P values with t denote differences according to time (that is, sampling dates), with dt referring to daytime (07 h 00 to 08 h 00 for a.m. – before noon; 14 h 00 to 15 h 00 for p.m. – after noon) and tdt referring to the differences considered for interaction treatment*daytime. LSD0.05 is the least significant difference to which means are compared to point out the significance at 5% level.

Nutrients in Water Seeping through Rice Field Soil

Samples of water that had filtered through rice field soil were analysed for N and P forms in order to assess the possible discharge of nutrients from the system to the underground environment. N forms did not differ significantly among the rice fields fertilised by effluent from ponds with one fish per m2 (RT2) and those fertilized with effluent from ponds stocked with three fish per m2 (RT3) (Table 3). However, water seeping in the fields treated by inorganic fertilizers (RT1) were found to have significantly higher concentrations (P = 0.001) of nitrates (0.30 ± 0.13 mg/l) than water from fields of RT2 (0.20 ± 0.09 mg/l) and RT3 (0.17 ± 0.08 mg/l) treatment. The RT1 N concentrations after seepage were slightly lower than those recorded in the pond effluent and water that flowed to irrigate the rice field. The TP concentration in water from the rice fields undergoing RT1 was significantly higher (P<0.05) than those in water from the rice fields undergoing RT2 and RT3 (which were not significantly different from each other).

Table 3: Concentration of nutrients in the outflow after water has leached into the rice field soil. RT1: rice fields fertilised by NPK and urea; RT2: rice fields fertilised by effluent of fishponds stocked with one fish per m2; RT3: rice fields fertilised with effluent of fishpond stocked with three fish per m2.

Treatment

Nutrients leaching through rice field soil

  TN (mg/l) TP (mg/l) NH4-N (mg/l) NO2-N (mg/l) NO3-N (mg/l)

PO4-P (mg/l)

RT1

2.58±0.77a

0.63±0.24a 0.28±0.08a 0.02±0.01a 0.30±0.13a 0.11±0.04a
(1.05–5.67) (0.1-1.3) (0.015-0.545) (0.001-0.066) (0.052-0.825)

(0.036-0.273)

RT2

3.23±0.89a

0.45±0.16b 0.23±0.06a 0.02±0.01a 0.20±0.05b 0.14±0.07b
(1.330-6.370) (0.1-1.1) (0.010-0.456) (0.004-0.040) (0.019-0.354)

(0.025-0.419)

RT3

2.66±0.65a

0.46±0.11b 0.28±0.09a 0.02±0.02a 0.17±0.05b 0.14±0.06b
(1.33-5.67) (0.2 –1.2) (0.044-0.552) (0.003-0.066) (0.044-0.825)

(0.038-0.287)

LSD0.05

0.71 (NS)

0.117(*) 0.07 (NS) 0.01 (NS) 0.063(*)

0.025(NS)

P value

<0.001 t

0.005 <0.001 t 0.014 trt*t 0.001

0.037

Data are mean values ± standard error of mean; different superscript letters in the same column denote treatments that are significantly different (P<0.05). The data in parentheses are the minimum and maximum recorded for each treatment; RT denotes rice field treatment; P values with t denote time-based differences (that is, sampling days); P values with trt*t refer to the differences considered for interaction treatment*time.

Nutrients in Rice Field and Fish Pond Soil

The pH, CEC, ammonia-N, TN, TP, and phosphates were analysed to characterise chemically the impact of integrated livestock (rabbits) and aquaculture on the soil at the bottom of the ponds as well as the soil in the rice fields. The results obtained for the start, midterm (90 days), and end (153 days) of the experiment are summarised in Figures 2 and 3. A slight increase over time in pH was observed in both the ponds stocked with one fish per m2 (PT1) and those stocked with three fish per m2 (PT2), with no significant difference being discerned between them (P<0.05). At the end of experiment, the pH averaged 4.78 and 4.92 in PT1 and PT2 respectively, while the averages were 4.65 and 4.70 respectively at the start of the experiment. The CEC averaged 9.69 and 7.98 meq/100g in PT1 and PT2 respectively, and were significantly different from one another (P<0.05). A decrease was noted in CEC, especially in the ponds stocked with the least fish, from the start of the experiment to the end.

TN concentrations were significantly higher (P<0.05) in PT2 than in PT1 at the end of experiment, but the observed N increase that took place over time within each treatment was not statistically significant (P<0.05). TN concentrations averaged 0.11 and 0.15% in PT1 and PT2 respectively, with a non-significant increase (P>0.05) with time, from 0.09 to 0.12% and 0.11 to 0.18% in PT1 and PT2 respectively.

There were no significant differences between P nutrients (TP and phosphates), nor between the treatments, nor among treatments, over time. As recorded for TN in the fish pond soil of PT1, the concentrations of TP and phosphates were slightly higher at midterm (that is, 90 days after stocking) than at the start and the end of experiment. This was most likely the result of the fish pond water being used to irrigate the fields, as pipes were placed near the sediment-water interface at the bottom of the ponds.

fig 2

Figure 2: N and P in the bottom soil of fishponds that were fertilised by rabbit droppings and stocked with one fish per m2 (PT1) and three fish per m2 (PT2) in a rabbit-fish-rice integrated system in Rwanda. Data were collected at the start of the experiment (that is, after 1 day), at midterm (that is, after 90 days), and at the end (that is, after 153 days after transplanting) of the experiment.

Figure 3 presents the nutrient pattern in the rice field soil that emerged during the rabbit-fish-rice integrated system experiment. No significant changes of the parameters were observed within each treatment over the culture time. Only ammonia-nitrogen and CEC increased from the start to the end of experiment. The treatments also did not differ significantly (P>0.05) from one another at the end of the culture time for these parameters. Generally, N nutrient concentrations, TN, and ammonia (NH4-N), decreased in the midterm point of the experiment and increased at the end of experiment in all treatments. The rice fields fertilised by effluent from highly stocked ponds (RT3) had, however, slightly higher concentrations of N nutrients than did the rice fields receiving effluent from low stocked fish ponds (RT2) and the rice fields fertilised by chemical fertilisers (RT1). The mean concentrations for TN were 0.11 ± 0.05%, 0.13 ± 0.04%, and 0.14 ± 0.04% N in rice field soil for RT1, RT2, and RT3 respectively. Even though no significant differences were observed with regard to TP and phosphates (PO4-P) between the treatments, changes could be signaled within treatments over time and among treatments at the end of rice culture period.

fig 3

Figure 3: Chemical parameters in rice fields fertilised were as follows:  RT1: chemical fertilisers (NPK and urea); RT2: effluent from fishponds stocked at one fish per m2; RT3: effluent from fishponds stocked at three fish per m2. Data were collected at the start of the experiment (that is, after 1 day), at midterm (that is, after 90 days), and at the end (that is, after 153 days after transplanting) of the experiment.

Phosphate concentrations were higher in RT3 (0.30 ± 0.2 mg P/kg) than in RT2 (0.23 ± 0.09 mg P.kg-1) and RT1 (0.22 ± 0.08 mg P.kg-1), and they decreased towards the end of the culture period. Inversely, TP was more highly concentrated in those rice fields that received NPK and urea (RT1) than in those (RT2 and RT3) fertilised by pond water effluent.

TP concentrations were high at the start (359.47 ± 112, 263.67 ± 74.77, and 288.17 ± 138.2 mg P.kg-1 for RT1, RT2 and RT3 respectively), but then decreased progressively to an average of 275.79 ± 73.8, 248.28 ± 107.1, and 186.06 ± 36.18 mg P.kg-1for RT1, RT2, and RT3 respectively at the end, with no significant differences recorded between the treatments.

Discussion

Source of Nutrients in the IRFR System

The productivity of all IAA fish ponds depended totally on inputs which originated mainly from on-farm and/or off-farm sources of nutrients – but all external to the fish pond [30,31]. Studies on the use of rabbit droppings and of the resource-flow in the IRFR system [32-34] have confirmed that rabbit droppings (faeces and urine) provide not only a better environment for tilapia but also a major source of nutrients on which the whole system of fish and rice production relied. The rabbit dung composition, in this study, showed that rabbit dung could be a better fertiliser than most other manure.

This study investigated the flow of nutrients (N and P) by means of their mass balance throughout the IRFR without considering a complete nutrient budget of the system. The mass balance of N and P nutrients showed that rabbit waste accounted for about 27.0% N and 79.1% of the P of the total nitrogen and phosphorus input supply. Of this, rabbit urine accounted for 20.0% N and 64.0% P of the total N and P respectively of the total fish pond inputs, thus highlighting the major role of rabbit urine in providing nutrients. The nutrient mass balance explains effectively the nutrient flow and contribution of each resource, but is not a good estimation of nutrient budgets which normally require an accurate estimate of the volume of water being exchanged in the system. This estimation poses difficulties: [35] reported the uncertainty and difficulty of estimating pond seepage and pond evaporation, arguing that methods based on changes in pond depth are prone to error. To avoid such errors, we opted for the nutrient mass balance. This method was also chosen because of the difficulty in determining the exact amount of pond mud, the denitrification, and the ammonia volatilization; in most studies these potential factors of N losses are estimated indirectly. The higher amount of nutrients contained in the influent water is due to the order of magnitude comparable to the organic resource amount as ponds are refilled after rice field irrigation by pond effluent; this confirms the success of such practices in Rwanda. The influent water provided up to 72.99% N and 20.91% P as an off-farm source of the N and P input to the pond; these quantities may have been principally constituted of dissolved organic nitrogen (DON) from the rice and vegetable fields upstream of the fish farming station. According to a study [36] the DON is decomposed slowly by bacteria and therefore accumulates over the rearing time, the DON was reported to be the major form of N [31,37] in fish ponds. Therefore, the nutrients available after decomposition of rabbit droppings by bacteria may have resulted largely from use during phytoplankton development.

Water Fertilisation and Nutrient Distribution

The concentrations of measured variables for water quality (Table 2) suggested good conditions for phytoplankton and tilapia growth. The significant increase during the day for pH and dissolved oxygen confirmed good phytoplankton activity; this activity, on the one hand, removes carbon dioxide by photosynthesis and, on the other hand, enriches the water with oxygen through the same process [12,38,39]. The removal of effluent to fertilise rice fields seems likely to have been the only probable reason for the fluctuation observed in TN and TP concentrations, during which N decreased mainly after the first month.

About 27% of the N and 79% of the P from the rabbit droppings were released in fish ponds, fertilising the pond water at a rate of 3.98 kg N and 1.94 kg P.ha-1.d-1; this is a higher rate than that (1.75 kg N and 0.39 kg P.ha-1.d-1) reported in an integrated Nile tilapia cage-cum-pond system [40] where tilapia were fed pellet feed and waste fertilised ponds were used to raise fingerlings. This rate is comparable to that (3.71 kg.ha-1.d-1 N and lower than 8.06 kg.ha-1.d-1 P) observed in caged hybrid catfish waste fertilising open-pond Nile tilapia [8]. The inputs from rabbits provided a pond fertilisation rate equivalent to the application of urea and triple superphosphates (TSP) at the rate of 4 kg.ha-1.d-1 of N and 1 kg.ha-1.d-1 of P used [7] in an integrated Lotus-Tilapia experiment (2 fish per m2) that resulted in a net fish yield (3345 ± 113.4 kg.ha-1.y-1), comparable to that obtained in the present study (2611 kg.ha-1.y-1 for 1 fish per m2 and 3459 kg.ha-1.y-1 for 3 fish per m2). The rabbit droppings thus raised substantially the TN and TP concentrations of pond water from 0.21 to 3.16 mg.l-1 of TN and 0.01 to 0.66 mg.l-1 of TP. Supplement material to that from rabbit waste might be canal water, fish waste, plankton die-off, and other external unaccounted sources such as levee and watershed erosion, small leaves from rabbit hutches, and leaves blown into the pond by wind [41,42]. Siddiqui and Al-Harbi (1999) [41], found that tilapia excreted 59-72% of the N and 60-62% of the P constituent in the feed. A study [43] observed that covering the pond edge substantially reduced nutrients in pond and concluded that run-off from the pond dyke was the major source of turbidity in the fish pond.

The effluent from the fertilised pond in this study held high amounts of TN (about 19175-18135 kg N.ha-1) and TP (3510-4225 kg P.ha-1 ) following their respective fish stocking rates (1‑3 fish per m2). When used to irrigate rice fields, these effluents provided the rice fields with about thirteen times the amount of N (1478 kg.ha-1TN) and more than twenty-six times (133 kg.ha-1 TP) of P obtained in treatment with inorganic fertilizers (NPK and urea). The role of rabbit droppings as pond fertiliser was thus clearly highlighted and the results showed that it was not necessarily dependent on fish stocking density. The reported study was limited in that only harvested fish, rice grain, and rice straw were assessed for N and P as major nutrient output of the integrated system.

N and P Recovered by Harvested Products

The assessment of N and P mass balance showed that with a low fish stocking rate, Nile tilapia recovered lower N and P from inputs than with a high fish stocking rate; this was probably due to the amount of fish waste in these ponds which logically surpassed that present in ponds with a low stocking rate. In low stocking rate ponds (1 fish per m2), Nile tilapia recovered 18.5% N and 16.9% P of the TN and TP of the rabbit droppings inputs, while this recovery was only of 4.9% N and 13.3% P of the total N and total P inputs, including that of the inflow canal water. In higher stocking density rate ponds (3 fish per m2), the fish recovered more (37.6% N and 34.3% P) of the total N and total P of the rabbit droppings input; including the canal water that refilled ponds, this was only 10.2% N and 27.13% P of the total inputs. Whatever the considered source of input, these nutrients recovery rates were higher than many recovered rates reported in various studies (Table 4).

The probable explanation for the differences shown in various recovery rates in Table 4 relies on how quickly each source makes nutrients available to the fish. It is known that when nutrients from feeds are directly used by fish, the recovery rate is higher than when fertilisers are used (Table 4). Tacon et al. (1995) in [44], found that supplementing feed in semi-intensive aquaculture farms improved N recovery, ranging from 5% to 25%, in fish. From Table 4, it can be argued that rabbit droppings must be better used by fish ponds than many other inputs to ensure a better environment for Nile tilapia growth.

Table 4: Nutrient recovery rates by Nile tilapia for various rearing systems.

Rearing Integrated System

Input origin

Recovery rates

Studies

TN (%)

TP (%)

Intensive and recirculation tank for tilapia aquaculture

Tank wastes

21-22 18.8

Siddiqui & Al-Harbi1(1999) in Piedrahita (2003)

Intensive Aquaculture in tilapia

Various feed

47.73 18.18

Schneider et al. (2005)

Tilapia-cum-tilapia

Caged tilapia waste

20.52 27.98

Lin and Yi (2003)

Hybrid catfish-cum-tilapia

Caged catfish waste

12.75 14.27

Diana (1995) in Lin and Yi (2003)

Domestic wastewater-tilapia

Treated sewage

13.00

El-Shafai et al. (2007)

Chicken-cum-Nile tilapia

Chicken manure

15.5-21

Schroeder et al. 2003

Rabbit-fish-rice

Rabbit droppings

37.6 34.3

This study

The rice field component of the system received fertilised pond effluent as organic input for rice growth. The results showed that rice grain accounted for a lower percentage of input in fields fertilised with effluent (0.44-0.50% N and 0.22-0.25 P of the total N and P of the effluent input) than in fields treated with NPK and urea (6.11% N and 6.54% P of the total N and P inputs). The rice straw in fields fertilised by effluents accounted for 0.77-0.79% N and 0.71%-0.88% P, while it accounted for 10.79% N and 23.24% P of the total N and total P inputs. The differences obtained here seem logically to be due to the order of magnitude of each source of input. The amount of nutrients supplied in the effluent was high and therefore remained in the soil, the seepage, and contributed to weed growth during the farming period.

Nutrients in Pond Sediment, Rice Field Soil, and Seepage Water

Nutrient mass losses were difficult to measure precisely because the amount of sediment, infiltrated water, and nutrients accumulated in the rice fields were not quantified but only their concentrations in water and sediment assessed. Changes in sediment concentrations of P and phosphates followed the activity applied in the fish ponds. Normally P is strongly adsorbed by pond soil [6,11] directly from pond water, while N is lost primarily through ammonia volatilisation and denitrification [45-47]. Munsiri et al. (1995) [42] stated that organic matter, N, P, and TP in pond bottom soil accumulates strongly in the upper 10-20 cm of sediment as a result of the fertilisation process due to microbial activity. In the present study, TN and ammonia nitrogen, as well as TP and phosphates, increased up to midterm (that is, 90 days) but thereafter, except for ammonia nitrogen, decreased until the end of the experiment. The observed decrease in P and TN was most likely due to adult fish movement and the various factors causing waves (for example, pressure from the pipe sucking water) which disturb the sediment-water interface, thereby allowing re-suspension of nutrients sucked by the pipe to irrigate the rice field. Overall, no significant changes in nutrient concentrations were observed in the rice field soil, neither among treatments nor over time, and this demonstrated that nutrients were used by growing rice at almost same rate in inorganic or effluent fertilised fields. The ammonia, TP, and TP pattern in rice field soil showed higher concentrations at the beginning of the experiment as a result of fertiliser application and irrigation by pond effluent, but all these nutrients decreased at the end of the experiment. These observations agree [39] whose findings identified an increase of nutrients in the soil during the first 15 days after transplanting (DAT). The decrease in N and P at the end of experiment was probably due to the nutrient uptake by the rice in the growing phase, caused by the strong nitrification processes in the upper layer of the soil (De Dautta et al., 1985 in [39].

The present integrated system was designed in such a way that all effluent used for irrigation could filtrate through rice soil before it reached the environment. Lower concentrations, but not significant (P>0.05), were observed for TN, TP, and phosphates, while nitrates decreased significantly and ammonia increased in the water that reached the under layer of soil. N forms were higher in seepage water than P forms, suggesting that microbial activities on N were more intense at the soil surface and in the pipes in which ammonia concentration increased and surpassed that in effluent water. The seepage water accounted for only between 80 and 88% of TN and TP of the effluent that entered the rice field, between 29 to 40% of the soluble phosphates, and up to 6.0% of the nitrates of the effluents. This observation suggests that nitrates and soluble phosphates were the nutrients most used by the growing rice.

Conclusion

This study analysed the flow of nutrients in the integrated rabbit-fish-rice system and demonstrated that about 27% N and 79% P in pond water were attributable to rabbit droppings (faeces and urine). Rabbit droppings provided a fertilisation rate of 3.98 kg N and 1.94 kg P.ha-1.d-1, leading to fish yields comparable to those obtained from using urea and TSP at a rate of 4 kg N and 1 kg P.ha-1.y-1, yielding 3 344.6 kg.ha-1.y-1 for 2 fish per m2 stocking density of male Nile tilapia in an earthen pond.

Fish recovered about 18.5-37.6% N and 16.9-34.3% P of the TN and TP in rabbit dropping input to the pond. The relatively large amount of N and P that passed through pond water made the it especially appropriate for rice fertilisation and could replace totally the inorganic fertilisers used in common practice in the culture of rice. The re-use of tilapia pond effluent, captured from the bottom of the pond, allowed the recycling of the large amount of N and P by providing the growing rice with required nutrients at a high rate (118.5-125.3 kg N and 22.9-21.2 kg P.ha-1.d-1). The lack of these nutrients, especially N, is the most limiting factor in irrigated rice fields (De Datta et al., 1988 in [39]. In this way, in an integrated pond effluent and rice culture system, a large amount of N accumulated in the rice field, making the soil able to be better used in for a demanding rotated crop.

This integrated farming seems particularly environmentally friendly and sustainable, thus appropriate for resource-poor farmers in developing countries, such as Rwanda, as it recycles nutrients, thereby reducing the investment costs and the negative environmental impacts of aquaculture.

Further studies are needed to document the best fertilisation/irrigation frequency and to investigate the most efficient use of the effluent nutrients through the expansion of the current integration system. It is also recommended that a study should be made that aims at determining the complete nutrient budget of the integrated rabbit-fish-rice system.

Acknowledgment

The authors wish to thank the Nile Basin Initiative/ATP project for providing financial support for this study. They are also grateful to the workers of the Rwasave Fish Farming and Research Station (SPIR) for their commitment during the experiment. Thanks to Dr. Gatarayiha for his comment regarding statistical analysis applied in this paper. We acknowledge efforts and help by Mrs. Beulah John who proofread this article while she was not feeling good, many thanks.

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fig 1

Treatment of Alimentary Lymphoma in Cat (Felis catus) by Injectable Homeopathy – Case Report

DOI: 10.31038/IJVB.2021521

Abstract

Lymphoma is the neoplasia most commonly found in cats, with different forms of presentation of the disease. Among the various types of lymphoma, alimentary lymphoma is considered the most common in the oncology clinic in this species, reaching 50% of all diagnosed lymphomas. In general, this disease can be lymphocytic or lymphoblastic, differing as to the acute or chronic character of its manifestation. The B-cell lymphoblastic lymphoma seems to be the most severe and challenging to treat. The therapy of choice for this disease is conventional chemotherapy. However, this type of protocol results in a certain toxicity degree, often making the treatment sequence unfeasible. Within this context, complementary therapies stand out for not presenting side effects. Therefore, the ultra-diluted Viscum album becomes an excellent alternative for this therapeutic approach. This study aimed to report a case of feline alimentary lymphoma of B-cell lymphoblast type, treated by injectable, homeopathic therapy. A complete resolution of the mass manifestation was observed as well as an increase in the patient’s survival, differently from those cases described in the literature.

Introduction

Hematopoietic tumors are considered to have the highest incidence among domestic cats [1-5], comprising onethird of all tumors in cats. They can be systemic or multicentric and affect different tissues [5]. Viruses such as the feline leukemia virus (FeLV) [6,7] and the feline immunodeficiency virus (FIV) [8] are among the possible causes for this disease emergence. Only 25% of cats with lymphoma are positive for FeLV, and about 20% of cats that develop lymphoma in the United States are seropositive for antibodies against FIV [8,9]. There is no evidence for racial or sex predisposition. However, some authors claim that neutered males are slightly more affected by lymphoma, especially the alimentary type [3]. The average age of patients diagnosed with lymphoma is 8 to 10 years [2,10]. In general, the alimentary lymphoma type occurs in cats of about 10 to 12 years old, negative for FeLV [9]. It is the most diagnosed type among the different lymphoma types, comprising about 50% of the cases [11]. In this context, alimentary lymphoma is defined as lymphoid neoplasia that affects the gastrointestinal tract and regional lymph nodes, usually affecting the small intestine, liver, and spleen [9]. It is considered the second most common neoplasia found in the gastrointestinal tract of cats [12]. It affects 50% of the felines diagnosed with lymphoma [5]. This type of neoplasia may manifest itself in two ways: lymphocytic, also called small cells or poorlydifferentiated, and lymphoblastic, also called large cells or highly differentiated, which may extend beyond the gastrointestinal tract, reaching peripheral, thoracic, and bone marrow lymph nodes [13].

Lymphoblastic lymphoma is often related to more severe and acute symptoms adding to the rapid onset and progression. Nearly 80% of cats with this neoplasia will have some palpable abnormality in the abdomen, which may be mass, thickening of the intestinal loops accompanied by hiatus or splenomegaly [14]. This neoplasia usually starts in the digestive system of cats and quickly spreads to other organs and systems. It rarely has a significant response to treatment [14]. The most prevalent immunophenotype in lymphocytic lymphomas is T cells, whereas the B cells are more likely to be in the lymphoblastic [15]. Affected cats generally have anorexia, significant weight loss, and a higher probability of presenting intussusception, obstructive masses, and septic peritonitis, resulting in a perforation. Cats with lymphoblastic lymphoma may or may not have a vomiting and diarrhea history [3].

The alimentary lymphoma diagnosis is performed by clinical history, physical examination, laboratory and imaging tests, aspiration cytology, biopsy, and immunohistochemistry [3]. The treatment consists of chemotherapy protocols, usually with combined medicines, with no evidence that the associated surgical procedure is more effective than chemotherapy alone, except when there is a mass totally or partially obstructing the food transit [10].

However, antineoplastic medicines cause different toxic effects, especially concerning liver parenchyma [16]. Rodaski et al. [17] reported that the hepatotoxicity of chemotherapeutic medicines generally coincides with the increase in serum enzymes such as alanine aminotransferase (ALT) and alkaline phosphatase (AP) [17,18]. Myelotoxicity is another frequent and severe limiting factor of chemotherapy, impairing the treatment effectiveness and increasing the possibilities of metastases [19-21].

Within this context, complementary therapies gain space both as a primary or complementary treatment for cancer patients since they do not present side effects and they stimulate the immune system, improving the quality of life and, consequently, increasing the patient’s survival [22]. iscum album (VA) is the most used plant in the world as a complementary therapy. It is used either in its phytotherapeutic or homeopathic form, presenting selective cytotoxicity effect and being aggressive only against tumor cells and not for normal cells [23], as well as for its immunomodulating and anti-inflammatory action [22]. Valle et al. [24] describe the in vitro selective cytotoxicity of ultra-diluted VA extracts when added to cell cultures of mammary adenocarcinoma and mesenchymal stem cells. This medicine’s cytotoxic activity was at least five times greater in the adenocarcinoma cells than in normal cells, suggesting a higher predilection for tumor cells by the medication.

Kirsch [25] reports a case in which he used VA (Iscador® M) extract as the only modality for the adjunctive treatment of the post-operative treatment of metastatic melanoma. He found the treatment to be extremely effective and very well tolerated in this patient, resulting in the complete remission of the neoplasia. Lefebvre [26] associated VA with the traditional chemotherapy in dogs and observed that the associated therapies decreased the total treatment time, reducing the chemotherapy side effects, such as leukopenia. Valle et al. [27] also described the successful treatment of transmissible venereal tumors using the VA homeopathic therapy. Therefore, the objective of this work was to report the case of a domestic feline, diagnosed with lymphoblastic lymphoma, immunophenotype Type B, who was treated with the ultra-diluted medicines VA and Magnesia phosphorica, and showed remission of the disease.

Materials and Methods

An 11-year-old male Siamese breed feline (Figure 1) weighing 3.8 Kg was attended at the Veterinary Hospital of UNIP, by the service of Natural Medicine, in February 2016. The animal presented a history of weight loss, apathy, lack of appetite, successive emetic episodes, and abdominal pain for three weeks. The animal showed 4% dehydration in physical examination, severe pain on abdominal palpation, normal mucous membranes, the temperature at 38oC, cardiac auscultation compatible with age and species, slightly increased respiratory rate, and lymph nodes of standard size and consistency for age and species. Laboratory tests (complete blood count, urea, creatinine, ALT, and alkaline phosphatase), FIV/FeLV tests, abdominal ultrasound imaging, digestive endoscopy, biopsy, and immunohistochemistry were requested

fig 1

Figure 1: Feline, male, 11 years old, Siamese breed.

Results

No alteration worthy of note was detected at laboratory tests. Most parameters were within the normal range for age and species in question. Creatinine was the only one altered, confirming the previous diagnosis of chronic kidney disease (Creatinine 2.45mg/dL). FIV/FeLV tests were negative. A mass was visualized in the stomach, in the fundus region (Figure 2a and 2b) at the ultrasound, causing an acoustic shadow. The animal was then referred for a gastric endoscopy, which resulted in the visualization of a mass of approximately 4.6 cm (Figure 3d) and an ulcerated region (Figure 3e) associated with it. The result of the biopsy was from a plasmacytic infiltrate (Figure 4). The immunohistochemistry analysis showed expression of CD79a, whereas no expression of AE1AE3, MUM1, CD3, tryptase, and C-Kit was detected. Therefore, it was concluded that the immunohistochemical and morphological profiles of the piece evaluated favor the diagnosis of immunophenotype B lymphoblastic lymphoma. An injectable homeopathy treatment was chosen, mainly because it is easy to handle, and there are no side effects to the treated patient. Viscum album at different concentrations was used such as D3, D6, D9, D12, which were daily administered in subcutaneous combinations, SID, in the following order: Day 1 – VAD3 + VAD6; Day 2 – VAD9 + VAD12; Day 3 – VAD30 + VAD3, and Magnesia phosphorica D35, one ampoule, subcutaneously, SID. Both medicines were used for 122 consecutive days.

fig 2

Figure 2: (a) Stomach US (sagittal section) showing a mass of approximately 3.6 cm in diameter, indicated by a green arrow; (b) Stomach US (transversal section) showing a mass of approximately 4.9 cm in diameter.

fig 3

Figure 3: (a) Esophagus; (b) Stomach (fundus); (c) Stomach (body); (d) Stomach tumor (antrum) – ulcerated tumor lesion; (e) Stomach – ulcerated antrum region; (f) Duodenum.

fig 4

Figure 4: 40X image – Plasma cell infiltrates observed.

The cat’s tutor reported that the animal started eating spontaneously again right in the first week after the beginning of the treatment. The tutor also reported that the pain had reduced after the third application of the proposed medicines. Further evaluation through imaging tests was performed after 122 days. The abdominal US was done again (Figure 5), and the alterations previously visualized were not observed. The following observation was recorded: the stomach wall was within the normal range (0.23 cm), with no ultrasound evidence of abnormalities on this exam. In the images visualized by endoscopy (Figure 6), the stomach had a clear and transparent mucous lake, with preserved shape and architecture. Mucous membranes, rugae of the mucosa, and gastric body showed typical shapes and features to the endoscopic macroscopy. A small sessile polyp (Figure 6d and 6e) was present between the body and antrum canal on the left wall. The antrum canal had a smooth surface and was a little hyperemic. No tissue proliferation was identified in a previous exam. The duodenum showed preserved shape and caliper, and the velvety mucous had a light pink color. A new fragment was collected for histopathological examination from the same previously injured site, which showed intraepithelial granular lymphocytes, non-malignant lymphoplasmacytic infiltrate (Figure 7). The animal was follow-up until the moment of its death due to a kidney disease preexisting to the lymphoma treatment. The death occurred 24 months after the treatment, without signs compatible with the relapse of the lymphoma.

fig 5

Figure 5: Stomach wall thickness (0.23), indicated by the green arrow, within the normal range for age and species.

fig 6

Figure 6: (a) Esophagus; (b) Stomach (fundus); (c) Stomach (body); (d) and (e) Stomach (antrum) with the presence of a polyp, indicated by a green arrow; (f) Duodenum.

fig 7

Figure 7: 40X Image – Lymphoplasmocyte infiltrate.

Discussion

Lymphoma is one of the most frequent hematopoietic neoplasias in domestic cats [12]. In cats, alimentary lymphoma is responsible for approximately 50% of all lymphoma cases and is considered as the malignant neoplasm most responsive to chemotherapy [28]. However, several side effects are reported, as previously described.

The alimentary lymphoma is one of the most prominent neoplasms within feline oncology, as it is a relatively aggressive tumor and, in most cases, of difficult treatment [9]. The National Cancer Institute Working Formulation (NCIWF) classified the feline alimentary lymphoma as high, intermediate, and low grades, the latter usually affecting the diffuse form of the disease and was the first type to be described. A less described form is the lymphoma of large granular lymphocytic cells, which is subdivided into immunoblastic and lymphoblastic [29].

The case here reported corroborates with Birchard [14] and presented more severe and acute clinical signs, in addition to a fast onset and progression, being within 80% of cats with this neoplasia. However, in contrast to Birchard [14], the animal evaluated presented the lesion in the fundus region of the stomach and not in the intestinal region. Therefore, no thickening of the intestinal loops or hepatosplenomegaly was recorded in this study. According to Pohlman et al. [30], alimentary lymphoma affects the stomach, small intestine, and large intestine in 24, 74, and 16% of the cases, respectively. The present case is within 24% of the cases that affect the stomach region.

Most cats with lymphoma have a life expectancy of six to nine months when treated with multiple chemotherapeutic agents, associated or not with surgical or radiotherapy treatments. Approximately 20% of the animals survive for more than a year. The prognosis for FeLVpositive cats is worse than the one mentioned above, and the survival is three to four months. FeLV-negative cats survive longer than those FeLV-positive, reaching 9 to 18 months of life, depending on the anatomical shape [31].

In contrast to Amorim [31], this study describes a feline alimentary lymphoma resolution over four months. It also reports the animal’s survival for 24 months, with no occurrence of clinical signs compatible with the initial pathology and with no administration of chemotherapy medication. The patient was treated using injectable, homeopathic medicines to immunomodulate the organism and generate a selective cytotoxic activity [23,24] through the ultra-diluted medicine VA. Injectable and ultra-diluted Magnesia phosphorica was also administered for the treatment of the tumor microenvironment. This protocol confirmed the effectiveness of the unconventional therapy in treating gastric lymphoma and showed excellent results, such as being minimally invasive, no side effects, and low cost compared to the therapies of choice for the treatment of this disease.

The main prognostic factor is the initial response to chemotherapy and if remission occurs. Cats with a good initial response to the chemotherapeutic treatment and with total remission usually survive, on average, one year. However, this case report describes the treatment using injectable homeopathy in which the patient demonstrated excellent response, with remission of the tumoral mass, with no side effects, and with the reestablishment of its health in 122 days. Also, the animal had 28 months of survival until the moment of this report.

Conclusions

In conclusion, the present case report offers one more option for successfully treating feline gastric lymphomas so as not to produce side effects to the patient, be minimally invasive, and of low cost when compared to conventional treatments. However, more studies are still necessary to better elucidate the mechanism of action of this medication class.

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