Monthly Archives: October 2021

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Integrated Molecular Breeding for Enhanced Genetic Improvement of Climate Smart and Insect Protected Hybrid Maize in Africa

DOI: 10.31038/MGJ.2021424

Abstract

Africa suffers from food deficits. Droughts along with associated insect pests have contributed to reduce crop yields, particularly maize, a major staple food crop for over 300 million people in Sub- Sahara Africa (SSA). While genetic improvements have gradually increased, albeit at low speed for genetic gains through classical breeding in Africa, mitigating the effects of climate change requires exploring innovative breeding approaches to accelerate yield response at an elevated pace. Two maize projects have explored integrated molecular breeding to improve genetic gains with new hybrid maize varieties released in Africa reaching 10 tons/ha from the abysmal low production potential of 2 tons/ha previously recorded for most open pollinated varieties (OPVs) grown by smallholder farmers. A combination of marker aided breeding and transgenesis may offer a very efficient means to rapidly transforming maize food system in Africa.

Introduction

Due to climate change, droughts have contributed to reduced crop yields [1], particularly maize, a major staple food crop for over 300 million people in SSA. The role of modern breeding in enhancing adaptation and resilience against abiotic stress and associated biotic stresses induced by climate change has been increasingly substantiated by science-based facts and evidence that supports the need for continuous investments in capacity for research and development in the developing world especially in Africa where food and nutrition is still a challenge. Until few years back, open pollinated varieties (OPV) maize were principally grown in Africa by smallholder farmers who substantially engaged in subsistence agriculture. The need to rapidly attain the UN SDGs [2] related to zero hunger, good health and well-being, and alleviation of poverty, means that Africa needs to transform to commercial agriculture that essentially requires increasing yield levels of maize that was for a long time just about 2 tons/ha and well below the average yields of approximately 5.5 tons/ha globally. The already dire yield levels in Africa, is unfortunately being threatened by climate change that necessitated an initiative to rapidly avail Africa, highly innovative platforms through public private partnerships (PPP) that offer the state-of-the- art modern breeding opportunities. This led to the commencement of the Water Efficient Maize for Africa (WEMA) initiative over a ten-year period that was immediately followed by TELA Maize Project currently in its 4th year of implementation. These projects, executed in a seamless stretch of continuity and gains, have explored novel technologies and strategies to rapidly develop climate smart and insect protected maize for Africa. The partnership comprises AATF, Monsanto (Bayer Crop Science), CIMMYT, and National Agricultural Research Systems (NARS) of Kenya, Uganda, Mozambique, Tanzania, and South Africa as first tier target countries and later with Ethiopia and Nigeria as second tier countries.

The Eastern and Southern African region (ESA) has a net deficit in maize. These projects have explored perhaps the most advanced modern breeding approaches on the continent that could help revolutionize agriculture for improved food and nutrition security. Both WEMA and TELA provide yet the biggest evidence of the importance of the roles of biotechnology in improving food systems and the need to invest further in research and development capacity based on modern breeding concepts. Some key significant results, lessons learnt, experience and implications for forward breeding and development of resilient crops are appraised in this paper for transformative approach to crop genetic improvement.

Enriched Pedigree-based Breeding Pipeline

Open pollinated maize has long been grown in the SSA borne out of the need to support or supplement farm family house food needs often requiring the re-use of grains as seeds. On the long run, yields are compromised with gradual decline in productivity overtime. The need to rejig African economy to fast track development and to stem increasing poverty and for modern African agriculture has justified the need for a shift from the use of OPVs to hybrid maize. Hybrid technology revolutionized maize breeding in 1920s in the Americas and has largely accounted for the phenomenal productivity levels observed for maize worldwide [3]. Africa research systems are rapidly evolving its hybrid maize breeding.

The WEMA project, to enhance capacity for hybrid maize breeding in Africa, accessed global maize germplasm through CIMMYT and over 700 germplasm elite lines from Monsanto (now Bayer Crop Science) breeding programs. CIMMYT’s germplasm offered rich genetic complementation for desirable traits for improved adaptation, good producibility, drought tolerance from Drought Tolerant Maize for Africa (DTMA) populations and other highly desirable traits, which were integrated through crosses with Monsanto lines having good genetics for yield enhancement and drought tolerance offered unique opportunities to improve maize germplasm for Africa. These materials have been with African national partners who explored the new enriched germplasm in classical breeding approaches to improve the genetic background of farmer-preferred maize germplasm to enhance maize performance under optimum and moderate stress conditions (24-49% moisture stress growing conditions) in Africa.

The enriched germplasm created good genetic base for the development of good populations for molecular breeding in attempts to strengthen forward breeding and rapid genetic gains. The improved germplasm provided strong power to explore biotechnology tools or platforms to track useful genetic variation and architecture critical to accelerated breeding. WEMA and TELA facilitated access to doubled haploids (DH) facilities of CIMMYT and Monsanto, which rapidly aided the development of thousands of improved inbred lines, and single-cross and three-way hybrids which have significantly improved productivity and genetic gain in maize in recent years [4]. Results indicate that superior DH lines outperformed top pedigree-based lines under both optimum-moisture and drought stress conditions. Yield range for DH lines under optimum-moisture conditions, for example, was between 3.5–4.7 tons/ha and were superior to pedigree-based lines with yield range of 2.2–3.4 tons/ha.  Similarly, under drought stress conditions, DH lines expressed yield levels of between 1.4 and 2.1 tons/ha compared to 0.06–1.2 tons/ha for pedigree-based lines.

Molecular Breeding Architecture for Fast-tracked Forward Breeding

Both WEMA and TELA projects used a stepwise approach that explored several molecular breeding paradigms which were arched as connected pipelines to strengthen, and drive accelerated improvement in genetic gains based on a complementary and highly synergistic system. Each segment of the breeding system adopted made a significant contribution to the whole process (Figure 1). The foundational basis for the molecular breeding architecture application adopted in the two projects, was the utilization of the enriched pedigree breeding populations used to further create bi-parental and multi-parental quantitative trait loci (QTL) mapping populations. These populations were used to identify useful genetic factors to dissect and better understand the complex underlying basis for drought tolerance and yield in maize. SNP markers were used for molecular studies by the project consortium to identify QTLs for the primary traits of focus (i.e., drought tolerance and productivity) which are mainly influenced by polygenic inheritance expectedly. MARS was used to identify QTLs of major and minor effects for improved performance under optimum-moisture and drought stress conditions.

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Figure 1: Integrated molecular breeding system of pipelines.

The ability to explore higher number of QTLs for trait improvement under marker assisted recurrent selection (MARS) efficiently helps to provide good measure of the phenotypic variance driving complex traits with better control than would be expected for marker assisted selection (MAS) that is more amenable to traits controlled by few genes. Both major and minor QTLs were mapped.  Over 180 QTLs were identified in trials for traits of adaptation and resilience mainly having phenotypic variance explained (PVE) of 1.2–13.1%. For traits like Maize Lethal Necrosis (MLN) disease, whose study were incorporated at the onset of the disease’s outbreak in 2012, three QTLs could explain up to 40–50% of the phenotypic variance [5]. Once QTLs are efficiently mapped, MARS as a molecular breeding (MB) approach, typically minimizes the frequency of phenotyping during breeding cycles when crosses are being made to develop best haplotype combinations and gene pyramiding to accelerate genetic gain. Genomic selection (GS), as further step was also subsequently used to advance genetic gain over MARS thus, integrating more genome coverage for additional genetic factors controlling crop performance both under optimum-moisture and drought stress conditions. Results indicate that MARS and GS increased genetic gains four times over pedigree selection in the project [6].

Hybrids developed through these conventional processes were released as DroughtTEGO® in the project target countries. In further progression towards improving the genetic gains of the drought tolerant hybrids developed, the inbred parental lines of the released best performing hybrids in the target countries were selected and used for trait integration for drought tolerance through genetic engineering in Bayer Crop Science facility. MON87460 (DroughtGard®, CspB gene) was used for the transgenesis. Pest build-up of stem borers (Busseola fusca, Chilo partellus, and Sesamia calamistis) on the fields are often associated with drought stress, so trait integration of MON 810 (Bt gene) for insect protection of maize was done as well and hybrids evaluated for efficacy and productivity effects. Meta analyses of field data from multiple years and several locations across countries for these trait integrations have revealed 17% yield increase for MON87460 efficacy and 43% increase in yield for MON810 efficacy (Figure 2). Further, results indicate that MON810 partially but significantly controlled the fall armyworm (Spodoptera frugiperda) insect pest in the studies.

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Figure 2: Efficacy of GM (Stacked MON810+MON84760) vs. Non-GM Genotypes and Commercial Checks.

Transgenic hybrid maize developed by the project has been released as TELA®, as its brand name. Thus far, TELA® hybrids have been released in South Africa while several other promising TELA® products are at advanced trial stages either for commercial release or deregulation in the other countries. Trait integration is still on-going with over 170 inbred lines traited already by the first quarter of 2021. A total of 128 maize hybrids have been released from these projects as at 2020 (Table 1) with five being TELA® within a short space of time through this PPP. Yields of the released hybrids are relatively at about 10 tons/ha under optimum-moisture conditions and nearly 5 tons/ha under drought stress conditions, exceeding current yields farmer grown varieties which were often 2 tons/ha or below when the initiatives started in 2008.

Table 1: Dissemination of Climate Smart Maize.

Year

Climate smart maize developed and released

2013

1

2014

22

2015

21

2016

55

2017

7

2018

11

2019

8

2020

3

Total

128

Impactive Integrated Breeding as Driver to Product Scaling

The integrated breeding strategy adopted by the projects encompassed extensive field trials to address the relevant diverse maize growing agroecologies of Africa to maximize scalability of the products in a rapid time and cost-efficient approach during scaling to other countries. WEMA wide trials were conducted first in the five first-tier target countries to assess and identify hybrids that were well suited/adapted to low-, mid- and high- altitude conditions in addition to selecting for early-, mid- and late- maturing varieties. They allowed the WEMA project to easily, based on hybrid descriptors, match DroughtTEGO® hybrids to different production zones outside the first-tier project target countries. Under the TELA project, with increased pedigree and genomic information, hybrid testing and selection of the best inbred lines and hybrids were efficiently deployed for testing in Ethiopia and Nigeria within few season trials with promising products advanced to national variety testing and then finally released within 2-3 years. In such a relatively short time, the DroughtTEGO® hybrids were availed for deployment to farmers in these second-tier target countries of the project. Product scaling to other countries is expected to progress through other initiatives for these products. The released DroughtTEGO® hybrids in both Nigeria and Ethiopia will be further traited for insect protection genes (MON810 and MON80934) and MON87460 for drought tolerance in collaborative engagement with the regulatory authorities of both countries.

Enabling Support System Needs of Africa

Molecular breeding requires efficient infrastructural support systems and good policies to drive implementation of product development with the best strategies as articulated above. While marker aided breeding does not have inhibitory laws holding its application, this is not the case for the genetically modified (GM)- based research where many countries in the Africa still have no regulatory frameworks to support its application. Where such systems are in place, cost are still prohibitory, making it more complicated to offer good entry for public-sector driven breeding initiative. A functional and easily facilitated regulatory systems are critical to building trust and confidence in the use of GM technologies and the expected products from such a process. AATF, working with its partnership has significantly improved the regulatory environment within Africa, getting its first GM food crop (Pod-borer Resistant [PBR] Cowpea) released for commercialization outside Republic of South Africa (RSA). It is hoped that TELA® hybrids will be released soon in the other countries outside RSA.

Although MAB has a friendlier environment, the lack of capacity and limited expertise in the application of this technology could hamper the effective use of the numerous strategies it offers for rapidly developing precise and improved products for farmer and consumer needs.  Increased investments in molecular breeding are, therefore, a key area requiring attention to maximize the benefits of modern breeding in Africa.

Conclusion

Biotechnology has evolved in the last few decades to address some severe limitations with classical breeding related to genetic variation, biological factors, speed, cost, and efficiency in responding to global needs of food and nutrition security as it relates to product development. The initiatives described above indicate that several molecular breeding approaches must be integrated to drive genetic gains and productivity to steer impact in huge proportions. Combining both classical breeding with molecular strategies result in better and robust products than if either strategy was used independently. The power of molecular breeding is largely dependent on the populations explored for genetic improvement as not every population is most suitable depending on the traits of focus. Given that breeding is often geared towards addressing several traits of different genetic basis (modes of inheritance and expression mechanisms), an integrated breeding approach is the most pragmatic way to addressing crop improvement needs of the 21st century. The breeding pipelines used in these studies will hopefully, lead to an array of drought tolerant hybrid maize several years to come in efforts to mitigate climate change impacts. With genome editing strategy coming on pace, it will no doubt further enrich the integrated breeding platform now evolving to modernize African agriculture.

References

  1. Meschede C (2020) The Sustainable Development Goals in Scientific Literature: A Bibliometric Overview at the Meta-Level. Sustainability 12: 4461.
  2. Voss-Fels KP, Stahl A and Hickey LT (2019) Q&A: modern crop breeding for future food security. BMC Biology 17: 18.
  3. Ray RL, Fase A, Rosch E (2018) Effects of Drought on Crop Production and Cropping Areas in Texas. Agric Environ Lett 3: 170037.
  4. Odiyo O, Njorogeb K, Chemining’wab G, Beyene Y (2014) Performance and adaptability of doubled haploid maize testcross hybrids under drought stress and non-stress Conditions. Int Res J Agric Sci Soil Sci 4: 150-158.
  5. Semagn K, Beyene Y, Babu R, Nair S, Gowda M, et al. (2015) QTL mapping and molecular breeding for developing stress resilient maize for sub-Saharan Africa. Crop Science 55: 1449-1459.
  6. Beyene Y, Semagn K, Mugo S, Tarekegne A, Babu R, et al. (2015) Genetic Gains in Grain Yield Through Genomic Selection in Eight Bi-parental Maize Populations under Drought Stress. Crop Science 55: 154-163.
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Exploding Five COVID-19 Myths on its Origin, Global Spread and Immunity

DOI: 10.31038/IDT.2021223

Abstract

By critically analysing and exploding the key foundation myths that have arisen around the origin, mode of spread and immunity on COVID-19 we lay out the evidence and critical arguments supporting an immediate end to all COVID-19 justified lockdowns. These emergency laws, invoked by many previously free and democratic societies, involve social distancing, obligatory wearing of masks, limited crowd sizes and gatherings (funerals, weddings, religious gatherings, sporting fixtures etc), the closures of schools and many small and large businesses not deemed necessary to containing the virus, border closures, and thus free travel movements, domestic and international. The basic premise in all these dictums is that the primary mechanism of spread of COVID-19 is assumed via person-to-person contacts only. We show this premise to be false. Our recommendations are anchored in the key relevant evidence and observations of the past two years gathered by us and published in a series of papers through 2020 and 2021. Our analysis documents the plausible putative first cause to the arrival of COVID-19 from space in a carbonaceous meteorite bolide the in stratosphere over China on October 11 2019; and then its blanket China-wide viral-laden meteorite dust contamination through November-December 2019 followed by further global dispersal of these viral-laden meteorite dust clouds by prevailing stratospheric and tropospheric wind systems, including human passaged virus aerosol-plumes adding to lower level (tropospheric) viral laden clouds. We explain why all lockdowns of any type cannot possibly work in principle against viral dispersal and transportation of this type – emergence of new clusters of disease, with poor evidence of connectivity through contact, clearly does not support person-to-person infections as the primary cause of spread. The initiation of mass infective events (“Mystery Cases”) in each regional and localised COVID-19 epidemic is caused by unsuspecting victims most likely catching the virus by rubbing up against a virus contaminated environment. We also deal with the efficacy of current vaccination roll outs on population-wide scales. It is most unfortunate that currently available mRNA expression vector vaccines, delivered by the intramuscular route (“Jab in the Arm”), may not only be dangerous in inducing many putative adverse reactions as their human safety is untested, they also cannot protect in principle against common cold and other respiratory pathogen infections like COVID-19 that arrive via the oral-nasal route. That evidence is discussed along with our recommendations for mankind’s preparedness for future suddenly emerging pandemics of this type.

Introduction

We have published recent papers that review the evidence that the prevailing global wind systems are the primary distributors of COVID-19 viral-rich clouds [1-3] and a detailed summary of the analysis of a clear set of mystery outbreaks in Victoria, Australia May-June 2021 [4] which constitute unequivocal evidence of a non-person-to-person introduction of the virus. These airborne viral in-falls from the troposphere have resulted in significant region-wide environmental viral contaminations, both small and large scale across the globe, of meteorite-derived viral-laden dust clouds. These include sudden strikes of COVID-19 outbreaks on crew and passengers on ships at sea [5,6] islands such as Sri Lanka that had avoided the epidemics until Oct 6 2020 [7] and the remote Chilean O’Higgins Army Outpost in Antarctica where most of the personnel were struck down suddenly and simultaneously with COVID-19 in late Dec 2020 [3].

While some infections can theoretically be caught by victims from breathing in viral-laden dust particles in the air, the case Incidence maps which show the stability of an infected zone outbreak in carefully analysed specified regions (as an example, selected parts of the State of Victoria in Australia and State New South Wales, covering pre-Winter and Winter months May-Sept both 2020 and 2021) suggest alternate explanations. We surmise that most infections are caught by unsuspecting victims from contact with a virus-contaminated environment (e.g. contaminated fingers or contaminated face masks themselves) with subsequent transfer to portals of entry via oral-nasal passages, initiating an infection in the lining of the respiratory tract. Case Incidence maps for Victoria, Australia and the prevailing weather directions of rain visiting Victoria from Southern Ocean are shown in Figure 1a and 1b.

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Figure 1a: Map of COVID-19 outbreaks (40-50% Mystery cases) in Victoria Winter 2021. Note the whole town of Shepparton 190 km north of Melbourne was a cluster of numerous and sudden mystery outbreaks (unlinked genomically in sequence to Melbourne ‘Delta’ outbreaks according to newspaper reports) as Melbourne was sealed off by a ‘ring of steel’ hard lock down with night time curfews, no movement in or out of Melbourne, no travel through country regions, and the border with New South Wales was sealed by police, army and surveillance drones.

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Figure 1b: Infection arc of Figure 1a showing very similar to prevailing Winter weather into Victoria from the Southern Ocean. Notice that the East of the State (Figure 1a) is basically virus free. The same pattern was observed in 2020 (see Appendix A).

The viral-laden dust clouds would need to be brought down to ground by local precipitation (rain). This likely occurred through most of 2020 across the globe given the localised stability of regional outbreaks (USA, Europe, Pakistan, Japan, South Korea, South Africa and the Indian subcontinent), particularly through April-May 2020 on the 40° N Latitude band prior to the strike on New York City. Early outbreaks in South Korea and Japan were also centred on this latitude line [1]. On either side of this line, during this 2020 time interval, there were many countries which represented infection “null zones”, which soon became engaged north and south of the 40° N line (France, United Kingdom, most countries in Europe and Russia and Scandinavian countries). Subsequently we have suggested that the putative meteorite viral-laden dust clouds then washed down and entered the Southern Hemisphere over the Atlantic Ocean [2]. The viral clouds were then brought to Australia in 2020 along the 40° S latitude Line, via the W->E Roaring Forties prevailing winds to Victoria and to a far lesser extent into NSW, Australia (May-Sept 2020, and then again in 2021, including the significant out breaks in French Polynesia 2020-21 as well as small outbreaks in New Zealand [3]. In Australia in both winters Western Australia (Perth), South Australia (Adelaide), Tasmania (Hobart, Launceston), and Queensland (Brisbane) were all null zones, only suffering transient outbreaks via infected international passengers entering by jet planes. It is very important to understand such null zones, as they confirm the annual regularity of the prevailing wind and weather systems – the COVID-19 strikes in Australasia were clearly governed by these predictable weather systems.

Later in the year 2020, and into 2021, the main spreads and regional in-falls could well have been of human passaged COVID-19 rich viral dust clouds generated by the significant tropospheric plumes of viral aerosols above United Kingdom, India, South Africa, Brazil and other countries through the later months 2020 and through 2021 [4]. Other genomic and epidemiological evidence to be referred to here is an analysis of >12,000 full length COVID-19 genomes and associated epidemiology data publicly available from the 2nd Wave COVID-19 epidemic in Victoria, Australia June-Sept 2020 [8]. This analysis builds on the COVID-19 full length genome analysis in clear hotspot epidemics in [9]. Here we expose to critical scrutiny the unscientific myths in wide mainstream media circulation (and also actively promoted by the same media particularly the global News Ltd media) which has driven the global response of all governments and their health authorities.

What Actually Happened in China Late 2019 and Early 2020?

Before exposing the key circulating myths we must have a clear-eyed view of what actually transpired in China late 2019 through January 2020, and into the explosive exponential rise in COVID-19 case numbers per day in January 2020 [9]. The earliest confirmed cases in retrospect emerged from late October-early November [10]. The widely discussed data is based on the Wuhan epidemic in Hubei province central China but it is clear from all the data collected at the time from across China that a series of China-wide explosive epidemics occurred simultaneously (Figure 2). Any explanation has to manage this clear fact – tens to hundreds of millions of Chinese were exposed and succumbed to COVID-19 infections over a short time period, too fast for any type of person-to-person (P-to-P) spread as is commonly assumed by mainstream epidemiological theory and bat-human and most Lab leak conspiracy theories.

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Figure 2: This is Figure 7 discussed in depth in Ref [11], Steele EJ, Gorczynski RM, Lindley RA, Tokoro G, et al. (2020) Origin of new emergent Coronavirus and Candida fungal diseases- Terrestrial or Cosmic? Advances in Genetics 106, 75-100 https://doi.org/10.1016/bs.adgen.2020.04.002

Current Myth#1

The COVID-19 pandemic began with a sudden explosive animal – to – human jump on China-wide scale of the earlier SARS-CoV-1 now in a bat or pangolin reservoir in South East Asia.

Both we and mainstream viral molecular evolutionists (e.g. Professor Andrew Rambaut, University Edinburgh; Professor Ed Holmes, University of Sydney) agree such a jump is statistically impossible on the basis of all existing SARS-CoV-2 “like” sequences isolated from putative bat, pangolin or cat reservoirs. We discuss these data and calculate the odds of a “jump” giving a COVID-19 sequence match [6]. For the closest known bat sequence, 96.2% similar to COVID-19 across the full length 29903 nucleotide (nt) positions of the Wuhan or Hu-1 reference sequence, the probability of getting a match of a correct nucleotide substitution at approx. 1100 positions is of the order one successful trial in 10684 random trial jumps. If we are generous and assume there is a sequence of 99% similarity to COVID-19 lurking in some unknown bat or pangolin animal reservoir it is 10184. If the reader has difficulty grasping the essence of such astronomical numbers a good comparator number is 1084, the number of Hydrogen nuclei in the known Big Bang Universe (H atoms quantitatively dominate the known Universe). So getting a successful jump outstrips, by many orders of magnitude, the molecular and statistical resources of the known universe. To re-state the obvious conclusion: this infection did not come from an infected bat via wet market contact (supported also by all the early reports that exclude such ‘origin’ sources on other grounds [11-13].

Current Myth#2

The COVID-19 pandemic began with a sudden explosive release of a genetically engineered virus just like COVID-19 (the full length 29903 nt Hu-1 sequence) from the Wuhan Institute of Virology. This has been actively and strongly pushed by Professor Nikolai Petrovsky (Flinders University), Sharri Markson the lead investigative journalist in News Ltd in Australia, other writers in The Australian newspaper, many Fox News Channel (News Ltd) talking Heads eg Tucker Carlson Tonight and others on FNC) and many writers in The Wall street Journal (News Ltd) and The London Times (News Ltd, including Professor Luc Montagnier [14]). It is a fair assessment that the News Ltd media in particular has actively pushed this Cold War Conspiracy. Theory propaganda globally on a massive scale. Ex-president Trump also argued the same case with his ‘China Virus’ accusations in 2020, despite having been told this story was most likely false “in a big power telephone communication” on Feb 6 2020 with President Xi – see Appendix B, pages xviii-xix Bob Woodward’s book Rage: “It goes through the air,” Trump said. “That’s always tougher than the touch. You don’t have to touch things. Right? But the air, you just breathe the air and that’s how it’s passed. And so that’s a very tricky one. That’s a very delicate one.”

Notice that none of the material put out by those advocating a human-engineered cause (Petrovsky, Markson, Carlson, Montagnier et al ) ever attempts to grapple with a wealth of precise facts that need to be considered (see Figure 2). Our own explanation of a natural cosmic cause is plausible in terms both of timing and location, given the Oct 11 2019 meteorite strike over Nth East China [15,16], and all existing historical and recent knowledge on life bearing carbonaceous meteorites arriving in the stratosphere prior to COVID-19 [17-19]. Our analysis comes to grips with this explosive first strike (Figure 2) of putatively tens of millions of mystery infections imposed across a vast area of China (Dec 20219-Jan 2020) and the subsequent sequelae of epidemics (and genetics of the virus) on the ground in the first few months after Oct 11 2019, first in China, then elsewhere in South East Asia, Western Pacific, then Iran, Italy, Spain and New York City [1,6,9]. Of course, following a mystery infection (falling from the sky) there would then be person to person (P-to-P) spread to close contacts and to close uninfected family members (the genetic data from the Wuhan sequences suggest 1 or at most two P-to-P transfers, [9]). This we do not deny. Such a human passaged transmission would have begun immediately in China, resulting eventually in a rising aerosol plume of human passaged COVID-19 virions being lofted into the troposphere above China. The infective strikes on the cruise ships in the South China Sea and Sea of Japan (Diamond Princess, Westerdam), the USS Theodore Roosevelt aircraft carrier (May 2020, north Pacific Ocean) and the sudden strike in late February 2020 on the other side of the Pacific Ocean on the Grand Princess cruise ship, support lower level West -to-East global transport of the Wuhan human passaged viral plume cloud across the Pacific in this time interval [3]. This is consistent with the available genetic evidence viz. unmutated and lightly mutated Hu-1 sequences (L or in Pango, B) among infected passengers/crew on that ship [9].

The meteorite viral-laden dust cloud arising from a cometary strike over Jilin, North East China on the 40° N line on the night Oct 11 2019 was, we believe, the likely first deposit of viral-laden dust into the stratosphere above China – and its East to West stratospheric jet stream transport ensured global spread – coincident with a first ground strike by the direct faster fall of a fragment of the viral-laden meteorite cloud to ground blanketing China through November and December 2019, although still centred on Wuhan. The estimate of the earliest cases in November fit this explanation [10]. This explanation is consistent with all known facts about the early months as the pandemic ignited in China. It is far more plausible and parsimonious than the animal jump or Lab leak theories, and does not require multiple additional, and implausible, assumptions (further discussed below and Appendix C). The cause of the many genuine ‘mystery cases’ observed in Victoria (and NSW) in Australia in 2020 [8], and 2021 needs to be interpreted in the same way, but on a far smaller scale of infection numbers [4]. The stability of the infection arc over two winters in Victoria (Figure 1 and Appendix B for 2020) implies prevailing weather patterns. The null zones of Perth (Western Australia), Adelaide (South Australia), Hobart & Launceston (Tasmania), Brisbane (Queensland), despite all the political finger pointing in Australia, are most simply explained as arguing that all those other Australian states were lucky- they were not in the “teeth” of prevailing weather winds and in consequence they have avoided the political, social and economic mayhem which has followed the “conventional dogma explanations”.

Implausibility of Lab Leak Theories

We next turn attention to confront in detail and properly assess the “Lab Leak Conspiracy” theories that are gaining widespread apparent momentum and respectability in the public mind. As stated above these models require multiple additional, and in our view implausible, assumptions, which are discussed in depth in a series of numbered points (below and Appendix C). In exploring in detail the implications of the ‘Predictions’ of this theory, as we would for any scientific theory, which must be tested also for coherence and robustness, and here to, by necessity, we will limit the number of tacit and overt assumptions (and Appendix C). The advantage of the latest claims is we can examine the predictions. The claim now is that an engineered COVID-19 virus culture at very high titre and thus dose was somehow deposited in the stratosphere and thus entered into the global weather system over China. In our view this is a concocted and politically convenient cold war conspiracy fantasy (Sharri Markson Wed 15 Sept 2021 p.1 The Australian newspaper “Revealed: US failed to act on Covid-19 intelligence, says Wei Jingsheng”, the latter is a Chinese defector to the USA).

In exploring the implications and predictions of this assertion for coherence and scientific plausibility, readers must also stay aware of the scientific plausibility of the argument, critique any data put forward to support it, and ask themselves whether it even “makes sense” to imply a ‘human purpose’ and ‘motivation’ for a first strike stratospheric cause which fits the observed and sudden China-wide infection data (vide supra). We have already made clear that in our view all the available scientific data is consistent with the pandemic being a natural phenomenon – like that which occurred 100 years ago in an era before viruses were not fully characterised and a time when DNA/RNA genetic manipulation biotechnology did not exist. As we shall show the assumptions needed to defend a conspiracy alternative are ad hoc, without independent evidence, and so also are the number of additional concepts needed to reconcile with the available epidemiologic and genetic data

Points to Consider as Arguments in Favour of a “Lab Leak Conspiracy”

  1. A balloon launch or drone plane flight released a viral ‘bomb’ in the stratosphere over China. There is no reported evidence, from China, US or European satellites of a balloon launch, drone flight, or spy-plane which could be responsible, in Oct-Dec 2019. No coherent argument (political) has been suggested for who might have been responsible for such a strike, and why.
  2. If it was from outside China, one would expect the Chinese military to have neutralised it quickly and for there to have been political repercussions-it is hard not to expect repercussions detected by the rest of the world if a launch occurred from within China itself. The viral vector vehicle is postulated to harbour a pure culture of COVID-19 virions with an exact genomic sequence to the Hu-1 (Wuhan) reference sequence, and would need to be in the stratosphere on the 40° N line above China in the period Oct-Dec 2019 to fit the known subsequent global spread and time lines. Simultaneous infection of multiple Chinese cities, with the biggest dose over Hubei/Wuhan, has also to be explained-does this imply multiple deliberate releases?
  3. How and where was the exact COVID-19 29,903 nt sequence made? Was it at the Wuhan Institute of Virology, or the National Institutes of Health (NIH), Bethesda Maryland, where Dr. Fauci’s group are based, and are known collaborators with the Wuhan laboratory (according to Tucker Carlson and many other news outlets). Furthermore, if the infection source was a product of a bioweapon development program, why was a common cold coronavirus chosen, which has such low mortality effects, causing death in <1% of the exposed population (with deficits in Type I and III Interferon responses [21-26]? One could claim that this was a “trial run”, but that also brings up the question (if this really does represent a trial bioweapon) how is it planned that the designers of this agent would be protected?

This short summary shows that Sharri Markson, Luc Montagnier, Wei Jingsheng, Nikolai Petrovsky and all the other writers elsewhere and at News Ltd on the influential The Australian newspaper in particular (Nick Cater, Adam Creighton, Paul Monk) have not thought through the implications of these proposals. There must be, as was the case with the 9/11 strike on the World Trade Centre, a significant amount of discoverable ‘human-factor’ associated-evidence behind this stratospherically launched viral attack over China and thus the world in Oct-Dec 2019, if there is any credibility to this theory-none has been reported. Scientific analyses of data and observations and building of explanatory models works in a different way. Science sticks to known facts, plausible mechanisms, with an absolute minimum number of useful assumptions, to explain the observed facts in a coherent way. As soon as the tested theory starts to flounder without the introduction of an ongoing series of ad hoc assumptions, the theory is abandoned and new, testable, hypothesis considered. Our published explanation has, to date, consistently explained the myriad of global data, without any need for further modification.

Current Myth#3

COVID-19 is a very severe respiratory disease resulting in death in many people.

All the current evidence strongly suggests that a very small immune defenceless group of patients lacking type I and type III interferon innate immunity responses are vulnerable and at high risk of death to COVID-19 infection [20-25]. In longitudinal studies these innate immune deficits are revealed, as expected, very early in infection in patients with a poor prognosis [24] (Figure 2c in that paper). Therapies to quell the respiratory crisis clearly need to be implemented very early in the infection in order to prevent life threatening pneumonia and other respiratory compromise. Included amongst such conventional therapies are pulse steroids (including prednisone; inhaled budesonide; dexamethasone) along with anti-viral agents (remdesivir) and other more novel immunobiologic interventions (monoclonal antibodies). Ivermectin therapy, although controversial, has also been suggested as a novel treatment [26]. What proportion of the population falls into the “immune defenceless elderly co-morbid group”? In surveying Cases and Deaths world-wide for some 18 months, and applying reasonable correction factors for the Numerator and Denominators in different countries and an assessment of the coverage and reliability of the tests and death outcomes in different countries and regions an estimate of 0.1% of all Covid-19 exposures appear to result in severe outcome, viz. death by COVID-19. A concrete example illustrates the calculation on data released on September 12 2021 at the NSW Dept Health Website, https://www.nsw.gov.au/covid-19/find-the-facts-about-covid-19#nsw-covid-19-datasets

For all COVID-19 Cases to date (for 2020 -21) there have been 41,999 confirmed cases of COVID-19 (severity has not been appended or made public here). There have been 14,701,732 PCR tests in a population of about 7 million over 2020 -21 to Sept 12 2021. The number of lives lost 2020-21 is 226. The great bulk of the deaths (as in Victoria in 2020 [9]) would occur in the ≥ 60 yr group (≥97%) or ≥ 70 yr group (≥94%). Clearly COVID-19 infection caused by any variant (raw meteorite dust or human passaged plume dust) causes high mortality in a very small vulnerable subset of the elderly population, as was evident in Wuhan in Jan 2020 and New York City (Mar-April 2020). What is this fraction? In NSW the Death rate is 0.54% on the above numbers, if you correct the Numerator (x2) and Denominator (divide by 2) for undetected cases and those dying with COVID-19 you arrive at a proportion close to the global estimate mentioned already of 0.1% deaths of all COVID-19 exposed cases in New South Wales in 2020-21. In the USA the correction to the Denominator is obligatory as in April-May 2020 the White House Chief Medical Advisor Dr Deborah Birx made it clear on several occasions in public that all deaths in COVID-19 positive patients would be scored as “COVID-19 deaths”. This has catastrophic consequences for an accurate appraisal of all the data coming out of the USA- the data, as presented, simply is not reliable, and needs to be corrected the way it has been done above. Indeed, the same erroneous calculation has almost certainly been going on all over the world – and is clearly also evident in public information released by the Victorian and New South Wales Departments of Health, their Chief Health Officers and their Health Ministers. viz a sensational headline of young people dying of COVID-19, only to be revealed later or fine print of the same report that many of the patients had very severe comorbidities (a curated and backed up digital file of most newspaper reports of this type in Australia 2020-21 has been maintained by the authors and the assertions can be backed up by news reports).

We posit the inescapable conclusion that the COVID-19 pandemic is a pandemic of a (slightly more severe?) common coronavirus (influenza-like) infection which >99% of people shrug off as they have throughout previous cold and flu outbreaks in past years. This has been dealt with in the past without widespread isolation, wearing of masks, and being locked at home with businesses and schools closed down. Indeed in past Influenza seasons the mortality rates in geriatric, aged care /nursing home facilities have often been higher during influenza epidemics (Table 1, summarised from Melbourne’s Herald-Sun p.32 29 August 2021). A comparison with influenza in Australia 2019 prior to COVID-19 shows that the seasonal influenza outbreaks in that year took a greater toll in cases and similar numbers in deaths. The numbers are biased because of the situation in Victoria [8]. There was massive political incompetence and chaos in Victoria in 2020 (and into 2021) – a reflection of the poor government and health system incompetence. Also, all the aged carers (usually Asian women with families to feed on poor wages) worked across multiple aged care and nursing homes and were very efficient viral vectors- a veritable bonfire of the nursing and aged care homes, almost simultaneous ignitions on scale. It was mainly caused by the single clone the L241f.1vic haplotype identified which the health authorities tracked and released genomic sequences of – although they did not release the genomes of the approx. 40% of mystery genome sequences (>3500) where it is hard not to see those infections not playing a role in the aged care and nursing homes. This is covered in detail [8].

Table 1: INFLUENZA v COVID-19: By the numbers.

Australian Influenza Cases in 2019

NSW

112,841
Vic

66,015

Qld

66,407
WA

22,720

SA

22,754
ACT

3,952

TAS

2,937
NT

1,458

Source: National Notifiable Diseases Surveillance System, Oct 2019.

Australian COVID-19 Cases in 2020-21

NSW

20,466
Vic

21,618

Qld

1,972
WA

1,064

SA

870
ACT

300

TAS

235
NT

201

Source: covid19data.com.au, 25 Aug 2021.

Australian Influenza Deaths in 2019

NSW

334
Vic

138

Qld

264
WA

80

SA

119
ACT

10

TAS

0
NT

5

Source: NSW Health, Victorian Influenza Snapshot, Qld Health, SA Health, ACT Health NT Health.

Australian COVID-19 Deaths in 2020-21

NSW

129
Vic

820

Qld

7
WA

9

SA

4
ACT

3

TAS

13
NT

0

Source: covid19data.com.au, 25 Aug 2021.

However, we have deduced, no real viral cloud in-fall occurred in the other Australian states. More than 95% of COVID-19 infections were in Victoria in 2020. The other states had mainly infected travellers from overseas or interstate from Victoria. Mystery infections in Victoria in 2020 were about 40% of all cases (often publicly confirmed as unlinked by genomic sequencing to known nursing home clusters) – these 3500-4000 genomes have yet to be released into the public scientific domain by the Peter Doherty Institute despite repeated requests in writing by the authors. Very few deaths this year so far in both Victoria and NSW, and mystery cases when reported are running at least at 50% of all PCR positive cases. All the details are not being released by the health authorities. It is conceivable that in 2021 lessons have indeed been learnt and aged care facilities may well be applying immediate therapies to the infected elderly to quell the respiratory crisis (and prevented employees working across multiple facilities). The infection flare-ups discussed below (Figure 3) appear now in large migrant 3-generation families under one roof in West-North suburbs of Melbourne (but same infection arc as 2020), and South-West arc of infections in Sydney, NSW.

fig 3(1)

fig 3(2)

Figure 3: Cases per day plots in Victoria and NSW May-August 2021.

So COVID-19 is potentially dangerous for those with severe innate immune deficit in type I and III interferon responses [8] and references above. The target vulnerable group that requires special immediate therapeutic care are our elderly citizens in geriatric, aged care and nursing homes – as has always been the case in past cold and flu seasons in Australia. Indeed, in the early phases of this pandemic, the global argument for any restrictions (“lockdowns”) was to give time for health care systems everywhere to “get their ducks in order” so they were not overwhelmed and could be better prepared to deal with infections in those most at risk-that valid argument was rapidly forgotten, and people seemed to accept the early response strategy as a valid long-term one, without ever questioning why this viral infection should merit such long-term draconian responses. It is apparent with COVID-19 that elderly grandparents that still live with a wider three-generation family under one household roof are now especially vulnerable – as is typically the case for many recently arrived migrant families in the communities of western Sydney and western /northern Melbourne in Australia, in particular.

Current Myths#4

Nature of “Virulence’ with COVID-19? “Highly virulent rampaging and transmissible variants” (UK Mutant, South African mutant, Indian Delta etc).

Virulence is a term now widely and loosely used in the media and by political leaders and Chief Health Officers, without any good consensus as to its biologic meaning. In the current “Delta” outbreaks in Victoria and NSW the public is told that “Delta” seems to be “speeding through the community” indeed so fast it out runs the contact tracing teams, and it must therefore represent a highly virulent and transmissible variant, and thus a forebearer of a dangerous disease. When the sudden outbreaks in Shepparton, 190 km north of Melbourne began to appear from August 21 2021, one might have hoped for a pause for critical thinking by Victorian Premier Daniel Andrews and Chief Health Officer Brett Sutton. A “ring of steel” had been erected around Melbourne (from Aug 11) and hard stage 4 lock downs (and night curfews) had begun much earlier. This meant that no one from Melbourne could have travelled to/from Shepparton- and given the northern border with NSW was sealed (by police, army and drones) no one from the highly infected northern state of NSW could have come to Shepparton. We argue that only one infection route could and should have been considered……. “It must have come via an airborne route”. There is no public evidence that this explanation has been considered. At the time of preparing this paper, Sept 12-13 2021, the hard Stage 4 lockdown is still in place, cases per day are going up, 50-60% of all cases are genuine “mystery cases”, mandatory masks required inside and outside, QR tracking everywhere, hysterical headlines every day “to get tested” then “get jabbed”. Full night curfews are still in place. Only AFL Footballers (and NRL Footballers) seem to be able to move around. Many businesses have literally gone broke and many families will never recover. The number of bordered up businesses in the neighbourhood of EJS (Prahran, Toorak, Armadale, and South Yarra) is staggering. Long term social and health damage has been caused in Victoria, we are now in our 8th month of hard Stage 4 lock down.

However, we must be very clear, these lockdowns have had zero impact on the spread or apparent ‘virulence’ of the virus and course of the epidemics. The lockdown during the 2nd wave in Victoria in 2020 also had no effect, leaving us with the following conclusion [3]: “With respect to the symmetrical nature of the bell-shaped curves (Figure 4 below) describing the distributions of cases per day seen in such well documented epidemics such as the Victorian 2nd Wave an important deduction can be drawn about the impact of extreme ‘lockdown’ social distancing measures aimed at reducing viral reproduction rate Ro to less than 1. We have statistically analysed the Gaussian features of the Victorian 2nd Wave (which peaked on August 1-2, 2020). The best Gaussian fit with R2 gives 0.8999 which implies an almost perfect statistical fit to a symmetrical bell-shaped curve. Such a result would be consistent with the epidemic curve being overwhelmingly dominated by the growth and decay of a localised atmospheric in- fall event. The hard Stage 4 lockdown in Victoria came into effect on August 2, 2020. Given this perfect symmetry we conclude that the hard lock down measures had little impact, if any, on the course of the 2nd Wave COVID-19 epidemic in Victoria, Australia. This conclusion is consistent with the independent analyses of the impact of extreme lockdown measures on the course of the COVID-19 lockdowns introduced in a number of States in the USA during 2020 [27].”

fig 4

Figure 4: New SARS-CoV-2 cases per day recorded in Victoria, Australia, during 2020. These data can be accessed at https://www.dhhs.vic.gov.au/victorian-coronavirus-covid-19-data

Further Comment on COVID-19 Virulence

In our view the high virulence of a variant is an illusion caused by occurrence of multiple simultaneous ‘mystery cases’ occurring over a defined short time periods- a month or two via airborne region wide viral contamination. The impression of speed of transmission is created as unsuspecting victims catch CVOVID-19 via touching their contaminated environment. What then is the nature of the this suddenly emergent pandemic? Since COVID-19 first emerged in China in Dec 2019- Jan 2020 we have been trying to quell and eliminate a variant annual respiratory viral infection (similar to a common cold) – most (>99.9%) of all infected people handle the virus by Innate Immunity and Adaptive Immune Responses in the cells and tissues lining the mouth, nose, respiratory tract and lung- there is a vulnerable group about 0.1% of all infected people. The best response would have been to provide therapies and pro-active care of all Immune Defenceless Elderly Co-Morbid citizens through the respiratory crisis: Vulnerable age group for death by COVID-19 is ≥ 70 yrs and median is somewhere around 80-90 yr. COVID-19 is therefore basically a common seasonal respiratory virus, but if there is an Innate Immune Deficit that would result in uncontrolled replication and potential pneumonia [8].

Another Media Claim: Rampaging Virulent Variants?

Answer: No it just appears that way.

According to the main stream media and political leaders the human passaged COVID-19 variants currently engaging Australia and Northern Hemisphere infected zones (2021) such as the UK Mutant (alpha’), Indian Plume Mutants (‘Delta’, Kappa’) are apparently highly rampaging and virulent transmissible variants. This is not true. They have been spread and globally transported as viral-dust clouds first by prevailing tropospheric winds from the plumes of human passaged viral aerosols that arose in the original host country, and were then brought to ground by precipitation (rain) in defined regions. Figure 1 is illustrative: In Australia the prevailing weather systems have struck repeatedly in Victoria (South West-West- North arc of Melbourne into Northern regions (Shepparton, and maybe also further north east to ACT). The East of the State of Victoria has been virus free, 2020, 2021; in Sydney, NSW a similar defined arc Bondi-South West-West Sydney suburbs in 2021. Thus a viral-laden contaminated environment causing large numbers of effectively (in time) simultaneous “mystery cases “of community transmissions i.e. the variant(s) only appear as “Rampaging Virulent variants”.

However, they are dangerous in geriatric, aged care/nursing homes and in large three generation migrant families viz. closed clusters of Immune Defenceless elderly Co-morbid communities, where massive viral amplifications to trillions of virions contaminating all peoples and fomite surfaces in immediate environment. Thus carers, medical staff, family members and close associate who then all develop a flu-like illness (due to sheer viral dose loads at infection) are at risk of infection and likely to become PCR Positive. These are the ramping flare-ups in PCR Positive numbers per Day often seen in the published Cases Per Day Plots in both Victoria and NSW in 2021 (Figure 4) – and in the Victorian 2nd wave in 2020 (Figure 2). These striking features are NOT being discussed or mentioned in the mainstream media or press conferences. Such patients will be High PCR cycle number positives (i.e. very low numbers of virus or viral fragments in oral-nasal swab); and the primary infected amplifying elderly patients are expected to be very low PCR cycle number positive cases.

The other evidence against is that the “ UK Mutant” entered Australia by jet plane in Jan-Feb 2021 at multiple portals of entry (Perth, Adelaide, Brisbane, Melbourne etc) and also dispersed contacts to regional cities in Australia, with large numbers (hundreds) of putative contacts- hotel cleaners, drivers, departure and arrival lounges, trains, buses, kiosk workers at food counters, taxis etc: The UK mutant DID NOT spread person-to-person in Australia (but may well have amplified in communities of Immune Defenceless Elderly co-morbids if such an entry had happened, but it did not. So again the group that should be monitored and cared for are our elderly citizens. As we have discussed [8] these negative transmission data led the Australian epidemiologist at The Australian National University, Professor Peter Collignon, to release his considered opinion to The Australian newspaper [28]: “…In retrospect, the Melbourne lockdown was unnecessary… From my perspective, if you’ve got very little community transmission, I’m not sure that a short lockdown achieves much extra, if you’ve got good contact tracing and good testing,” he said. … “If I look at the lockdowns done in Adelaide, Brisbane, Perth, and now Melbourne, it didn’t turn up one more case than contact tracing did. … “The UK strain has not spread uncontrollably and wildly.” Further research is required to understand why the putative highly virulent “UK Mutant” did not spread when introduced via multiple entry points into Australia in the first few months of 2021.

Current Myths#5

Efficacy of current Jab in the Arm vaccines?

We have discussed [8, 29] why all “Jab in the Arm” vaccines, whilst stimulating systemic immunity in the blood stream (IgG and IgM complement fixing and other classes of serum antibodies and later potentially enduring cytotoxic T lymphocyte adaptive immunity) may not be the best antigen-delivery route for activating enduring mucosal immunity (non-complement fixing yet very avid neutralising secretory IgA including mucosal adaptive T cell responses). This can be expected based simply on current textbook knowledge and past experimental experiences. This explains why many examples are now emerging of a failure of twice vaccinated individuals to be protected against catching COVID-19 e.g. many high profile politicians, sportsmen, whole US baseball teams travelling on the road, and of course the current wide-spread infections in the State of Israel despite most of the population being double vaccinated. Further, the phenomenon of antibody dependent enhancement (ADE) means that such individuals are at additional risk to formation of complement fixing antigen-antibody complexes in lung capillary airways if they become subsequently COVID-19 infected compounding the severity of the pathogenic cytokine storms [30]. This unintended adverse consequence has been discussed at length by Professor Dolores Cahill in a recent May 21 2021 interview [31]. Indeed apart from all the other deep and genuine concerns widely held by scientists and in the community about the safety and adverse affects of these novel engineered mRNA expression vector vaccines [31], it is clear also to us, that the vaccine roll out has played little if any role at all in the clear decline of the severity of the pandemic in Northern Hemisphere infected zones [32]. Thus in exemplar countries, with a substantial vaccine roll out at time of writing, Sweden, Denmark, Netherlands, United Kingdom, France, Germany, Italy, and Israel it is clear the decline in respiratory disease severity as assessed by the metric “% COVIDI-19 associated Death” was well advanced and effectively over before the vaccine roll out began (Figure 5 for Denmark).

fig 5

Figure 5: Percent Deaths Among COVID-19 cases versus the timing of the Vaccination roll out (% population vaccinated) in Denmark.

In the case of Denmark there is clear supportive independent evidence that natural herd immunity induced by prior oral-nasal infections throughout 2020 prior to the vaccine roll out was the clear cause of the type of decline in COVID case severity curve typical of many countries in Figure 5. Thus, to directly quote from [8]: “Natural infections with SARS-CoV-2 (in recovered patients) would therefore be expected to induce protective dimeric sIgA mucosal immunity. Certainly the recent longitudinal population scale study in Denmark implies that prior infection with SARS-CoV-2 affords upwards of 80% protection in the population under 65yr against reinfection between the first and second major surges of SARS-CoV-2 in Denmark in 2020; with the protective rate in the re-infected elderly vulnerable group a half lower again at 47% [33]. These are encouraging findings suggesting, at the time of writing, that natural ‘herd immunity’ could be well underway in Denmark and similar Northern hemisphere infected zones in 2020 and into likely surges and waves of SARS-CoV-2 in 2021.” There is also reason to believe, given the failure of a typical ‘virulent’ mutant (UK Mutant) to spread widely and quickly by P-to-P spread in Australia that the human passaged variants are attenuating- typical during decline phases of all epidemics as the host v parasite interaction tempers the replicative efficacy of the pathogen.

Our Recommendations

Given that all the fundamental assumptions of all governments and all their chief health advisors and epidemiologists have been wrong about every aspect of the COVID-19 pandemic – from its origin, its global mode of spread and the best way to medically treat and induce vaccine-immunity against oral-nasal acquired cold and flu infection, we recommend the following:

  1. All lockdown measures to stop P-to-P be immediately lifted viz. social distancing, mask wearing, curfews, crowd controls, border closures, restrictions on business operations, school closures, church closures, sporting club closures, fitness centre closures etc.
  2. Abolish vaccination rollouts and stop vaccine mandates and passports: All government (and main stream media) propaganda about vaccines protecting individuals needs to cease; all vaccine mandates of all types cease (for work, business trading, travel domestic and international) be lifted.
  3. All State and International borders be immediately opened.
  4. Immediate financial compensation scheme by the Federal Government to help all Australian citizens affected by any of these clearly erroneous and wrong emergency power laws especially small business owners.
  5. An apology is in order for wrongful actions that have caused harm. From: Governments and their Chief Health Officers and associated organisations that implemented all lockdown and vaccine procedures. In Australia, The Therapeutic Goods Administration (TGA) including major scientific organisations that actually gave a scientific blessing to the Federal and State Governments justifying their actions (The Peter Doherty Institute, The Australian Academy of Science) all need to apologise.

As we have suggested on numerous occasions the world needs to accept that suddenly emerging diseases from space have been a regular feature of our history and the evolution of life on Earth. Thus, the need for early warning surveillance, via orbiting satellite platforms and sampling the meteorite and cosmic dust on the external surface of the International Space Station. This would seem a logical step now for mankind to take as a unified collective. Since many suddenly emergent pandemic diseases are often cold or flu viruses that target the respiratory tract it would be sensible to design all such future vaccines to mimic the natural infection portal of entry via nose and mouth. Vaccines designed to be delivered via the oral-nasal route would certainly induce acquired mucosal secretory IgA immunity which is the most likely population-wide identifiable immune factors responsible the currently observed population-scale ‘Herd Immunity’ [32,33].

References

  1. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Predicting the Future Trajectory of COVID-19. Virology: Current Research 4:1. https://www.hilarispublisher.com/open-access/predicting-the-future-trajectory-of-covid19-44601.html
  2. Wickramasinghe NC, Wallis MK, Coulson SG, Kondakov A, Steele EJ, et al. (2020) Intercontinental Spread of COVID-19 on Global Wind Systems. Virology: Current Research 4:1. https://www.hilarispublisher.com/open-access/intercontinental-spread-of-covid19-on-global-wind-systems-45198.html
  3. Steele EJ, Gorczynski RM, Lindley RA, Tokoro G, Wallis DH, et al. (2021) Cometary Origin of COVID-19 (2021) Infect Dis Ther 2:1-4. https://researchopenworld.com/cometary-origin-of-covid-19/
  4. Steele EJ, Gorczynski RM, Carnegie P, Tokoro G, Wallis DH, et al. (2021) COVID-19 Sudden Outbreak of Mystery Case Transmissions in Victoria, Australia, May-June 2021: Strong Evidence of Tropospheric Transport of Human Passaged Infective Virions from the Indian Epidemic. Infect Dis Ther 2:1-28. https://researchopenworld.com/covid-19-sudden-outbreak-of-mystery-case-transmissions-in-victoria-australia-may-june-2021-strong-evidence-of-tropospheric-transport-of-human-passaged-infective-virions-from-the-indian-epidemic/
  5. Howard GA, Wickramasinghe NC, Rebhan H, Steele EJ, Gorczynski RM, et al. (2020) Mid-Ocean Outbreaks of COVID-19 with Tell-Tale Signs of Aerial Incidence Virology: Current Research 4:2. https://www.hilarispublisher.com/open-access/midocean-outbreaks-of-covid19-with-telltale-signs-of-aerial-incidence.pdf
  6. Steele EJ, Gorczynski RM, Rebhan H, Carnegie P, Temple R, et al. (2020) Implications of haplotype switching for the origin and global spread of COVID-19. Virology: Current Research 4:2. https://www.hilarispublisher.com/open-access/implications-of-haplotype-switching-for-the-origin-and-global-spread-of-covid19.pdf
  7. Wickramasinghe NC, Steele EJ, Nimalasuriya A, Gorczynki RM, Tokoro G, et al. (2020) Seasonality of Respiratory Viruses Including SARS-CoV-2. Virology: Current Research 4:2. https://www.hilarispublisher.com/open-access/seasonality-of-respiratory-viruses-including-sarscov2-51923.html
  8. Lindley RA, Steele EJ (2021) Analysis of SARS-CoV-2 haplotypes and genomic sequences during 2020 in Victoria, Australia, in the context of putative deficits in innate immune deaminase anti-viral responses. Scand J Immunol. 00:e13100 https://doi.org/10.1111/sji.13100
  9. Steele EJ, Lindley RA (2020) Analysis of APOBEC and ADAR deaminase-driven Riboswitch Haplotypes in COVID-19 RNA strain variants and the implications for vaccine design. Research Reports. doi:10.9777/rr.2020.10001 https://companyofscientists.com/index.php/rr.
  10. Pekar J, Worobey M, Moshiri N, Scheffler K, Wertheim JO (2021) Timing the SARS-CoV-2 index case in Hubei province. Science 372: 412-417. [crossref]
  11. Steele EJ, Gorczynski RM, Lindley RA, Tokoro G, Temple R, et al. (2020) Origin of new emergent Coronavirus and Candida fungal diseases-Terrestrial or Cosmic? Advances in Genetics 106: 75-100. https://doi.org/10.1016/bs.adgen.2020.04.002
  12. Huang C, Wang Y, Li X, Ren L, Zhao J, et al. (2020) Clinical Features of Patients Infected with 2019 Novel Coronavirus in Wuhan. Lancet 395: 497-506. [crossref]
  13. Cohen, J (2020) Wuhan seafood market may not be source of novel virus spreading globally. Science https://www.sciencemag.org/news/2020/01/wuhan-seafood-market-may-not-be-source-novel-virus-spreading-globally
  14. Luc Montagnier Gilmore Health https://www.gilmorehealth.com/chinese-coronavirus-is-a-man-made-virus-according-to-luc-montagnier-the-man-who-discovered-hiv/
  15. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Comments on the Origin and Spread of the 2019 Coronavirus. Virology: Current Research 4: 1. https://www.hilarispublisher.com/open-access/comments-on-the-origin-and-spread-of-the-2019-coronavirus-33365.html
  16. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Growing Evidence against Global Infection-Driven by Person-to-Person Transfer of COVID-19. Virology Current Research 4: 1. https://www.hilarispublisher.com/open-access/growing-evidence-against-global-infectiondriven-by-persontoperson-transfer-of-covid19.pdf
  17. Hoyle F, Wickramasinghe NC (1979) Diseases from Space JM Dent & Son London
  18. Steele EJ, Al Mufti S, Augustyn KA, Chandrajith R, Coghlan JP, et al (2018) Causes of Cambrian Explosion-Terrestrial or Cosmic? Biophys Mol Biol 136: 3-23. [crossref] https://doi.org/10.1016/j.pbiomolbio.2018.03.004
  19. Steele EJ, Gorczyski RM, Lindley RA, Liu Y, Temple R, et al (2019 ) Lamarck and Panspermia-On the efficient spread of living systems throughout the cosmos. Prog Biophys. Mol. Biol. 149: 10-32. [crossref] https://doi.org/10.1016/j.pbiomolbio.2019.08.010
  20. Acharya D, Liu G, Gack MU (2020) Dysregulation of type I interferon responses in COVID-19 Rev. Immunol 20: 397–98. [crossref]
  21. Blanco-Melo D, Nilsson-Payant BE, Liu WC, Uhl S, Hoagland D, et al. (2020) Imbalanced Host Response to SARS-CoV-2 Drives Development of COVID-19. Cell 181: 1036-1045. [crossref]
  22. Hadjadj J, Yatim N, Barnabei L, Corneau A, Boussier J, et al. (2020) Impaired type I interferon activity and exacerbated inflammatory responses in severe Covid-19 patients. Science 369: 718-724. [crossref]
  23. Sette A, Crotty S (2021) Adaptive immunity to SARS-CoV-2 and COVID-19. Cell 184: 861-880. [crossref]
  24. Lucas C, Wong P, Klein J, Castro TBR, Silva J, et al. (2020) Longitudinal analyses reveal immunological misfiring in severe COVID-19. Nature 584: 463-469. [crossref]
  25. Zhang Q, Bastard P, Liu Z, Le Pen J, Moncada-Velez M, et al. (2020) Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. Science 370: eabd4570. [crossref]
  26. Bryant A, Lawrie TA, Dowswell T, Fordham EJ, Mitchell S, et al. (2021) Ivermectin for Prevention and Treatment of COVID-19 Infection: A Systematic Review, Meta-analysis, and Trial Sequential Analysis to Inform Clinical Guidelines. American Journal of Therapeutics 28: e434–e460. [crossref]
  27. Luskin DL (2020) The failed experiment of COVID-19 lockdowns. The Wall Street Journal. https://www.wsj.com/articles/the-failed-experiment-of-covid-lockdowns-11599000890
  28. Baxendale R, Robinson N (2021) Spread of UK coronavirus variant limited to close contacts. The Australian.
  29. Gorczynski RM, Lindley RA, Steele EJ, Wickramasinghe NC. 2021 Nature of acquired immune responses, epitope specificity and resultant protection from SARS-CoV-2. Under submission
  30. Lee WS, Wheatley AK, Kent SJ, DeKosky BJ (2020) Antibody-dependent enhancement and SARS-CoV-2 vaccines and therapies. Microbiol 5: 1185-1191. https://www.nature.com/articles/s41564-020-00789-5
  31. Professor Dolores Cahill in a recent May 21 2021 interview on Asia Pacific Today: https://rumble.com/vjhasl-professor-dolores-cahill-says-the-mrna-vaccines-cause-injury-and-death..html
  32. Steele EJ, Gorczynski RM, Lindley RA, Tokoro G, Wallis DH, et al. (2021) An End of the COVID-19 Pandemic in Sight? Infectious Diseases and Therapeutics 2: 1-5. https://researchopenworld.com/an-end-of-the-covid-19-pandemic-in-sight/
  33. Hansen CH, Michlmayr D, Gubbels SM, Mølbak K, Ethelberg S (2021) Assessment of protection against reinfection with SARS-CoV-2 among 4 million PCR-tested individuals in Denmark in 2020: a population-level observational study. The Lancet 397: 1204-1212.
fig 1

Application of Hybrid CTC/2D-Attention End-to-End Model in Speech Recognition during the COVID-19 Pandemic

DOI: 10.31038/MGJ.2021423

Abstract

Recent research in the field of speech recognition has shown that end-to-end speech recognition frameworks have greater potential than traditional frameworks. Aiming at the problem of unstable decoding performance in end-to-end speech recognition, a hybrid end-to-end model of connectionist temporal classification (CTC) and multi-head attention is proposed. CTC criterion was introduced to constrain 2D-attention, and then the implicit constraint of CTC on 2D-attention distribution was realized by adjusting the weight ratio of the loss functions of the two criteria. On the 178h Aishell open source dataset, 7.237% word error rate was achieved. Experimental results show that the proposed end-to-end model has a higher recognition rate than the general end-to-end model, and has a certain advance in solving the problem of mandarin recognition.

Keywords

Speech recognition, 2-Dimensional multi-head attention, Connectionist temporal classification, COVID-19

Introduction

Speech recognition technology is one of the important research directions in the field of artificial intelligence and other emerging technologies. Its main function is to convert a speech signal directly into a corresponding text. Yu Dong et al. proposed deep neural network and hidden Markov model, which has achieved better recognition effect than GMM-HMM system in continuous speech recognition task [1-3]. Then, Based on Recurrent Neural Networks (RNN) [4,5] and Convolutional Neural Networks (CNN) [6-11], deep learning algorithms are gradually coming into the mainstream in speech recognition tasks. And in the actual task they have achieved a very good effect. Recent studies have shown that end-to-end speech recognition frameworks have greater potential than traditional frameworks. The first is the Connectionist Temporal Classification (CTC) [12], which enables us to learn each sequence directly from the end-to-end model in this way. It is unnecessary to label the mapping relationship between input sequence and output sequence in the training data in advance so that the end-to-end model can achieve better results in the sequential learning tasks such as speech recognition. The second is the encode-decoder model based on the attention mechanism. Transformer [13] is a common model based on the attention mechanism. Currently, many researchers are trying to apply Transformer to the ASR field. Linhao Dong et al. [14] introduced the Attention mechanism from both the time domain and frequency domain by applying 2D-attention, which converged with a small training cost and achieved a good effect. And Abdelrahman Mohamed [15] both used the characterization extracted from the convolutional network to replace the previous absolute position coding representation, thus making the feature length as close as possible to the target output length, thus saving calculation and alleviating the mismatch between the length of the feature sequence and the target sequence. Although the effect is not as good as the RNN model [16], the word error rate is the lowest in the method without language model. Shigeki Karita et al. [17] made a complete comparison between RNN and Transformer in multiple languages, and the performance of Transformer has certain advantages in every task. Yang Wei et al. [18] proposed that the hybrid architecture of CTC+attention has certain advancement in the task of Mandarin recognition with accent. In this paper, a hybrid end-to-end architecture model combining Transformer model and CTC is proposed. By adopting joint training and joint decoding, 2D-Attention mechanism is introduced from the perspectives of time domain and frequency domain, and the training process of Aishell dataset is studied in the shallow encoder-decoder network.

Hybrid CTC/Transformer Model

The overall structure of the hybrid CTC/Transformer model is shown in Figure 1. In the hybrid architecture, chained chronology and multi-head Attention are used in the process of training and grading, and CTC is used to restrain Attention and further improve the recognition rate.

fig 1

Figure 1: An encoder-decoder architecture based on Transformer and CTC.

In end-to-end speech recognition task, the goal is through a network, the input 𝑥 ㉠𝑥1,…,𝑥𝑇 , calculate all output tags sequence 𝑦 ㉠   𝑦1,…,𝑦𝑀               corresponding probability, usually 𝑀 ≤ 𝑇, 𝑦𝑚 ∈ 𝐿, 𝐿 is a finite character set, the final output is one of the biggest probability tags sequence, namely

𝑦* ㉠ argmax 𝑃i𝑦g𝑥s          (1)

𝑦

Connectionist Temporal Classification

Connectionist Temporal Classification structure as shown in Figure 2, in the training, can produce middle sequence 𝜋 ㉠ 𝜋1,…,𝜋𝑂 , in sequence 𝜋 allow duplicate labels, and introduce a blank label 𝑏𝑙𝑎𝑛𝑘: <−> have the effect of separation, namely 𝜋i ∈ 𝐿 𝖴 𝑏𝑙𝑎𝑛𝑘 . For example 𝑦 ㉠ wo,ai,ni,Zhong,guo ,

𝜋 ㉠ − ,wo, − , − ,ai,ai, − ,ni,ni, − ,zhong,guo, − ,

fig 2

Figure 2: Connectionist Temporal Classification.

𝑦’ ㉠ − ,wo, − ,ai, − ,ni, − ,zhong, − ,guo, − , this is equivalent to construct a many-to-one mapping 𝐵:𝐿’ → 𝐿≤𝑇 , The 𝐿≤𝑇 is a possible 𝜋 output set in the middle of the sequence, and then get the probability of final output tag:

𝑥   ㉠ ∑𝜋∈ 𝐵−1i𝑦’s 𝑃i𝜋g𝑥s (2)

Where, 𝑆 represents a mapping between the input sequence and the corresponding output label; 𝑞𝑡 represents label 𝜋𝑡 at time 𝑡 corresponding probability. All tags sequence in calculation through all the time, because of the need to 𝑁𝑇 iteration, 𝑁 said tag number, the total amount of calculation is too big. HMM algorithm can be used for reference here to improve the calculation speed:

𝑃𝑐𝑡𝑐𝑦 𝑥 ㉠ ∑𝑇𝑦’𝑢㉠1𝛼   𝛽𝑡i𝑢s𝑡𝜋𝑡                     (3)

Among them, the 𝛼𝑡 𝑢 𝛽𝑡i𝑢s respectively are forward probability and posterior probability of the -th label at the moment    to. Finally, from the intermediate sequence     to the output sequence, CTC will first recognize the repeated characters between the delimiters and delete them, and then remove the delimiter <−>.

Transformer Model for 2D-attention

Transformer model is used in this paper, which adopts a multi-layer encoder-decoder model based on multi-head attention. Each layer in the encoder should be composed of a 2-dimensional multi-head attention layer, a fully connected network, and layer normalization and residual connection. Each layer in the decoder is composed of a 2-dimensional multi-head attention layer that screens the information before the current moment, an attention layer that calculates the input of the encoder, a three-layer network that is fully connected, and a layer normalization and residual connection. The multi-head attention mechanism first initializes the three weight matrices.

𝑄Ǥ𝐾Ǥ𝑉 by means of linear transformation of the input sequence:

𝑄 ㉠ W𝑄X ; 𝐾 ㉠ W𝐾X ; 𝑉 ㉠ W𝑉X                (4)

Then the similarity between the matrix           and K is calculated by dot product:

ƒ 𝑄,𝐾 ㉠ 𝑄𝐾𝑇 (5)

In the process of decoder, requiring only calculated before the current time and time characteristics, the similarity between the information on subsequent moment for shielding, usually under the introduction of a triangle total of 0 and upper triangular total negative infinite matrix, then, the matrix calculated by Equation (5) is transformed into a lower triangular matrix by replacing the negative infinity in the final result with 0. Finally, Softmax function is used to normalize the output results, and weighted average calculation is carried out according to the distribution mechanism of attention:

𝐴𝑡𝑡𝑒𝑛𝑡i𝑜𝑛 𝑄,, ㉠ 𝑠𝑜ƒ𝑡𝑚𝑎𝑥 ƒ 𝑄,𝐾      𝑉             (6)

Multi-head attention mechanism actually is to multiple independent attention together, as an integrated effect, on the one hand, can learn more information from various angles, on the one hand, can prevent the fitting, according to the calculation of long attention, if the above results when the quotas for time calculation, then the final result stitching together, converted into a linear output:

𝑚𝑢𝑙𝑡i𝐻𝑒𝑎𝑑 𝑄,, ㉠ 𝑐𝑜𝑛𝑐𝑎𝑡 ℎ𝑒𝑎𝑑1,…,ℎ𝑒𝑎𝑑𝑛  W𝑂           (7)

2D – Attention

The Attention structure in Transformer only models the position correlation in the time domain. However, human beings rely on both time domain and frequency domain changes when listening to speech, so the 2D-Attention structure is applied here, as shown in Figure 3, that is, the position correlation in both time domain and frequency domain is modeled. It helps to enhance the invariance of the model in time domain and frequency domain.

fig 3

Figure 3: The structure of 2D-Attention.

Its calculation formula is as follows:

2𝐷 − 𝐴𝑡𝑡𝑒𝑛𝑡i𝑜𝑛 𝐼 ㉠ W𝑂 * 𝑐𝑜𝑛𝑐𝑎𝑡i𝑐ℎ𝑎𝑛𝑛𝑒𝑙ƒ,…,ℎ𝑎𝑛𝑛𝑒𝑙ƒ,

1              𝑐

𝑐ℎ𝑎𝑛𝑛 ,…,𝑐ℎ𝑎𝑛𝑛𝑒𝑙𝑡s           (8)

1              𝑐

𝑤ℎ𝑒𝑟𝑒 𝑐ℎ𝑎𝑛𝑛𝑒𝑙ƒ ㉠ 𝑎𝑡𝑡𝑒𝑛𝑡i𝑜𝑛i W𝑄 * 𝐼 𝑇, W𝐾 * 𝐼 𝑇, W𝑉 * 𝐼 𝑇s

i               i               i               i

𝑐ℎ𝑎𝑛𝑛𝑒𝑙𝑡 ㉠ 𝑎𝑡𝑡𝑒𝑛𝑡i𝑜𝑛i W𝑄 *  , W𝐾 * 𝐼 , W𝑉 * 𝐼 s

i               i               i               i

After calculating the 2-dimensional multi-head attention mechanism, a feed-forward neural network is required at each layer, including a fully connected layer and a linear layer. The activation function of the fully connected layer is ReLU:

𝐹𝐹𝑁 𝑥   ㉠ 𝑚𝑎𝑥 0,W1 + 𝑏1 W2 + 𝑏2               (9)

In order to prevent the gradient from disappearing, the residual connection mechanism should be introduced to transfer the input from the bottom layer directly to the upper layer without passing through the network, so as to slow down the loss of information and improve the training stability:

𝑥 + 𝑆𝑢𝑏𝐵𝑙𝑜𝑐𝑘i𝐿𝑎𝑦𝑒𝑟𝑁𝑜𝑟𝑚i𝑥ss         (10)

To sum up, the Transformer model with 2D-attention is shown in Figure 4. The speech features are first convolved by two operations, which on the one hand can improve the model’s ability to learn time-domain information. On the other hand, the time dimension of the feature can be reduced to close to the quotaslength of the target output, which can save calculation and alleviate the mismatch between the length of the feature sequence and the target sequence.

fig 4

Figure 4: Overall network architecture of Transformer model with 2D-Attention.

The loss function is constructed according to the principle of maximum likelihood estimation:

𝐿𝑎𝑡𝑡 ㉠− 𝑙𝑜𝑔𝑝 𝑦1,2,…,𝑦𝑇’ 𝑥1,𝑥2,…,𝑥𝑇

㉠ ∑𝑇’    𝑝i𝑦   g,,…,,s           (11)

𝑡’ ㉠1      𝑡’              1     2

𝑡’ −1

The final loss function consists of a linear combination of CTC and Transformer’s losses:

𝐿 ㉠ 𝜇𝐿𝐶𝑇𝐶 + 𝛾𝐿𝑎𝑡𝑡            (12)

FBANK Feature Extraction

The process of FBANK feature extraction is shown in Figure 5. In all experiments, the sampling frequency of 1.6KHz and the 40-dimensional FBANK feature vector are adopted for audio data, 25ms for each frame and 10ms for frame shift.

fig 5

Figure 5: Flowchart of FBANK feature extraction.

Speech Feature Enhancement

In computer vision, there is a feature enhancement method called “Cutout” [19]. Inspired by this method, this paper adopts time and frequency shielding mechanism to screen a continuous time step and MEL frequency channel respectively. Through this feature enhancement method, the purpose of overfitting can be avoided. The specific methods are as follows:

(1)    Frequency shielding: Shielding ƒ consecutive MEL frequency channels:

[ƒ0,ƒ0 + ƒs, replace them with 0. Where,        is from zero to custom frequency shielding parameters              randomly chosen from a uniform distribution, and ƒ0 is selected from                0, − ƒ randomly, 𝑣 is the number of MEL frequency channel.

(2)    Time shielding: Time step [𝑡0,𝑡0 + 𝑡s for shielding, use 0 for replacement, including             from zero to a custom time block parameters randomly chosen from a uniform distribution, 𝑡0 from [0,𝑟 − 𝑡s randomly selected. The speech characteristics of the original spectra and after time and frequency shield the spectrogram characteristic of language contrast as shown in Figure 6, to achieve the purpose of to strengthen characteristics.

fig 6

Figure 6: Feature enhancement contrast chart.

Label Smoothing

The learning direction of neural network is usually to maximize the gap between correct labels and wrong labels. However, when the training data is relatively small, it is difficult for the network to accurately represent all the sample characteristics, which will lead to overfitting. Label smoothing solves this problem by means of regularization. By introducing a noise mechanism, it alleviates the problem that the weight proportion of the real sample label category is too large in the calculation of loss function, and then plays a role in inhibiting overfitting. The true probability distribution after adding label smoothing becomes:

1, iƒii ㉠ 𝑦s

1 − s,   iƒii ㉠ 𝑦s

𝑃i ㉠0,  iƒii G 𝑦s 𝑃i ㉠s

𝐾−1, iƒii G 𝑦s

Where K represents the total number of categories of multiple classifications, and is a small hyperparameter.

Experiment

Experimental Model

The end-to-end model adopted in this paper is a hybrid model based on Linked Temporalism and Transformer based on 2-dimensional multi-head attention. Compare the end-to-end model based on RNN-T and the model based on multiple heads of attention. The experiment was carried out under the Pytorch framework, the GPU RTX 3080.

Data

This article uses Hill Shell’s open source Aishell dataset, which contains about 178 hours of open source data. The dataset contains almost 400 recorded voices from people with different accents from different regions. Recording was done in a relatively quiet indoor environment using three different devices: a high-fidelity microphone (44.1kHz, 16-bit); IOS mobile devices (16kHz, 16-bit); Android mobile device (16kHz, 16-bit) to record, and then by sampling down to 16kHz.

Network Structure and Parameters

The network in this paper uses four layers of multi-head attention, and the input attention dimension of each layer is 256, the input feature dimension of the forward full connection layer is 256, and the hidden feature dimension is 2048. The combined training parameter λ is 0.1, the rate of random loss of activated cells is 0.1, and the label smoothing is 0.1. The epoch times are 200.

Evaluation Index

In the evaluation of experimental results, word error rate (WER) was used as the evaluation index. Word error rate is identified primarily for the purpose of make can make between words and real words sequences of the same, the need for specific words, insert, substitute, or delete these insertion (I), substitution (S) or deletion (D) of the total number of words, divided by the real word sequence of all the percentage of the total number of words namely

W𝐸𝑅 ㉠ 100 × 𝐼 + 𝑆 + 𝐷 %

𝑁

Experimental Results and Analysis

Table 1 shows the comparison between the 2D-attention model without CTC and the 2D-attention model with CTC. Compared with the ordinary model, the performance of the model with CTC is improved by 6.52%-10.98%, and the word error rate of the end-to-end model with RNN-T is reduced by 4.26%. Performance improved by 37.07%.

Table 1: Comparison of model word error rate.

Model

Test-WER/%

RNN-T

11.50

4Enc+3Dec

9.320

4Enc+4Dec

9.165

4Enc+4Dec+0.1CTC

8.567

6Enc+3Dec

8.130

6Enc+3Dec+0.1CTC

7.237

Figure 7 shows the comparison of the loss functions of the two models (2D-attention model without CTC and 2D-attention model with CTC). Compared with the ordinary model, the loss of the constrained model with CTC can reach a smaller value.

fig 7

Figure 7: Contrast chart of loss changes.

Conclusion

In this paper, we propose a hybrid architecture model of Transformer using CTC and 2-dimensional Multi-head Attention to apply to Mandarin speech recognition. Compared with the traditional speech recognition model, it does not need to separate the acoustic model and the language model to train, only needs to train a single model, from the time domain and frequency domain two perspectives to learn the speech information, can achieve advanced model recognition rate. It is found that compared with the end-to-end model of RNN-T, the performance of Transformer model is better, and the increase in the depth of the encoder can better learn the information contained in the speech, which can significantly improve the performance of the model for Mandarin recognition, while the increase in the depth of the decoder has little effect on the overall performance of speech recognition. At the same time, by introducing a link of sequence alignment is improved, the model makes the model to achieve the best effect, but on some professional vocabulary is not accurate, the subsequent research by increasing solution of language model, at the same time, in view of the very deep network training speed slow problem, to improve and upgrade.

Acknowledgement

This work was supported by the Philosophical and Social Sciences Research Project of Hubei Education Department (19Y049), and the Staring Research Foundation for the Ph.D. of Hubei University of Technology (BSQD 2019054), Hubei Province, China.

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fig 1a

Comparative Transcriptomic Analysis for Wheat Etiolated and Green Seedlings during Vernalization

DOI: 10.31038/MGJ.2021422

Abstract

Light can promote the growth and development of wheat seedling during vernalization. However, the mechanism has not been sufficiently explored. In this study, transcriptomic analysis was performed on wheat etiolated seedlings and green seedlings vernalized in dark and light, respectively. Results showed that light could promote photo morphogenesis and photosynthesis of wheat seedlings and increase fresh weigh of seedlings, including root biomass and leaf area. The number of differentially expressed genes (DEGs) between etiolated and green seedlings increased with vernalization time increasing, and the maximum value occurred on vernalization 40 d. GO and KEGG enrichment analysis showed that the main DEGs on vernalization 40 d were significantly different from those on 10, 20 and 30 d in functions. Top GO and KEGG enrichment related to photosynthesis, such as chloroplast, thylakoid, photosynthesis and oxidoreductase activities, were identified on vernalization 40 d. Then a series of candidate genes were identified, 15 of which were confirmed by qRT-PCR. The above findings provide valuable information for understanding the molecular mechanism of light on wheat seedlings during vernalization.

Keywords

Winter wheat, Vernalization, Seedlings, Light, Photosynthesis

Introduction

Wheat (Triticum aestivum L.) is one of the most widely cultivated crops in the world. Its growth and development are determined by complex genetic and environmental factors, in which genes related to vernalization and photoperiod sensitivity play more important roles [1,2].

Winter wheat is sensitive to vernalization and requires a period of continuous cold temperature for its transition from vegetative to reproductive growth [3]. The vernalization response is also integrated with the environmental cue of light. VRN3 is an integrator of the vernalization and photoperiod pathways in temperate cereals, the role of which has been well documented [1,4]. Plants have a sophisticated network to decipher the information of light-temperature integration. The sensation can be defined as a process in which a sensory receptor changes its activity as a result of a stimulus. The photoreceptors phyB and phot have been identified as temperature sensors [5-7].

Light is one of the major environmental factors that regulate seedling growth and development. After seed germination under the soil, dark-grown seedlings usually grow heterotrophically from seed reserves and accumulate protochlorophyllide (Pchlide) via a process referred to as skotomorphogenesis (etiolation; [8]. Upon exposure to light, Pchlide is rapidly converted into chlorophyll to initiate photoautotrophic growth, resulting in large-scale genes expression of photomorphogenesis (greening) [9]. Photomorphogenesis is marked by chlorophyll biosynthesis, differentiation of protoplastids into chloroplasts, initiation of carbon assimilation, elongation and thickening of hypocotyl, and the activation of shoot apical meristem leading to the development [10,11]. There is a comprehensive regulatory network that corresponds to specific morphological aspects in seedling skotomorphogenesis and photomorphogenesis [12-14].

The vernalization in light can promote winter and semi-winter wheat varieties flowering earlier than in dark for [15-17], when plants are stimulated by two external signals, light and low temperature. Some vernalization-responsive genes or proteins have been identified during wheat vernalization by high-throughput transcriptomics and proteomics [18,19]. However, the extent to which genes contribute to wheat seedling development during vernalization remains unclear.

In this study, we conducted RNA-seq analysis to determine the effect of light on transcriptomic changes of wheat seedlings during vernalization. Further, the hypothetical molecular mechanisms of several genes responding to vernalization of wheat in light were discussed.

Materials and Methods

Plant Materials and Vernalization

The uniform seeds of winter wheat Liangxing 99 (vrn-A1/vrn-B1/vrn-D1) were selected and cultivated on plates supplied with moist vermiculite at 25°C in dark, 30 seeds per plate. After 3 d, the developed seedlings were vernalized in dark or in continuous light (25 µmol m-2 s-1) in a growth cabinet at 6°C. The light was provided by cool white fluorescent lamp. At each timepoint of vernalization 0, 10, 20, 30 and 40 d, the fresh weight of single plant, fresh weight of seedling leaves, fresh weight of roots, and the longest root length were all measured. Three biological replicates were conducted. SPSS19.0 and Sigmaplot 12.0 were performed to analyze the difference between etiolated and green seedlings.

RNA-seq Sample Preparation and Sequencing

At each investigation timepoint, about 500 mg samples of shoots and leaves per treatment were collected from 5-15 seedlings for total RNA isolation (Figure 1a and 1b). When sampling, the collected leaves and shoots were immediately frozen in liquid nitrogen and then stored at -80°C. Total RNA was extracted with TRIzol™ Reagent (ThermoFisher, USA) following manufacturer’s instructions and confirmed using the 2100 Bioanalyzer (Agilent Technologies). mRNA was purified and then constructed into sequencing library using TruSeq RNA Sample Preparation Kit v2 (#RS-122-2001, Illumina, USA) following manufacturer’s recommendations. The obtained libraries were adjusted and pooled at a concentration of 20 nmol. Sequencing was performed with 300-400 bp, paired-end reads on the NextSeq 500 (Illumina). Each treatment had two biological replicates.

fig 1a

fig 1b

Figure 1: Etiolated and green wheat seedlings used for generating transcriptome, which were vernalized in dark and in light respectively. On each panel, seedlings from left to right were vernalized for 0, 10, 20, 30, and 40 d, respectively.

Data Processing, De-novo Transcriptome Assembly, Differential Expression Gene Analysis

Clean reads with Q-score>20 was further analyzed by removing the adapters and filtering low Q-score reads from raw reads. Reference genome index was constructed using Bowtie2 Software (http://bowtie-bio.sourceforge.net/bowtie2/index.shtml) based on the data in Ensembl (http://www.ensembl.org/). The clean reads were aligned to the reference genome by Tophat2 (http://tophat.cbcb.umd.edu/). The original expression level of corresponding gene was considered to be the alignment value (read count) and was analyzed by HTSeq0.6.1p2 (http://wwwhuber.embl.de/users/anders/HTSeq). The read count was normalized with reads per kilobases per million mapped (RPKM), with >1 as gene expressing threshold. Furthermore, the differential expression genes (DEGs) were analyzed by DESeq with |fold change| >2, P-value <0.05, and false discovery rate (FDR) <0.05.

Functional Analysis on DEGs

Gene ontology (GO, http://geneontology.org/) terms with corrected P-value of less than 0.05 were considered to be significantly enriched. KEGG (Kyoto Encyclopedia of Genes and Genomes, http://www.kegg.jp/) enrichment pathways of DEGs were confirmed with P-value<0.05. The DEGs related to photosynthesis and having a minimum 3-fold change were further analyzed.

Evaluation of RNA-Seq by qRT-PCR

To verify the reliability and accuracy of our transcriptomic data, 15 DEGs associated with photosynthesis, signaling interaction, amino acids metabolism, fatty acid metabolism, etc. were selected and evaluated by qRT-PCR. The primers designed with Primer 5.0 Software (PREMIER Biosoft, USA) are detailed in Table S1. Actin was used as an internal control [20]. Using the identical RNA samples for RNA-seq, qRT-PCR was performed on a C1000 Thermal Cycler (CFX96 Real-Time System, Bio-Rad, USA) using a Quant One Step RT-PCR (SYBR Green) Kit (TianGen, China) following manufacturer’s instructions. Three independent biological replicates and three technical replicates per biological replicate were conducted. The PCR efficiency of target and reference genes were determined by generating standard curves and the relative expression values were calculated using the 2–∆∆CT method [21]. With the expression level value on 0 d set as 1, each DEG expression level was recorded and its significance was analyzed by the independent t-test at P-value <0.05. In addition, the relative expression levels of DEGs were analyzed based on RNA-Seq and qRT-PCR, respectively.

Results

Performance of Wheat Seedlings Vernalized in Dark and in Light Conditions

At the beginning, the seedlings for vernalization treatments were exactly the same. On vernalization 10 d, etiolated seedlings, which was vernalized in dark, showed significantly higher fresh weight (including single plant fresh weight, shoot fresh weight and root fresh weight) and root length than green seedlings (Figure 1). However, with the initiation of the photosynthesis and photomorphogenesis, the fresh weight of green seedlings (vernalized in light) were gradually increased and became more than that of etiolated seedlings from vernalization 20 d (Figure 2A). Although green seedlings had less shoot fresh weight compared with etiolated seedlings on vernalization 40 d (Figure 2B), their root fresh weight and length were both significantly more than etiolated seedlings. This indicated that light promoted the growth of wheat seedlings during vernalization (Figure 2C and 2D).

fig 2A,2B

figure 2c, 2d

Figure 2: Performance of wheat seedlings development at five timepoints (0, 10, 20, 30, and 40 d) under dark and light vernalization treatments. A: fresh weight of single plant; B: fresh weight of shoots; C: fresh weight of roots; D: length of the longest root. *, data are mean ± SD of three replicates, P-value <0.05.

Identification of Differential Expressed Genes

The expression level of the DEGs was calculated and normalized to FPKM (fragments per kilobase million), and then DEGs between etiolated and green seedlings were screened with fold change >2 and P-value <0.05. The number of DEGs between etiolated and green seedlings on vernalization 0, 10, 20, 30 and 40 d were 0, 6131, 6971, 7249, and 11807, respectively (Table 1). The maximum was on vernalization 40 d, indicating that more metabolic activities had occurred in green seedlings.

Table 1: Primers for quantitative real-time PCR (qRT-PCR).

Gene ID

Forward primer (5’−3′)

Reverse primer (5’−3′)

TRIAE_CS42_4AL_TGACv1_289136_AA0965610

TGCGCGGACAATATATCTCA GTGCAGGATCAAACACATCG
TRIAE_CS42_7BL_TGACv1_579174_AA1904930 AGTGGTATGCCTGCGAGTGC

CTGCTGCTTGTTGATGATTGC

TRIAE_CS42_5DL_TGACv1_432937_AA1395210

CGATGCCAACAGCGACAA CGCCATTGATACCCGTCTT
TRIAE_CS42_3AL_TGACv1_195180_AA0645990 GCTACGCACTTTACGGTATCACA

ACCTTCGCCAACTCCTTCTC

TRIAE_CS42_2DS_TGACv1_179360_AA0606510

CATCATTGGAGGGAGAAACCG CCGCATACTTGGCAAACCTG
TRIAE_CS42_3B_TGACv1_237526_AA0832830 GGAGCTGGTCGAGTTGAAGA

GAACCAAGCCGCTATCTGGT

TRIAE_CS42_1BS_TGACv1_052086_AA0181320

ACCTGGTGTTGCCGATAGAAT CGTTGGGTCGTCAAACTCATAC
TRIAE_CS42_2BL_TGACv1_727308_AA2170970 ACTATCACCCATCGCATCACA

ACACGCCTTCCATTCTCCC

TRIAE_CS42_3AL_TGACv1_195180_AA0645980

CGGGCCTCGCAATTTACA AGTCCTCGCCAACTCGGTCT
TRIAE_CS42_5DL_TGACv1_433817_AA1422930 ACCGCCAAACAAACCCAA

GCAGTCACGAAACCCACCAT

TRIAE_CS42_6AS_TGACv1_486935_AA1566680

ACAGCACCAACTACTGCATCC GGAAGAAGACGACCATCTCCA
TRIAE_CS42_6BS_TGACv1_514208_AA1656980 TCGAGGGGTACTGCATTGTC

CTTGATCTCCTTCACCTTGAGC

TRIAE_CS42_7BS_TGACv1_594457_AA1957650

TACCGACTTCTGCTTCCACTCA ACCCCAGTAATCATCAATACATCC
TRIAE_CS42_5DL_TGACv1_433244_AA1406760 GTTCTACACGCCGGACAAGA

GGTAGCGGTGGATAGGGTTT

TRIAE_CS42_6BL_TGACv1_505061_AA1629060

CGGACTGGTTCAGGAAGGAC CACGTGATGTGAGGGTAGGC
Actin GAAGCTGCAGGTATCCATGAGACC

AGGCAGTGATCTCCTTGCTCATC

Evaluation of RNA-Seq Data by qRT-PCR

To verify the RNA-seq results, 15 DEGs on vernalization 40 d were further analyzed by qRT-PCR. The expression level of every DEG in etiolated seedlings was set as 1. Then their expression level in green seedlings were recorded. qRT-PCR and t-test analysis showed that each of the 15 DEGs showed significantly different expression levels between etiolated and green seedlings, which was consistent with the result from transcriptome sequencing. Also, their expression patterns correlated well (R2 =0.8123) with those obtained from RNA-seq analysis (Figure 3). Therefore, the transcriptome changes obtained by RNA-seq were accurate.

fig 3a, 3b

fig 3c, 3d

Figure 3: Correlation analysis of the 15 differentially expressed genes (DEGs)’ expression levels revealed by RNA-seq and qRT-PCR, respectively. The plots indicate the log2 (Fold change) in RNA-seq and qRT-PCR.

GO Enrichment Analysis of DEGs

The functions of DEGs were annotated by GO enrichment analysis (P-value <0.05) and then they were divided into three terms: biological process, cellular component and molecular function. The topGO enrichment results for DEGs on 10, 20 and 30 d were almost the same. The biological processes of DEGs were mainly involved in cell wall macromolecule catabolic process, aminoglycan catabolic process, chitin catabolic process and oxidation-reduction process (Figures S1-S3); the cellular components were mainly extracellular region, cytoplasmic region, endoplasmic reticulum, photosystem and membrane part (Figures S4-S6); the molecular functions were mainly involved in oxidoreductase activity, chitinase activity, catalytic activity, heme binding, iron ion binding and tetrapyrrole binding (Figures S7-S9).

On vernalization 40 d, a total of 2180 DEGs between etiolated and green wheat seedlings were annotated by GO enrichment analysis (P<0.05). The biological process was mainly involved in photosynthesis, chloroplast organization, cellular ketone biosynthesis process (Figure S10), the cell components were associated with chloroplast, plastid, thylakoid (Figure S11), and the molecular function was associated with chlorophyll binding, fructose-bisphosphatase activity, catalytic activity (Figure S12). This result indicated that the DEGs between etiolated and green seedlings on vernalization 40 d were mainly related to photosynthesis.

KEGG Pathway Analysis of DEGs

KEGG enrichment pathways were selected by DESeq with |fold change| > 2, P-value <0.05, and false discovery rate (FDR) <0.05. The top KEGG pathway of DEGs on vernalization 10, 20 and 30 d were nearly the same. They were involved in amino acids metabolism, fatty acid metabolism, metabolism of cytochrome P450, photosynthesis, environmental adaptation, etc. (Figure 4a-4c). While on vernalization 40 d, the top KEGG enrichment pathways were mainly involved in photosynthesis (photosynthesis-antenna proteins, porphyrin and chlorophyll metabolism, photosynthesis, photosynthetic biological nitrogen fixation, carbon fixation in photosynthetic organisms, etc.), secondary metabolism(including synthesis of flavonoid, anthocyanin, ubiquinone and terpenoid-quinone biosynthesis, indole alkaloid, phenylpropanoid, riboflavin, etc.), nitrogen and carbon metabolism (including vitamins, amino acids, carbon, methane, glyoxylate and dicarboxylate, etc.) and environmental adaptation (circadian rhythm, longevity regulating pathway, and estrogen signal transduction, etc.) (Figure 4d).

DEGs Related to Photosynthesis during Wheat Vernalization

To further understand the effect of light on photosynthesis during vernalization, we focused on the DEGs with a minimum three-fold change in expression between etiolated and green seedlings at V40 d according to KEGG enrichment analysis. Compared with etiolated seedlings, the up-regulated genes in green seedlings were related to chloroplast component, nitrogen and carbon synthesis, while the down-regulated genes were related to catalase, dehydrogenase, ubiquitin, phosphate dikinase and glutamine synthetase.

Discussion

The effect of light on the morphological development of seedlings is achieved through regulating the expression levels of a series of genes [22]. In this study, we used whole-transcriptome sequencing to analyze the seedlings vernalized in dark and in light conditions to identify their molecular changes at different times of vernalization. The results showed that light can regulate a series of genes related to skotomorphogenesis and photomorphogenesis, which is consistent with previous studies [11,12,22,23].

Usually, either triggering photosynthesis or initiating flowering is the acting mode of light on plants. The former is the energy source of plant, while the latter is the developmental key from vegetative growth to reproductive development [24,25]. Interestingly, the results in this paper indicated that light can significantly increase the length and fresh weight of roots but inhibit the growth of above ground part of seedlings. Previously, it has been proved that light influence root development and plasticity through complex signaling pathways [26]. Generally, the roots of dark-grown seedlings are much shorter and have a much thinner diameter than those of light-grown seedlings [27,28]. In speed breeding, green plant vernalization can promote winter wheat flowering earlier in the subsequent development process [16,17]. Therefore, during vernalization process, supplementation of light may be conducive to promoting the morphological development of roots and leaves, as well as indirectly promoting later flowering development.

In our study, GO and KEGG enrichment analysis shows that the significantly DEGs between seedlings vernalized in dark and in light are mainly involved in photosynthesis with the elongation of wheat vernalization. Chlorophyll is essential for harvesting light energy during photosynthesis. It is proved that the complex integration of intracellular chloroplast retrograde redox signaling combined with intercellular, and vascular-mediated signaling pathways during vernalization process enhance both photosynthetic capacity and plant biomass production in cold-grown winter cereals.

In this experiment, the level of chloroplast, photosystem II 10 kDa polypeptide, fructose 1,6-bisphosphatase, pyruvate, phosphate dikinase (PPDK) was higher in green seedlings than in etiolated seedlings. Chlorophyll is essential for light harvesting and energy transduction during photosynthesis. Leaf color results from the processes of chlorophylls accumulation in leaf, which is related to chloroplast development and division, biosynthesis [29]. Photosystem II (PSII) is a multisubunit protein-pigment complex embedded in the thylakoid membrane that harnesses light energy to split water into oxygen, protons, and electrons [30]. Fructose 1,6-bisphosphatase is required for optimum regulation of photosynthetic carbon metabolism. Fructose 6-phosphate (F6P) is the branch point for metabolites leaving the Calvin cycle and moving into starch biosynthesis through the conversion into glucose 6-phosphate (G6P) [31]. Pyruvate, phosphate dikinase (PPDK), a key role in the C4 photosynthetic pathway, proposed first functionally seated in C3 plants as an ancillary glycolytic enzyme [32]. In intact spinach chloroplasts, light-induced dephosphorylation of C(3) PPDK was shown to be dependent on photosystem II activity but independent of electron transfer from photosystem I [33-35].

Therefore, the above up-regulation genes associated with photosynthesis and Calvin cycle improves the biomass of seedlings under light. Meanwhile, the developing seedlings under dark could reduce their light-harvesting capacity and components of photosynthetic apparatus.

Conclusions

The analysis of DEGs between seedlings vernalized in dark and in light indicates that light influences plant growth and development by triggering photosynthesis and feeding plants energy. Thus, the supplementation of light during wheat vernalization can directly improve the biomass of seedlings, as well as indirectly promote the later reproductive development.

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How the Medical Profession Contributes to COVID-19 Vaccine Hesitancy

DOI: 10.31038/JNNC.2021434

 

Hopefully the pandemic will be over within another year. In the meantime, the medical profession and public health officials continue to denigrate and sanction ‘anti-maskers’ and ‘anti-vaxxers’, as discussed in previous papers [1-6]. This behavior inflames the people characterized as anti-vaxxers and anti-maskers, increases polarization, and breeds distrust in the medical profession. These effects of the denigration and sanctions can do nothing but increase vaccine hesitancy. The medical profession should stop putting all blame for vaccine hesitancy on a misinformed public, and instead should examine its own contributions to vaccine hesitancy. I am double vaccinated. There are a number of topics that illustrate the unhelpful attitudes and unscientific statements of doctors and public health officials during the pandemic. These are reviewed below.

Ivermectin

Ivermectin for COVID-19 has been attacked aggressively in the courts, the media and the medical literature as being ineffective. It has been referred to as a ‘horse worm drug’ even though it has long been approved by the FDA for use in humans. The main study cited to justify the banning of ivermectin from clinical practice randomized 238 patients with mild-moderate COVID-19 to ivermectin and 238 to placebo [7]. The authors reported adverse events occurring in 77% of participants receiving ivermectin and 81.3% of those on placebo, indicating both that ivermectin is safe compared to placebo, and a high nocebo effect rate in both groups. Both groups received a 5-day course of ivermectin or placebo. There was an escalation of care to a higher level in 4 participants receiving ivermectin and 6 receiving placebo. The median time to resolution of symptoms was 10 days on ivermectin and 12 on placebo. There were no statistically significant differences between groups on any outcome measures. However, ivermectin resulted in a 17% reduction in time to symptom resolution. The authors cited four randomized controlled trials of ivermectin that had not yet been published, all with positive results, including one with substantial differences between ivermectin and placebo on a range of clinical measures [8].

Although the reduction in time to symptom resolution was not statistically significant in the JAMA study [7], a 17% reduction in duration of symptoms would result in a very large reduction in personal suffering across a large sample. If ivermectin also reduced hospitalizations and deaths by 17% in a future randomized controlled trial, that would be very helpful. Normally, in medicine, a study like this would not be used to support a ban on using the medication in hospitals or clinics. Rather, there would be a call for further research, and prescribing the medication would be regarded as a legitimate off-label use of the medication in clinical settings, given that it is generic, cheap and safe, especially if there were no more effective medications available. Although there is a posture of science and protecting patients in mainstream medicine, the behavior of the medical profession with regards to ivermectin has been starkly different from standard practice. In standard practice, the existence of a trial showing a reduction in time to symptoms resolution of 17%, plus a set of unpublished trials showing a positive effect, would never result in the aggressive dismissal of that medication. This is disturbing because such deviations from standard medicine could happen regarding any disease or treatment in the future, if politics over-ride standard practice. It doesn’t matter if ivermectin proves not to be useful in properly designed future trials. The problem is the unscientific hostility towards a cheap, generic, safe and potentially useful medication. The standard mantra – “there is no evidence that ivermectin works” – is not scientifically true. That is an attitude, not a scientific statement.

Lockdown Mandates

The justifications for lockdowns at the height of a pandemic are clear and valid, but there has been an over-use and over-reaction in government lockdown mandates. For example, as a former resident of the Northwest Territories in Canada, I was interested to read that the level of lockdown there has just been increased by the top public health physician. Why? In a population of 44,991 people [9], throughout the entire pandemic there have been 2 COVID-19 deaths [10] and 918 confirmed infections as of September 24, 2021. This is a death rate of 2/44,991 = 0.00004 and an infection rate of 0.02. As percentages, these are an infection rate of 2% and a death rate of 0.004%. How do those numbers justify an increased lockdown? Similarly, in the Canadian province of New Brunswick, levels of lockdown have been increased recently [11]. The province of 781,315 people has recorded 49 deaths (49/781,315 = 0.0006, or a death rate of 0.06%): the increased lockdown level is justified by one additional recent death. These lockdowns in response to those levels of threat do not make sense. This does not mean that one should be ‘anti-lockdown’, but it calls into question the judgment of public health officials. Excessive lockdowns will breed distrust in the medical profession and public health officials and fuel vaccine hesitancy.

The Wuhan Lab Leak Theory

It is possible that the COVID-19 pandemic started with a lab leak at the Wuhan Institute of Virology [6]. It is also possible that it did not. A serious problem in the medical profession has been the vitriol and condemnation directed at anyone who supported the Wuhan lab leak theory, at least for the first year of the pandemic. This vitriol was justified by a letter in The Lancet on March 7, 2020 [12] in which the authors stated that: “We stand together to strongly condemn conspiracy theories suggesting that COVID-19 does not have a natural origin. . . Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus. We support the call from the Director-General of WHO to promote scientific evidence and unity over misinformation and conjecture.”

The problem with this letter [12] was the major conflicts of interest that the authors did not disclose [13]. Rather, they represented themselves as objective scientists. Of the 27 authors of the letter, 26 had direct connections with the Wuhan Institute of Virology. For example: Peter Daszak and five other authors were affiliated with EcoHealth Alliance, which funded gain of function research on coronaviruses at the Wuhan Institute of Virology; three authors were affiliated with Britain’s Welcome Trust which funded research at the Wuhan Institute of Virology; and five were coauthors of Dr. Ralph Baric, who is an author on papers from the Wuhan Institute of Virology. The Lancet letter was designed to shut down any suggestion that the pandemic could have started with a leak from the Wuhan Institute of Virology. This is not objective science. It is using an appearance of science for politics and self-protection. This kind of posturing by leading figures in virology and public health carries the risk of blowback once it is exposed for what it is, which in turn can do nothing but undermine confidence in public health and the medical profession.

Treating the Unvaccinated as Untouchables

There is nothing wrong with trying to motivate people to get vaccinated for COVID-19. It seems clear that the risk for severe illness, hospitalization and death all drop substantially with vaccination. However, it is less clear that vaccination by itself reduces the rate of viral transmission in public when social distancing is in place. We know that vaccinated individuals can have break-through infections. Regardless, unvaccinated people are now being shunned, denigrated, and financially punished: they are becoming untouchables. For example, the New York Metropolitan Transportation Authority recently changed its policy to continue a $500,000.00 death benefit for the families of employees who die of COVID-19, but canceled the benefit for families of unvaccinated employees [14]. Similarly, Southwest Airlines withheld an award of an extra 16 hours of pay from unvaccinated workers while also cutting sick pay for unvaccinated workers [15]. In New York, the Governor is considering bringing in out-of-state health care workers and declaring a state of emergency due to the number of health care workers refusing to get vaccinated [16]; recent legislation prevents them from coming to work. Bringing in out-of-state health care workers would compound staff shortages and burnout in other states. In addition, the New York state labor department issued guidance that people who lose their jobs due to vaccine refusal will not be eligible for unemployment benefits. These government actions will cause ‘anti-vaxxers’ to regard their own actions as morally justified civil unrest, which will in turn reinforce their behavior and increase the dividedness and hostility in the United States.

The motive of encouraging people to get vaccinated is fine, but these methods are not. They create two classes of citizens and punish one class financially for exercising what, up till now, has been a right. Why do we not punish smokers and the morbidly obese for occupying hospital beds and imposing costs on society, including increased insurance premiums? Such punishment would be widely regarded as a human rights violation. The difference is that unvaccinated people increase the risk of infection for others. However, smoking can increase the health risks for other people due to second-hand exposure, yet no one punishes smokers or their families financially. No-smoking areas are designed to protect people, not to punish smokers, who experience only a minor inconvenience from not being able to smoke indoors. The problem here is not the fact that vaccination rates are lower than is desirable. The problem is that public health and medicine are becoming tools for punitive social control. If unchecked, this could escalate in a dangerous direction. The medical profession has been contributing to the creation of a class of untouchables, the unvaccinated. This has been done through nasty condemnation, threats to withhold medical services, and government financial penalties. More people have died from drug overdoses in the twenty-first century than from coronaviruses. There are negative attitudes towards ‘addicts’ in both the general public and the medical profession, but the pandemic ramps such attitudes up because of the fear it generates. These negative attitudes push people away from the medical profession. There are two forces at work: doctors driving anti-maskers and anti-vaxxers further away into isolation and extremism, and extremists pulling them in that direction. Rather than attacking the attractive force, the medical profession should reduce the repulsive force.

Face Masks

There are no randomized controlled trials that demonstrate a reduction in viral transmission in public from wearing face masks, and there are multiple trials demonstrating no effect [2,4]. A year and a half into the pandemic, the negative trials are still not referenced by doctors, the CDC, public health officials and governments who strongly recommend or mandate face masks. This is an example of politics over-riding science. Two recent studies reported by the CDC [16,17] that are characterized as providing strong evidence in favor of face masks do not actually do so. In one study [16], the authors surveyed 3142 counties but included only 16.5% of them in their final analysis, which rules out the results being representative or valid. In the other study [17], the authors surveyed 999 schools and divided them into 210 schools that adopted masking early in the study time period, 309 that adopted masks late, and 480 that never adopted a mask mandate. They reported the percentage of schools experiencing a COVID-19 outbreak during the study period, but they never defined an ‘outbreak’. Whether an outbreak could be one case, or required some minimum number of cases was not stated. Thus, the no-mask schools, in principle, could have had fewer total cases than the masked schools because they had a smaller number of cases per outbreak. The authors concluded that, “this was an ecologic study, and causation cannot be inferred.” In their text [17,18], the percentages of schools with outbreaks were: early mask 8.4%; late mask 32.5%; and no mask 59.2%. However, in their table the percentages were: early mask 8.0%; late mask 20.0%; and no mask 24%. The numbers in the table suggest that there was no difference between late masking and no masks – the lower percentage in the early mask schools could have been due to the virus not being as widespread in the early part of the study period, rather than a mask effect. Why doctors, public health authorities and governments recommend mask mandates remains a mystery. Mask mandates are a risky strategy because once the public catches on that face masks do not work for reducing viral transmission in public, the medical profession could experience blowback and there could be increased vaccine hesitancy.

Concluding Thoughts

The problem outlined here is not with ivermectin, face masks, the Wuhan lab leak, or mandates as such. The problem is the misinformation being provided by doctors, governments and public health authorities during the pandemic. This misinformation can do nothing but increase distrust in the medical profession and vaccine hesitancy. Physicians have contributed to the creation of a social class of untouchables – the ‘anti-maskers’ and ‘anti-vaxxers’ – who are denigrated and accused of spreading misinformation, which they often do. But the social ostracism of this class, which includes a significant number of medical workers, is compounding the problem of vaccine hesitancy, not solving it. The medical profession should take a look at its own misinformation rather than attacking members of the public. Attacking is different from educating. This does not mean that vaccine hesitancy is entirely the medical profession’s fault – but medicine should examine its own role in vaccine hesitancy and any unintended consequences of its attitudes, behavior and recommendations.

References

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fig 1

Study of Epidemiology and Human Papilloma Virus Prevalence in Oral Cavity Cancers

DOI: 10.31038/MGJ.2021421

Abstract

Oral cavity cancers (OCC) are the most common malignancies in the subcategory of head and neck cancers, and represent the 6th most common cancer in the world. These cancers have become more frequent in individuals without a history of alcohol-tobacco abuse, which are the major risk factors. Other factors have been suggested, such as viral infections, but especially genetic alterations. This work establishes the epidemiological profile and researches the presence of viral DNA in OCCs. The epidemiology was highlighted with 105 patients using the Epi Info software. HPV DNA was sought in 50 samples of diseased tissue and blood by attempting to amplify its L1 region by PCR. At the epidemiological level, the results show a mean age of 53.2 years, a sex ratio of 0.8 and a low consumption of tobacco (16.2%) and alcohol (4.8%). HPV was not detected in any of the samples. Thus, the epidemiological profile of OCCs in Senegal is different from that in other countries, and HPV is not associated with its occurrence.

Keywords

Cancer, Oral cavity, HPV, Epidemiology

Introduction

The epidemiology of cancers of the oral cavity is part of the more general framework of cancers of the upper aerodigestive tract (UADT) [1]. They account for approximately 25 to 30% of UADT cancers [2]. In general, they appear from the sixth decade of life [3] with alcohol and tobacco being identified as the main risk factors. They are ranked as the 6th most common cancer worldwide, and 3rd in developing countries [4]. Globally, they had 354,864 new cases in 2018, or 2% of all cancers, and approximately 177,384 cases of deaths, or 1.9% of cancer deaths [5]. Men account for 69.4% of cases, with a higher cumulative risk of dying before age 75. Age-standardized incidence rates are lower in West Africa, with little difference between men and women at 1.2 and 1.1 cases per 100,000 persons/year, respectively [5,6]. The five most affected countries are India (77,003 cases), the United States (26,064 cases), China (21,413 cases), Pakistan (12,761 cases), and Bangladesh (10,550 cases) [7]. Reports have shown that the global incidence is higher in more developed regions, but mortality is higher in less developed regions, which reflects social inequality [8].

According to GLOBOCAN [9], it is the 16th most common cancer in Senegal, with 130 new cases during the last 5 years and 111 deaths. The average age is about 52 years and the female sex predominates, with the majority being non-alcoholic-tobacco users [10,11]. In Africa in general and in Senegal in particular, data on cancers of the oral cavity are scarce and besides that the epidemiology differs from other countries.

Based on epidemiologic and clinicopathologic evidence, it has been proposed that Human Papillomavirus (HPV) infection is linked to the development of oral cancer [12]. HPV is one of the most common sexually transmitted infections and belongs to a large family of viruses, the papovaviridae. They are small (about 55 nm in diameter) and epitheliotropic. Their genome is composed of 7,200 to 8,000 base pairs with molecular weights of 5.2 x 106 daltons. They have a double-stranded circular DNA with a capsule of 72 capsomers of icosahedral structures, without a lipoprotein envelope [13]. Numerous papillomaviruses are known, with over 150 types; however, not all genotypes are considered carcinogenic [14]. Based on their potential oncogenic activity, HPV subtypes have been divided into high-risk (HPV-HR) and low-risk (HPV-LR) viruses. HPV-HR are associated with cancer development and are called viral “oncogenes” [15]. The prevalence of HPV in normal oral mucosa (latent infection) and its relationship to oral cancer have generated conflicting opinions. Most of the published studies have included several head and neck subsites, which have prevented specific analysis of HPV involvement in oral carcinogenesis [16]. In addition, the frequency of HPV infection in oral cavity cancer shows a lot of variation between studies around the world [17]. To support the implication of HPV in oral tumors, few studies have been conducted to determine the frequency of HPV DNA exclusively in squamous cell carcinoma of the oral cavity, particularly in Senegal. Hence, this study aims to update the epidemiological profile of oral cavity cancers and to detect the presence of HPV in them.

Methodology

This study was approved by the Research Ethics Committee of Cheikh Anta Diop University (Reference: Protocol 0272/2018/CER/UCAD). One hundred and five (105) patients diagnosed with OCCs between March 2017 and October 2020, at the Department of Stomatology and Maxillofacial Surgery of the Hospital Center University Aristide Le Dantec in Dakar were the subject of this study. Demographic, clinico-pathological, and etiological data were collected from the patients’ clinical records and then entered with Microsoft Excel 2016 spreadsheet for statistical analyzes, thereby allowing the description of the epidemiological profile of OCC in Senegal. Epi Info software version 7.2.4.0 enabled these analyses to be carried out by providing, among other things, the number of patients, the frequency, and the 95% confidence interval for each parameter studied. For statistical tests, a p value <0.05 is considered significant.

DNA extraction was performed from blood and tissue using the Zymo research kit and the Purelink viral RNA/DNA kit according to the manufacturer’s conditions. In order to test for the presence of viral DNA in the OCCs, the L1 gene was amplified using the primer pair (MY09/11). PCR was performed using 25 µl of master mix, 1 µl of forward primer, 1 µl of reverse primer, 1 µl of MgCl2, 20 µl of ultrapure water and 2 µl of DNA. The following conditions were used: 94°C for 5 min; 35 cycles (94°C for 30 s, 55°C for 30 s, 72°C for 1 min); 72°C for 15 min. A positive control (PC) for cervical cancer was used.

Results

Characteristics of the Population

The clinical parameters of the one hundred and five (105) patients enrolled in this study are listed in Table 1. More than half (55.4%) come from the different regions of Senegal. Age at diagnosis ranged from 22 to 90 years, with 38.1% of patients aged between 50 and 64 years old. There was a slight predominance of women, with a sex ratio of 0.8, and they were older than men (55.7 years vs. 49.9 years) with a non-significant p-value of 0.12. Histologically, 93.3% of cases are squamous cell carcinomas, and are generally well differentiated (64.8% of cases). Different structures of the mouth are affected: the gum (30.5% of cases), the tongue (17.1%) and the inner face of the cheek (15.2%) are the most affected. Among the patients whose tumor size was reported, the majority (23 cases) were larger than 4 cm in size. The presence of lymphadenopathy (s) was noted in 21.9% of patients, and 48.6% were at an advanced stage (stage III or IV). The rate of alcohol and tobacco use was low, with only 16.2% of smokers and 4.8% of alcohol users. Note that 21.9% of cases have poor oral hygiene.

Table 1: Epidemiological and clinical characteristics of patients.

Characteristics

Minimum Maximum

Average

Age (year)

Overall age

22 90 53.2
Men 22 78

49.9

Women

25 90

55.7

Number

Frequency (%)

CI (95%)

Gender

Male

46 43.8 34.1-53.8
Female 59 56.2

46.2-65.9

Sex ratio

0.8

Age groups

Under 35 years

19 18.1 11.3-26.8
35 years – 49 years 19 18.1

11.3-26.8

50 years – 64 years

40 38.1 28.8-48.1
65 years and older 27 25.7

17.7-35.2

Origin

Dakar

41 39 29.7-49.1
Other regions 55 52.4

42.4-62.2

Neighboring countries

9 8.6

4-15.6

Histopathology

Squamous cell carcinoma

98 93.3 86.7-97.3
Adenoid carcinoma 1 1

0-5.2

Verrucous carcinoma

1 1 0-5.2
Sarcoma 4 3.8

1-9.5

Lymphoma

1 1

0-5.2

Differentiation

Good

68 64.8 54.8-73.8
Average 15 14.3

8.2-22.5

Weak

8 7.6 3.3-14.5
NP 14 13.3

7.5-21.4

Tumor site

Gum

32 30.5 21.9-40.2
Tongue 18 17.1

10.5-25.7

Cheek

16 15.2 9-23.6
Lip 8 7.6

3.3-14.5

Palate

6 5.7 2.1-12
Floor 2 1.9

0.2-6.7

Facial mass

9 8.6 4-15.6
Mixed 14 13.3

7.5-21.4

Tumor size (cm)

T ≤ 2

3 2.9 0.6-8.1
2 ˂ T ≤ 4 18 17.1

10.5-25.7

T ˃ 4

23 21.9 14.4-31
Large extension 18 17.1

10.5-25.7

NA

43 41

31.5-51

Lymphadenopathy

Positive

23 21.9 14.4-31
Negative 82 78.1

69-85.6

 

Stage

Early (stage I + stage II)

13 12.4 6.8-20.2
Advanced (stage III + stage IV) 51 48.6

38.7-58.5

NA

41 39

29.7-49.1

Common risk factors

Tobacco

17 16.2 9.7-24.7
Alcohol 5 4.8

1.6-10.8

No Alcohol-smoking

66 62.8 52.9-72.1
NA 17 16.2

9.7-24.7

Oral hygiene

Poor

23 21.9 14.4-31
Good/NA 82 78.1

69-85.6

TOTAL

105

100

Table 2 shows the distribution of age groups in relation to gender. For all age groups, the incidence is higher in women except those under 35 years of age.

Table 2: Distribution of the different age groups in relation to gender.

Men Women
Age groups Number Frequency (%) Number Frequency (%)

Total

Under 35 years

13

68.4 6 31.6

19

35-49 years

8

42.1 11 57.9

19

50-64 years

14

35 26 65

40

65 years and older

11

40.8 16 59.2

27

P-value=0.11

Amplification Reactions of the HPV L1 Region

The result of this PCR for 10 cancerous tissue and one positif control is shown in figure 1. The latter shows the absence of viral DNA for our samples, except for the positive control which shows a band, of about 450 bp. The result is the same for all samples (tissue and blood).

fig 1

Figure 1: Electrophoretic migration profile of PCR products from the L1 region.
MW:molecular weight; TC = Cancerous tissue PC: positive control; TN: negative control.

Discussion

One of the first activities of this study was to collect tumor samples as well as clinical data from patients with OCC at the Department of Stomatology and Maxillofacial Surgery of the Hospital Center University Aristide Le Dantec. Of the 105 cases, 59 (56.2%) were women as opposed to 46 (43.8%) men. This shows that in Senegal, there is a slight predominance of women in the incidence of OCC, with a sex ratio of 0.8. This sex ratio is identical to that found in Senegal by Dieng et al. [11], and not far from the result of Millogo et al. [18] in Burkina with a sex ratio of 0.85. In this study, the hypothesis is supported according to which the aesthetic concern would lead women of our societies to consult more often than men as soon as a significant anomaly is noticed in the oro-maxillo-facial sphere. However, oral cancer is considered worldwide as a male pathology and especially in the most affected countries like India [7]. Indeed, in India, a study by Singh et al. [19] identified 84.8% of men as opposed to 15.2% of women.

Cancer is a disease whose risk increases with age. In Europe and America, the average age of patients with OCC is estimated to be around 60 years old [3]. In Africa, the average age range is from 47.8 years in Côte d’Ivoire to 49.15 years in Burkina [18]. In our study, the modal class 50 – 64 years represents 38.1% of the cases (40 patients), with a mean age of 53.2 years for the entire study population. This result is close to those found by Touré et al. [10] and Dieng et al. [11] with 52.6 and 52.9 years of mean age, respectively. This age difference with developed countries could be explained by the difference in standard of living and therefore easier access to medical care, disfavoring for example poor oral hygiene for these populations [2,18]. Indeed, poor oral hygiene is thought to play a direct role in the occurrence of OCCs [20] and it may play a non-negligible role in Senegal [21]. It was often poor in the study by Touré et al. [10], and for the study of Millogo et al. [18], all patients experienced poor oral hygiene. In our case, these represent 21.9% of the study population, but with missing data.

Despite the fact that older people are more exposed, our results show that young people are also not spared from the disease, especially among men. In fact, in our results, 38 patients were not yet in their fifties and 19 of them were under 35 years of age, 68.42% of whom were men. Touré et al. [10] had observed in their cohort that 38% of patients were under 50 years of age. In many countries of the world, there has been an alarming increase in the incidence of oral cancer, especially among young men [3]. This could be explained by earlier exposure to common risk factors such as tobacco use [7] as is the case in India or Pakistan. In these regions, the average age of patients is between 41 and 50 years and one-third of the population aged 15 years uses tobacco in any form [22]. However, the consumption of these substances (tobacco and alcohol) is not common among patients with OCC in Senegal [10,11]. Our results confirm this with only 17 smokers (16.2% of cases), and 5 alcoholics (4.8%). The low alcohol consumption is explained by the fact that 95% of the population is Muslim [21].

The fact that 93.3% of the cases in our study were squamous cell carcinomas is not surprising, since it is well known that they account for more than 90% of all oral cancers [23]. Most studies have confirmed the predominance of squamous cell carcinomas, but with different frequencies. They were the predominant histological type for: Singh et al. [19] for all cases (100%), Dieng et al. [11] with 98% of cases, and 55.9% for Millogo et al. [18]. The latter support the hypothesis that the predominance of squamous epithelial tissue in the mucosa is the cause of this high frequency of squamous cell carcinomas.

The tongue is one of the most common sites in OCCs with 40% of cases [8] especially in Western countries due to excessive smoking and alcohol consumption [22]. In 2005, according to Touré et al. [10], the mandible (24.8%), tongue (21.9%) and maxilla (15.2%) represented the majority sites. The gum (30.5% of cases), tongue (17.1%) and inner face of the cheek (15.2%) are the most affected sites in our study. The fact that the maxillary and mandibular gingiva are grouped together may have caused this high rate for the gingiva. This distribution of tumor sites could be explained by poor dental hygiene: either non-healing after dental extraction, creating an open wound in the gum area; or decayed teeth, traumatizing the cheek or tongue, especially for the latter.

More than half of OCCs were diagnosed at stage III or IV [20]. This was the case in Senegal based on previous studies with an average of 86% of cases diagnosed at advanced stages [10,11]. For 48.6% of the cases in our study, the disease was at an advanced stage (stage III or IV), with the presence of lymphadenopathy in 23 cases (21.9%). However, a lot of data are missing to make an estimate of the stage of the disease in our study population. The diagnosis at an advanced stage shows an irregularity or a late consultation of our population at the level of oral care structures, which can be explained by a weakness at the financial level or by the ignorance for example of the early signs of the disease. Other authors such as Millogo et al. [18] point to the omnipresence of traditional medicine as perhaps the first resort in our societies

This epidemiological study has certain limitations, such as the large number of unspecified data for a few parameters, or the failure to take into account other parameters such as occupation. The existence of a register or database of oral cancers, which compiles data from all hospital services receiving patients with this pathology, would allow us to know a little more about this disease and its incidence in Senegal.

Searching for HPV DNA was also one of the objectives of the study. It was done by gene amplification of its L1 region on 50 extracts of cancerous tissue and 50 extracts of blood, and none revealed the presence of this virus. This suggests that there is no significant association between OCCs and HPV infection. Ndiaye et al. [21] found only 3.4% HPV-positive cases in a study conducted in Senegal on head and neck cancers (HNC). This study, in addition to our own, shows that the prevalence of HPV in HNCs in Senegal is low. This is more or less the same observation that has been made in some African countries. For example, HPV was found in 6.3% of HNC cases in a study in South Africa; [24] 0.74% in Central Africa for Kofi et al. [25]; and like our case, it could not be detected in studies in Mozambique [26] and Nigeria [27]. These results are different from what has been reported in other parts of the world. In a systematic review by Kreimer et al. [28] compiling data from 60 studies, the overall HPV positivity was 25.9%; and North American countries were more representative than Europe or Asia. Ndiaye et al. [29] reported a positivity of 31.5% when compiling 148 studies. Ndiaye et al. [21] argue that there are ethnic disparities regarding the prevalence of the virus in these cancers, with less of it being found to affect the black race. Indeed, studies in the US have shown this to be the case [30,31]. For example Settle et al. [30] found 34% positivity in whites as opposed to 4% in blacks. This racial difference would be explained by risky sexual practices, especially oral sex, which is believed to be more prevalent among whites; but also by genetic differences between the two groups, impacting host immunity or viral integration [27]. It also appears that smoking, besides being an independent risk factor in developed countries, makes infections more likely to persist, thus increasing the risk of developing HPV-related diseases [32].

Furthermore, it is recognized that the highest prevalences of HPV infection in HNCs are found in the oropharynx (45.8%) including the tonsils (53.9%), compared to 24.2% for the oral cavity [29]. Thus, the oral cavity is not the preferred site for HPV in HNCs.

Conclusion

As a result of the heterogeneous etiology and lack of definite prognosis of oral cavity cancers, this study aimed to contribute to a better understanding of the epidemiological and molecular profile of patients with OCC in Senegal. An epidemiological profile different from that of Western or Asian countries was found. Indeed, it is that of a relatively young individual, often of a female gender, nonalcoholic-smoker. Added to this is the absence of HPV in patients with OCC in Senegal. Thus, the risk factors are not yet clearly identified, and this opens the way to the search for other factors such as those related to the environment, lifestyle or diet, but especially genetic events.

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fig 2

Methods and Technologies of Internal Speech Recognition by Non-Invasive Neurointerfaces

DOI: 10.31038/ASMHS.2021531

Abstract

The brain coordinates the reproduction and understanding of internal speech. The processes of thinking are given in the form of internal speech. The perception of internal speech involves the primary and secondary crust centers of analyzers, which record the corresponding waves, signals and rhythms and qualify them as language. This is achieved in two ways: either use functional neuroimaging and other additional research methods that allow localizing the structures currently functioning, or select patients with damage to certain areas and conduct a detailed neurocognitive study in comparison with healthy people from the control group, determining which functions in this lesion fall out. The principal issue of internal speech research is languages. A more complex question is the study of the connection of thinking, memory with internal speech. Now, especially when neurologists take into account the plasticity of the brain, functional relationships, general principles, pathways of excitation are of greater interest. Technologists of non-invasive neurointerfaces use methods and technologies to localize structures that control the understanding and reproduction of internal speech, the communication between them, the stages of speech signal processing and the role of each structure at these stages. The introduction to the study highlights approaches and methods for identifying various functional speech aspects. The mental lexicon section discloses the semantic component and the syntactic component, as well as the perceived and reproducible forms of words of internal speech. The section holographic human consciousness describes aspects of storing life information. The hologram of consciousness is the main form of storage of information about human life. In the section, holographic fixation of internal speech presents functional magnetic resonance tomography focused on BOLD effect detection, which is today the optimal tool for mapping neuronal activity, more precisely, the functional state of neural networks – the basis for visualizing our holographic images in real time. Using nanoresonators with Fourier transducers, the brain activity of a human internal speech holographic image can fix mental noninvasive neurointerface in language form by mental lexicon.

Keywords

Mental lexicon, Holographic consciousness, Neurointerface, Functional magnetic resonance tomography

Introduction

Internal speech is related to thinking: the modern position of cognitive science is such that without internal speech, thinking, primarily abstract-logical, is impossible [1]. If the studies are supplemented by functional neuroimaging, they are also of particular interest as a reflection of neuronal plasticity processes [2,3]. Electrophysiological studies use the method of induced potentials. The area in which the identified potential is generated can be determined based on its severity in different leads:

– The potential N400, negative, reaches the maximum amplitude 400 ms after the presentation of the corresponding stimulus, most pronounced in the centroparietal zone, reflects the processes of semantic analysis, that is, awareness of meaning.

– LAN potential (front left negative wave), resembling a N400 in delay, but most pronounced in leads from the left frontal departments, responds to the use of parts of speech that do not fit into the syntactic structure of this sentence (for example, “soft toy” instead of “soft toy”) [4];

The most famous electrostimulation studies belong to Canadian neurosurgeon Wilder Penfield. He described the results of his work in the monograph “Language and Brain Mechanisms,” still relevant for neurologists and cognitive specialists [5].

This can also include studies using deep brain stimulation [6] and transcranial magnetic stimulation, which began to be carried out relatively recently.

Functional neuroimaging methods are currently leading methods in the study of the neurophysiology of internal speech. Let us judge which structures are functioning at the moment:

– Functional magnetic resonance imaging (fMRI) and positron emission imaging of certain brain regions;

-diffuse-tensor MRI allows visualization of conducting brain pathways connecting these areas; magnetoencephalography (MEG) makes it possible to measure and graphically represent magnetic fields that are formed due to electrical activity of the brain.

The structure responsible for understanding speech is the Wernicke zone, the posterior part of the upper temporal gyrus. This area is adjacent to the auditory cortex, specialized in speech perception and contains sensory images of words and their combinations characteristic of the native language. The model also claims that sensory images do not carry semantic content – this aspect of speech cannot be specifically localized in the brain, but, nevertheless, in the process of signal processing, there should be an appeal to the “repository” of concepts – the semantic units of our speech. There are links between the Wernicke zones and the “repository” of concepts [7].

The “double flow” model was open to visual perception. After treatment in the visual cortex of the occipital lobe, the signal follows ventral and dorsal flows. Ventral goes to the temporal lobe and is necessary for identifying the object (answers the question “what?”), And dorsal goes to the parietal lobe and is designed to recognize the spatial characteristics of the object, its position and possible ways of interacting with it (answers the question “how?”)

Primary processing regarding the phonological composition and frequency-time characteristics occurs in the back of the upper temporal gyrus and the areas surrounding the upper temporal furrow, for the most part this is the Wernicke zone. The ventral flow is directed to the front and middle parts of the temporal lobe, it participates in the actual recognition and lexical analysis of speech (understanding its meaning, correlating with concepts stored in memory). Dorsal participates in sensorimotor integration, that is, correlation with motor images of words, and includes two separate paths: both pass through the temporal-parietal region, then the first is directed to the lower frontal gyrus, and the second to the prefrontal cortex. Presumably, one of them participates in the perception of internal speech, that is, controls the construction of segment sequences and provides more complex skills.

Hicoca-Popel claims that the perception of internal speech, through the functioning of the ventral flow, occurs bilaterally, and the intermediate center of dorsal flows working exclusively in the dominant hemisphere is placed in the temporal-parietal zone along the sylvium groove, at the junction of the temporal platform and operculum parietale [8].

In ventral flow, which is mainly involved in semantic and syntactic processing, excitation also moves along several paths. The lower frontal-occipital tuft connects the lower frontal cortex and dorsolateral frontal cortex with the posterior part of the temporal and parietal lobe. It passes through the anterior leg of the external capsule into the temporal lobe and gives branches to the middle and lower temporal gyrus, as well as the occipital lobe [9]. When stimulating this beam, semantic paraphasias are observed in the experiment [10]. Dorsal flow, in turn, is related to extended syntax and is evolutionarily later and perfect [11].

In speech perception activation of interested structures is asymmetric [12-14]. Differences were found in the activation of parietal and frontal centers: it is shown that the latter are characterized by a large degree of lateralization, this indirectly indicates in favor of the possible bilateral activity of the ventral flow, which, however, as the level of treatment increases to a more complex one, is “interrupted” by a more lateralized dorsal [15]. There is mutual activation between symmetric speech structures of different hemispheres. What is observed in healthy patients as equilibrium [16]. The left hemisphere is logical, and the right emotional and creative, for example, specifically-shaped thinking, tasks related to the manipulation of objects, images. The left hemisphere is more specialized for recognition of time characteristics, and the right hemisphere is more specialized for recognition of frequency characteristics [17]. This distribution was shown for the anterior part of the upper temporal gyrus, where information is processed immediately after the primary auditory cortex [18]. This is confirmed, for example, by recent tractographic analysis [19].

Scientists at Carnegie Mellon University and Minnesota State University have been able to create a virtually non-invasive technology that will allow paralyzed patients to control mechanisms and robotic prostheses with the power of thought. To do this, they had to overcome the main problem of non-invasive neurointerface: unlike the implant, it receives a much more noisy signal, and therefore, the accuracy and speed of control decreases. With the help of the latest sensors and machine learning, the researchers were able to get signals from the depths of the brain, clear them of interference and for the first time achieved high quality control by a robotic hand, On the BrainBit neurointerface tape there are 4 dry EEG electrodes, reference and common electrodes, as well as a miniature electronic module. This allows you to register a professional electroencephalogram with the best quality among the neurointerfaces available on the market. The device amplifies and digitizes the received signal and transmits it using the Bluetooth protocol to a computer, smartphone or tablet. Unlike analogues, the position of the electrodes on the tape BrainBit corresponds to the international arrangement of electrodes 10-20. Electrodes provide direct contact in areas of temporal lobe T3 and T4, as well as in occipital region O1 and O2. According to advanced international studies, these zones are optimal for recording the level of four main types of brain waves. BrainBit records electrical activity in the form of “raw data” of EEG, which are presented as levels of the four main rhythms of the brain. All brain activity data obtained can be sent to the cloud for analysis and processing by machine learning methods. The BrainBit SDK contains a set of tools for developers that allow you to obtain both raw EEG data and calculated values ​ ​ of brain activity rhythms. The SDK facilitates complex data processing and analysis by simplifying application development. The application can display the state of the user’s brain based on color indicators. These graphical indicators complement qualitative and quantitative indicators demonstrating the current state of the brain.

Mental Lexicon

A mental lexicon is a collection of word information that includes the actual meaning of a word, a semantic component, a syntactic component, as well as perceived and reproducible forms of words [2]. In the mental vocabulary, the brain finds and learns what we ourselves are going to fish. We are trying to look where our thought processes take place into the mental lexicon [2].

Firstly, morphemes are considered its smallest unit – minimal meaning-containing units [2]. These are roots, suffixes, prefixes. At the same time, the mental lexicon can have several levels, and on one of them the minimum unit will be a word.

Secondly, it is not a list that is sequentially viewed, but a network where each unit is associated with many others. The essence of such an organization is that words related in meaning are often used in the same mental situation, and if internal talk is about one, it would be wise to keep the rest carefully. The more often words are used together, the stronger the connection between them, the more inclined it is to move along this connection during the associative process. Freud’s invented free association method confirms this.

Thirdly, the mental lexicon does not have one organizing principle, but several at once. The master is semantic, that is, the connections are made by value. The importance of this principle is proved by the semantic priming effect, in the Russian-language literature the term “precedence effect” is used. Two words are used in the experiment: “previous” is always a real word, and “target” can also be a real word, a pseudo word that is built in accordance with phonetic principles, but is not in the language, or simply an unreadable set of letters. The subject needs to click the button to decide whether the target word shown to him is real, a pseudo word (similar in structure to the present, but non-existent, as a “deep cusd”) or an impracticable set of letters – the so-called situation of the “lexical solution.” If the “previous” word is associated in meaning with the “target,” the subject performs the task many times faster: the memory has already passed to the “catalog section” in which this word was in one semantic bundle, it remained only to find it [2].

The mental lexicon is central to the organization of internal speech. Each word is present in the “library” in all grammatical forms, for example, the times of verbs or the genera of adjectives. Due to this, semantic and syntactic information is extracted simultaneously at the lexical access stage. When calling the word “red,” the names of other colors, red objects and others associated with it are activated in the semantic network (Figure 1).

fig 1

Figure 1: Semantic principle of mental lexicon organization

Lexical selection is the stage at which, among all activated word forms, the most suitable is selected. Lexical integration is the combination of all words into larger structures: phrases, sentences, up to whole internally connected texts. The preparation of texts includes macro and micro planning.

Communication is one way to influence the environment. Therefore, communication, like any action, is subordinate to the motivational sphere and can be aimed at meeting the need or eliminating inconvenience. On the example of instructive expressions, this can be seen especially clearly, but our other statements seem to have the same goal, because there are simply no other sources of motivation. Thus, any statement should be formulated based on the result that we want to receive – this aspect of the preparation of the message is called macro-planning. When microplanning, the question is developed how the information should be presented: which group of words to use, in which relationships to put them. After preparing the message at the output, a “concept” is obtained, the general meaning of the whole sentence.

The mental lexicon is a specific concept, and it manages smaller, more formal units than the “repository of concepts.” Similarly, only people can be the bearers of ideas that really understand them, and although all the rich variety of expressions for these ideas are stored in the library, only books that read them “animate.”

The formulation of expressions is to give the sentence a specific form, grammatical and phonetic, ready for pronunciation. The concept obtained in the first stage interacts already with the mental lexicon; the first thing to decide on is part of internal speech. At the output, we get the corresponding lemma – the initial form of the word. Many different word forms are associated with lemma. According to the grammatical principle, lexical selection of word forms occurs. Then there is morphemic analysis. The resulting word will need to be called, preparation for which is phonological analysis: analysis of the number of syllables and the position of emphasis in the word.

There is little neuroscience evidence that addresses the issue of mental lexicon; they make it possible to create a holistic picture. Elizabeth Warrington and colleagues investigated the problem of selective items belonging to only one category, and how they can relate to semantic memory. It turned out that semantic memory is divided into “categories.” In our mental vocabulary, not every word is connected with each so that you can come to it in a different way; some kind of division, dispersal is still there. Warrington identified such groups: living beings, which are mainly associated with terms describing their appearance and other properties perceived by the senses; and artificial objects – they are usually described by the function that they perform.

Human Holographic Consciousness

Human consciousness, like a hologram, contains everything that is in a multiple updating system from finite shifting professions. The hologram of consciousness is the basis for storing information about human life.

The principle of the hologram “everything in each part” allows a fundamentally new approach to the issue of organization and order. The hologram shows that some things cannot be investigated by an analytical method: to dissect an object and study its constituent parts. If we dissect anything on the hologram, then we will not get the parts of which it consists, but we will get the same, but with less accuracy.

Our ability to quickly find the right information from the vast volume of our memory is provided by a brain that works on the principle of a hologram. Indeed, one of the most amazing properties of human thinking is that each piece of information is instantly and mutually associated with the other – another property inherent in the hologram.

Memory location is not the only neurophysiological mystery that has become more solvable in the light of Pribram’s holographic brain model. The other is how the brain is able to translate such an avalanche of frequencies that it perceives by various sensory organs (frequencies of light, sound frequencies, and so on) into our specific idea of ​ ​ the world. Frequency coding and decoding is exactly what the hologram handles best. Just as the hologram serves as a kind of lens, a transmitting device capable of turning a apparently meaningless frequency interfere into a coherent image, so the brain, according to Pribram, contains such a lens and uses the principles of holography to convert frequencies from the senses into the inner world of our perceptions.

Pribram’s idea that our brains construct solid reality by relying on input frequencies has also received experimental confirmation. It has been found that any of our sensory organs has a large frequency range of susceptibility. In particular, the researchers found that our visual organs are susceptible to sound frequencies, that our sense of smell depends somewhat on what is now called osmotic frequencies, and that even our body cells are sensitive to a wide frequency range. This is the work of the holographic part of our consciousness, which converts separate chaotic frequencies into continuous perception.

The holographic model also shows that consciousness is not a function of the brain, but, on the contrary, the neural networks of the brain are controlled by consciousness, which, therefore, does not die if the brain dies. In holographic reality, thought is as real as consciousness.

A single universe has projections in the form of a discretely updated frequency wave-like structure – a hologram, the main content of which is consciousness, which is its copy. Discrete update of the projection by consciousness means the appearance of durations, which qualifies as time.

A single universe enters time by means of its own projection in the form of a frequency wave-like structure – a hologram, forming its own time and at the same time – the general of the entire structure of being due to its holographic essence (the whole and part coincide). The active living in the holographic projection of the Single, copying fragments of the passive from the Single, are combined with them individually and as a whole, and through themselves form the current time, space and things in motion.

The conversion of wave matter (packets of information) from the holographic projection of the Single in any living creature, including in man, into his environment, is carried out by him no longer in the form of images, but in the form of material objects of different “density” and various forms using the corresponding matrices (shaping abilities), creating both the living being itself and its environment within the framework of common time, which is the consequence of the action of a single consciousness in a combined set of living beings.

The formation of objects of various forms in accordance with the mass-forming abilities (matrices) of a living creature is carried out according to the type of work of a 3D printer.

The holographic image of living beings allows them to be separate, living each time their own life, having their own time, their own being, and at the same time in their totality – to be a single being that is eternal both in its singularity and in each of its own.

As for the genome, it is based on a program copied by consciousness in a projection from the Unified to the molecular chains of the genome in accordance with its existing shaping abilities for each particular case.

Information is an activity property. Without material objects-carriers, including consciousness itself, information does not exist. For each person, discrete information is automatically (with the help of a single consciousness) converted into things, images, meanings, feelings, which are also quite material components of each individual consciousness, entailing subsequent actions of the carrier of consciousness.

Living beings are involved in the information process. With the help of information processing centers, they are able to immerse themselves in a liveable environment. All human achievements are connected in the form of acquired experience in this field, existing knowledge and skills with certain target focus.

In the form of light and sound, a person can approach the harmony of his own wave basis of the ideal, which is actually the holographic basis of a person.

The time of any living creature, in particular, and man, is an information process during which material objects are recognized by consciousness by scanning the environment by the processing centers at its disposal. The informational (impulse) nature of time formation is asymmetric (one-sided), differing from the usual real or energy interactions of objects in that a living being unilaterally scans the surrounding one, sequentially copying the data recognized and grouped by it. This high-frequency complete update of one position of the next, etc., in particular, does not allow you to go back or run forward due to the asymmetry (one-sidedness) and completeness of the update of each position. Therefore, it seems to each person that time flows in one direction: from the past to the future through the present. Due to the complete updating of one position by another, that is, irretrievably and infinitely, in the form of an infinitely updated ultra-high-frequency wave-shaped holographic projection in the form of intermittent moments-durations (pulses of information).

For humans, information passes every moment to brain neurons from different human sensory organs in the form of sequences of nerve impulses; each of the pulses contains corresponding information. Immediately after the pulse generation, the nerve fiber is in the so-called refractor state, and cannot be reactivated for 1-2 milliseconds, that is, the nerve fiber is able to conduct nerve pulses with a frequency not higher than 500 hertz. The duration of the pulse itself passing through the nerve fiber is a fraction of a millisecond in each moment.

A pause between nerve impulses containing information means that they do not go continuously. However, this pause is below the threshold of perception by her consciousness and therefore does not fall into it. In particular, the moving picture for human consciousness is provided by an interval between the run-through successive frames of about 0.04 seconds, which is said threshold. Its duration, as you can see, is more than an order of magnitude longer than the duration of the pause. Therefore, the resulting discrete sequential moments (in each of them there is an update of the “reality”) of a person’s own time, which contain in their sequence all the paintings and all the events of life for a person, merge into a continuous, inseparable flow in his mind.

Each person, starting from the moment of birth, selects through sensations from a diverse environment only those information that can be deciphered, or information, in accordance with the achieved level of consciousness development (shaping abilities). The holographic approach to the structure of consciousness fully reflects the connections of various regions of the brain.

Holographic Recording of Internal Speech

Magnetic resonance imaging (MRI) today is used not only for diagnostics, but also for mapping the functional state of neural networks, allowing you to literally see the brain’s work in real time [20-24].

The ability to directly observe the dynamics of cognitive (cognitive) brain activity appeared only with the introduction of functional magnetic resonance imaging technology into research practice.

A little more than two decades ago, employees of the American research organization AT&T Bell Laboratories described the principle of visualizing the activity of brain zones in real time using magnetic resonance imaging (MRI). A dynamic study of active zones of brain structures at the time of their activity was first tested on a person two years after the first publication.

MRI (magnetic resonance imaging) is a diagnostic procedure based on the effect of nuclear magnetic resonance. Modern MRI techniques allow not only to visualize organs with high quality, but also to investigate their function. Due to the absence of ionizing radiation, this method can be used without restrictions and repeated studies are repeatedly carried out.

It follows that the relative magnitude of the MRI signal can serve as a measure of the activity of brain zones. Moreover, the results obtained under the control of electroencephalography on the visual cortex of the primate open brain suggest that the MRI signal is a linear response to the electrical activity generated by the active neural ensemble.

Functional MRI focused on BOLD effect detection is today the optimal tool for mapping neuronal activity, more precisely, the functional state of neural networks – the basis for visualizing our holographic images in real time.

Closely related to fMRI technology is the neurobiological technology “of the brain-computer interface. We are talking about the possibility with the help of an electroencephalogram to obtain a display of a stable hologram of the bioelectric activity of the brain, tying it to the function of brain structures and the formation of new stable neural ensembles in them. The electroencephalogram is a source of information on intracerebral events. At the same time, fMRI makes it possible to visualize the real temporal and spatial dynamics of the brain. If you briefly describe the most general route of activation of brain structures during internal speech, then after the start, the broad cortical fields of the brain are first involved in the work, and the cognitive route in the cerebellum ends.

Psychology is one of the most promising areas of use of neuroimaging technology by FMRT, because this scientific field is practically devoid of ideas about the localization (in the anatomical sense) of cognitive functions.

In one of the works of American researchers, an attempt was made to answer the question of the localization of brain structures designed to classify such cognitive categories as equality and efficiency. It turned out that the emotional assessment of the “effectiveness,” “justice” and “general benefit” of the decision is carried out by three different brain structures. The brain department, called the “shell” (lat. Putamen), is responsible for efficiency, the bark of the “islet” (lat. Insula) protects the interests of justice, a cumulative measure of efficiency and inequality, that is, utility, assesses the septal organ (lat. Septum), while other areas of the brain are involved in the cognitive process.

The development of cognitology, a direction of neurosciences that studies the basic mechanisms of the brain’s work: “mental strategies,” their localization, dynamics, ways of using and improving in everyday life, also opens up great prospects. The so-called “interactive stimulation” makes it possible to organize training feedback directly through the “interested” brain structure (Figure 2).

fig 2

Figure 2: Brain functions

By visualizing the cingulate gyrus or hippocampus, you get a chance of “direct conversation” with the brain. Knowing how the brain is activated, you can restore the holographic image of internal speech by a resonant energy trace. Using nanoresonators with Fourier transducers, brain activity of human internal speech holographic image can fix mental noninvasive neurointerface in language form by mental lexicon [25,26].

Conclusion

Thanks to the development of holographic methods, technologies and the creation of smart neuroiterfaces, in the coming years humanity can move to a completely different world in which everything will be technological. Almost all modes of transport will be controlled through neurointerfaces with smart artificial intelligence. Human thinking will be a kind of hybrid of biological and non-biological. We are considering the prospect of connecting to the cloud from the human neocortex. Already, we can connect a computer to the human brain and thus convey feelings and emotions to the Internet. It will be possible to read memories and impressions from the human brain, transmit them over the Internet or even upload them to the brains of other people. This will open the way to turning the Web into a brain-net, that is, a brain-net. You will be able to share your memories and load them into a break-no, and then loved ones with their eyes and heart knock via smart neurointerface will survive your events and experience joy. Neurointerfaces with intelligent artificial intelligence and technological singularity are already in demand in the industrial and social spheres. Especially in environments and situations incomprehensible to the consciousness of specialists, where huge risks arise.

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Alternative Treatments of Postpartum Uterine Diseases in Dairy Cows

DOI: 10.31038/IJVB.2021534

Abstract

The ultimate goal of treating postpartum uterine diseases (PUDs) in dairy cows is to reach clinical cure in a reasonable amount of time and to improve reproductive performance while minimizing milk and meat residue issues, and consequently, reducing economic losses. Even though some local antibiotic treatments are effective to mitigate the effect of PUDs, veterinarians will eventually use more natural alternatives to meet the global context of antimicrobial resistance and protect human and animal health. Research advances have improved our understanding of the uterine involution and the ethiopathology of the different pathological postpartum conditions in dairy cows. This has opened new therapeutic and preventive approach, however, most recent research is still in the early experimental stages and under scrutiny. The aim of the present article is to review non-antibiotic approaches used to treat or prevent PUDs in dairy cows. The authors include: Chitosan microparticles, essential oils, mannose, bacteriophages, dextrose, paraffin, ozone, probiotics, antiseptics, homeopathy, apitherapy, vaccines, pegbovigrastim, recombinant IL-8, and genomic selection.

Keywords

Postpartum uterine diseases, Dairy cows, Reproductive performance, Alternative treatments, Non-antibiotic

Introduction

The ultimate goal of treating postpartum uterine diseases (PUDs) in dairy cows is to reach clinical cure in a reasonable amount of time and to improve reproductive performance while minimizing milk and meat residue issues, and consequently, reducing economic losses. Acute puerperal metritis in cows is usually treated with systemic antimicrobial drugs (cephalosporin, or tetracycline, ceftiofur, penicillin) and a fluid therapy in severe cases [1]. Because of concerns about antibiotic resistance and residues, some veterinarians advocate waiting 24 h to 48 h before instituting an anti-microbial therapy, thus allowing a spontaneous cure of about 30% [2]. In severe cases, this is frequently not advised in order to protect the welfare of the animal. Indeed, manipulation of the uterus and drainage of the fetid watery red-brown discharge are not recommended because of the risk of perforation of the friable and painful uterine wall and bacteremia [3]. There is no evidence of improvement of the clinical condition or reproductive efficiency with other treatments, such as estrogen [4] which is now illegal in many countries, or oral calcium [5]. In cases of pyometra, PGF2a or its analogue [6] is the treatment of choice, allowing luteolysis of the persistent corpus luteum, expulsion of uterine exudates, and reduction of the bacterial load in 90% of cases with a recurrence rate of about 10% [7], in which case the PGF2a treatment should be repeated. In refractory cases, a local antibiotic may be added to the second injection of PGF2a. Veterinarians need to remember that the use of intrauterine nitrofurazone infusion has been known to reduce conception rates. Endometritis (clinical and subclinical) is most often treated with intrauterine infusion of a specific formulation of cephapirin (Metricure, Merk) which has beneficial effects on clinical cure and subsequent reproductive performance [8-12]. Although prostaglandins are still used for treatment and prevention of endometritis, there is no evidence of efficacy neither for improving reproductive efficiency nor for reducing its incidence [2], Lefebvre and Stock 2012). However, this hormone is essential in synchronization protocols for controlled breeding programs. The aim of the present article is to review non-antibiotic approaches used to treat or prevent PUDs in dairy cows.

Alternative Medicine

Veterinarians could substitute antibiotics for natural alternatives, especially in the global context of antimicrobial resistance and given the World Health Organization’s position on the use of medically important antibiotics and the One Health program. Despite the well documented detrimental impact of PUDs on the cow reproductive health, treatment and prevention practices of farmers are not always recorded and consistent. For example, [13] have shown significant disparity as to how farmers treat metritis. To mitigate the impact of PUDs, several non-antimicrobial therapies to treat or prevent uterine diseases have been proposed. However, most of them are still in the early experimental stages and under scrutiny. In addition, the scientific merit of most in vivo studies seems to be compromised by experimental factors: absence of precise clinical definition, inconsistencies of outcomes, lack of negative controls, insufficient numbers of animals per treatment group, use of inadequate or rebutted diagnostic methods, disparity in the studied population, lack of randomization, and faulty experimental design. However, these studies carry forward the limits of our understanding and provide a different perspective on the treatments of PUDs in dairy cows. These new approaches include: Chitosan microparticles, essential oils, mannose, bacteriophages, dextrose, paraffin, ozone, probiotics, antiseptics, homeopathy, apitherapy, vaccines, pegbovigrastim, recombinant IL-8, and genomic selection. These alternative therapies attempt to improve the avoidance (chitosan, mannose, dextrose), the tolerance (probiotic, paraffin, and ozone), and resistance (pegbovigrastim, recombinant IL-8, and genomic selection) of defense mechanisms in the genital tract of dairy cows.

Alternative Therapy for PUDs

Chitosan is recognized by the FDA and synthesized from chitin of the exoskeleton of arthropods and cell walls of certain fungi and yeast and has a large antimicrobial spectrum in neutral and acidic environment [14]. The normal pH of the cow’s genital tract is neutral between 6.84 and 7.51 [15]. The product claims to improve the cow’s resistance by reducing the uterine bacterial load. More specifically, the antimicrobial activity of chitosan microparticles is associated with the disruption of the bacterial cell membranes by interactions with the outer membrane protein A (OmpA) leading to cell death [14]. The cows with metritis were administered 24 g (in 40 ml of sterile distilled water) of chitosan particles in the uterus for 3 days (D0; day of diagnosis, D2, and D4), and compared to ceftiofur crystalline-free treatment (6.6 mg/kg SC in the base of the ear at D0 and D3) or no treatment at all as the control group [16]. No improvement of clinical sings was measured. However, the treatment decreased milk production, reproductive performance (conception rate at first AI, and pregnancy rate at 300 DIM), and survival rate of treated cows compared to the control group [16]. Case definition and the number of local treatments may have rendered the results even more uncertain. Therefore, intrauterine use of chitosan is not recommended in dairy cows.

Essential oils (about 3000) are volatile substances naturally produced by plants as secondary metabolites and are known for their antibacterial, antifungal, insecticidal, and antiviral properties. The special biological properties and fragrance of essential oils are in a great portion due to terpenes and phenylpropanoids [17]. An important point to know is that essential oils have several compounds and their bioactivities result from the complex interactions between the different classes of compounds. Essential oils have antioxidative, anti-inflammatory, and antimicrobial properties making them good candidates in infectious process like UPDs [18]. A compound of certified organic essential oils (Optimum UterFlush, Van Beek Natural Science, Orange City, IA, n=107) was infused every other day for a total of 3 times between 1 and 12 DIM in the uterus of puerperal toxic metritis dairy cows and the results were compared to the intrauterine iodine povidone infusion group (n=113), and the control group (health cows, n=400) in organic farms [19]. The first service conception rates were 23%, 37%, and 38% in cows infused with iodine, the essential oils and the control group of healthy cows respectively (p=0.05). At 150 DIM, 75%, 31.1%, and 44.8% were pregnant in the healthy, iodine, and Optimum Uterflush groups respectively. The survival analyses indicated a tendency to shorten the interval from calving to first AI (P=0.08). The odds of pregnancy at 150 DIM for cows with Optimum Uterflush group was 1.81 times the odds of cows infused with iodine. In the study, all cows received intravenous calcium and hypertonic saline in addition to oral aspirin. The effect of Optimum UterFlush was not tested on healthy cows. The first results are very encouraging and further research on a larger scale is needed.

Carbohydrate

Three rationales have motivated researchers to use sugars as intrauterine remedy for postpartum uterine infections: 1) sugars disrupt attachment of bacteria to tissues, 2) sugars inhibit microbial growth, and 3) sugars are hypertonic and attract fluid in the uterus and facilitate eviction of debris and bacteria when the uterine cervix opens. Often lectins present on the surface of the infectious organism bind to complementary carbohydrates on the surface of the host tissues. In this way, the pathogen is not washed away by natural cleansing system of the host. Furthermore, the adhesion represents a good source of nutrition, facilitates the delivery of the toxins, and eventually the penetration of the bacteria into the tissues. The lectins present elongated multi-protein appendages with sugars (typically saccharides) on the surface of bacteria increase infectiousness (ex. fimH for E. coli) for the organism [20]. Anti-adhesion therapy consists in the inhibition of these lectins by suitable carbohydrates for prevention or treatment of microbial diseases. Mannose [21] and 50% dextrose [22-25] have been tested in cows with metritis and endometritis. Since the publication of the ability of mannose to block growth of E. coli in human wounds and to inhibit its adhesion on endometrial cells in mares with endometritis [26], research has been done in cows with PUDs. Adhesion of pathogenic organisms to host tissues is often the prerequisite for the initiation of infectious diseases. By inhibiting bacterial adhesion to the cell membrane (like endometrial cells), the risk of initiating infection should be lower. The hyperosmotic effect of the high concentration of sugar may also inhibit growth by breaking down bacterial membrane of bacteria. Mannose was used to reduce the risk of metritis in dairy cows [27] by administration of 50 g of sugar intrauterine 2 days after calving. The treatment was not successful in improving uterine health in treated cows compared to those receiving the placebo. Similarly, 200 mL of 50% dextrose solution infused intrauterine of endometritis cows at about 30 DIM did not improve neither the cure rate, the first conception rate, nor the calving-to-conception interval [22,23]. However, the cure rate of endometritis was improved with the dextrose treatment in other studies [25]. Nevertheless, it improved the median of days open compared to systemic treatment ceftiofur or no treatment at all (control). Also, the resulting accumulation of transudate in the uterus after infusion of dextrose is not well documented. Thus far, treatment of metritis and endometritis using 50% solution of dextrose remains to have sound results.

Parafin

Intrauterine infusion of liquid paraffin for endometritis has been proposed to increase the resilience of the uterus in the postpartum period. Unfortunately, the condition of cows with endometritis infused with 100 ml at around 30 DIM did not improve, but instead, sustained a reduction in their reproductive performance [22]. Without additional studies, liquid paraffin should not be considered, as an option for the treatment of endometritis in dairy cows.

Ozone

Ozone is a gas consisting of 3 atoms of oxygen in a dynamic unstable structure essential for life on earth due to its ability to absorb wavelengths of harmful UV radiation coming from spectra of sunlight [28]. Because ozone manifests strong bactericidal, fungicidal, viricidal, yeasticidal, and protozocidal properties, it is used in medical therapies, and is available in different types of products: vegetal ozoned oil with emollient, cicatrizing, antibacterial, and hygienic compounds in several forms (creams, gasses, syringes, paillettes, foam, and boluses) [29]. Ozone inhibits growth of bacteria by damaging the capsule and cell membrane through the activity of peroxidases, and may block replication of bacterial DNA, and often acts as a supportive therapy in infectious diseases. Gram-positive bacteria seem more sensitive to ozone than Gram-negative bacteria. The most important activity of ozone is probably the synthesis of cell membrane enzymes like superoxide dismutase, catalase, and glutathione peroxidase to counter the damaging effects of O2 free radicals [30]. It reduces the cascade of pro-inflammation by promoting immunosuppressive cytokines like IL-10 and TNFß1 by neutrophils, monocytes, and lymphocytes [31]. The therapeutic efficacy of ozone is most likely dependent on the strength of the oxidative stress produced. Moderate oxidative stress activates nuclear transcriptional factors (NrF2) suppressing NFkB and stimulating inflammatory responses. Ozone has been used to prevent [32] and treat [33,34] endometritis and metritis respectively with some positive effect. Even though ozone therapy is used in several human conditions (autohemotherapy, antineoplastic therapy, obstructive arterial diseases, macular degeneration, autoimmune diseases, and diabetes), it still not accepted yet as medical treatment in all countries [31]. In terms of efficacy of ozone in dairy cows with endometritis, the low number of animals in studies does not allow readers to draw clear conclusion.

Bacteriophage

The use of bacteriophages and phage-derived endolysins may represent an alternative treatment for PUDs in dairy cows [35]. Bacteriophages are host specific viruses of particular species or strains of bacteria. Phages produce endolysin which digests the bacterial wall, enters the cells and integrates the genome (prophage) of the host cell and replicates, resulting in lysis of the cell wall [36] in the biofilms produced by certain bacteria such as E. coli, T. pyogenes, coagulase-negative staphylococcus and S. aureus [37]. Intrauterine infusion of bacteriophages specific to E. coli and T. pyogenes 2 days prepartum and postpartum have shown no effect on uterine health and reproductive performance, instead, have increased the incidence of retained fetal membranes and metritis [21]. As for paraffin, the use of bacteriophages in PUDs in dairy cows is not recommended and more research is needed.

Probiotics

Probiotics are defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Probiotic products include probiotic-containing drugs, medical and conventional foods, dietary supplements, and animal fodder. However, it excludes microbial transplants, fermented foods, dead microbes, and microbial products such as protein, polysaccharide, and nucleotide components. Probiotics work by producing substances that have desirable effects on the body like improving the immune response or maintaining a healthy microbiome [38]. In humans, probiotics have shown promises for the prevention of antibiotic-associated diarrhea (Clostridium difficile), necrotizing enterocolitis, sepsis, and for treatment of infant colic, periodontal diseases, and ulcerative colitis. Prebiotics are not the same as probiotics since prebiotics are food components that selectively stimulate the growth or activity of desirable microorganisms. Probiotics may contain a variety of microorganisms, but one of the most common is Lactobacillus which is the major member of the vaginal microbiome in women. In dairy cows, several doses of cocktails of lactic acid were infused in the vagina (before calving) and in the uterus (after calving) to measure the effect on the incidence of metritis and endometritis [39-41]. Treatments with the lactic acid cocktails reduced the incidence of metritis and endometritis, improved vaginal mucus secretion of immunoglobulin A, and decreased the inflammatory response by reducing neutrophil gene expression. Therefore, intravaginal and intrauterine infusion of probiotics seem effective in reducing the incidence of PUDs. The probiotic functionality and efficacy are species specific and therefore, different cocktails may have different effects.

Apitherapy

Another alternative way to treat PUDs is apitherapy. Honey products have been used extensively since ancient times for anti-putrefactive (mommies), antiseptics, cicatrizant, anti-inflammatory, antimicrobial, antioxidant agents [42], and antibiofilm activities [43,44]. It is an influential antioxidant and a free radical scavenger. Nonetheless, for several decades now, modern medicine, propelled by new developments and the wide applications of antibiotics, in which the honey as medical treatment has be sunk into oblivion. Given the repeated occurrence of antibiotic resistance, there has been renewed interest in the medical applications of honey products (propolis, venom, royal jelly, venom, and pollen) for livestock. The active components of honey, such as glucose, fructose, flavonoids, polyphenols, and organic acids are largely responsible for its therapeutic activity. For example, flavonoids found in honey have been shown to induce apoptosis and prevent the release of IL-1ß, Il-6, TNFa, iNOSm and Cox-2 [45]. The propolis has antifungal properties and can be used as an antibiofilm [46]. Honey possesses therapeutic potential and its antimicrobial activity is widely documented as a large number of in vitro studies of MIC and MBC confirmed its broad-spectrum antimicrobial properties [47]. The immunomodulatory response to honey products also manifests itself in the activation of lymphocytic function, the activation of macrophages, and the stimulation of cytokines release by monocytes [48]. Abdul-Hafeez et al. (2019) infused 100 ml of 70% Egyptian cotton honey for 3 consecutive days in the uterus of repeat breeder dairy cows (n=16) with purulent vaginal discharge unresponsive to standard antibiotherapies and obtained 75% conception rate at first insemination after treatment. However, the small number of animals in the study does not allow us to draw any definite conclusions.

Homeopathy was introduced by Samuel Hahnemann around 1797 as a new method to treat diseases with dilute remedies. There are 3 major fundamental principles of homeopathy: 1) law of similia, 2) law of simplex (the single remedy), and 3) law of minimum. The law of similia means “like cures like”, the medicine must have the capability of producing similar symptoms of the disease to cure a person. Hahnemann stated that only one single and simple medicinal substance is to be administered in a given case of time. The reason for this is that if more than one remedy is used, the doctor will never know which element was curative and the different ingredients may even result in interactions that may have adverse effects in the body. The third law is probably the most debated. Under this principle, the quantity of medicine given to a patient is minimum and appropriate for a gentle remedial effect to avoid any aggravation.

In the scientific community and veterinary practice, the use of homeopathy in food-producing animals is controversial even though it is common practice on organic farms. As the other alternatives, the development of the homeopathy is fueled by overuse of antibiotic in humans and animals which has promoted the antibiotic resistance [49]. The mechanism of action of homeopathic drugs are not known however for example, Lachesis is used for several inflammatory conditions including uterine infection because it is believed that it stimulates the local immune defense and helps the mucosa to regenerate [50,51]. In ruminants, clinical trails reported on uterine infections in dairy cows [52]. Homeopathic studies on fertility addressed especially the peripartum period (retained placenta, endometritis) and almost exclusively in a preventive instead of the therapeutic approach. In a randomized, controlled, and double-blinded clinical trial, [53] compared three different mixed formulas of homeopathic remedies (Traumeel, Lachies, and Carduus administered IM) in dairy cows with clinical endometritis at calving, 7 to 13 DIM, 14 to 20 DIM, and 21 to 27 DIM. In contrast to the second law, the researchers did not use an individualized therapy. The homeopathic treatments were not effective in preventing endometritis or improving the metabolic condition and the reproductive performance. Another randomized, controlled, and blinded trial with 105 cows with compound remedies resulted in a significant reduction of noncycling cows compared to the control group [54]. Homeopathic treatments reduced significantly the number of days to pregnancy [55] and fewer services per conception [50]. No trial was repeated in a comparative manner. Due to low number and quality of studies available (high risk of bias), there are limited evidence for statistical difference between homeopathic remedies and the control.

Antiseptics (chlorhexidine, propylene glycol, lugol’s iodine, iodine, polyvinyl-pyrrolidon-iodine, formaldehyde, and Betadine solutions) have been routinely used in veterinary practice for many years to treat postpartum uterine infections in dairy cows [56,57]. It was postulated that intrauterine infusion of irritating antiseptics would trigger an acute inflammation transforming chronic endometritis into an acute condition (local irritation) by stimulating the uterine immune defense [58]. Antiseptics have also an microbiocidal effect. In addition, it is expected that a local condition like endometritis could be treated locally (intrauterine infusion). Intrauterine infusions of 2% and 4% polycondensated m-cresolsulphuric acid formaldehyde in dairy cows with endometritis between 22 and 28 DIM did not improve the conception rate compared to the prostaglandin treatment [59,60]. Similar results were obtained with intrauterine infusion of 2% polyvinylpyrrolidone-iodine at 35 DIM [57], n = 531) which was detrimental to reproductive efficiency. However, no detrimental effect was measured in cows without endometritis. [61] infused in the uterus 100 ml of Betadine without improvement of the reproductive performance compared to intrauterine infusion of antibiotics or intramuscular prostaglandins. The reduction of the reproductive performance with intrauterine infusion of antiseptics may be associated with the irritating effect on the endometrium which could have caused fibrosis. Another concern about the infusion of iodine derivatives into the uterus is the significant increase of iodine concentrations in the milk [62,63]. In conclusion, irritation of the endometrium by intrauterine infusion of antiseptics has a negative effect on uterine defense and reduces self-healing ability. Unfortunately, several studies are typically lacking negative controls and insufficient numbers of animals per treatment group as well as a faulty experimental design with absence of randomization.

Alternative Prevention to Reduce PUD Incidence Rates

In the past decade, research on innate immunity has provided a better understanding of the PUD etiopathology in dairy cows, but the potential role of adaptive immunity in postpartum uterine defense is not yet perfectly understood and the production of a vaccine against metritis is still in the early stages of development [64,65]. The lymphocyte population composed of B-cells, T-cells, and NK cells were found in endometrium of cows [16]. Authors noted that the B-lymphocyte population in water buffaloes was widely distributed through the endometrium, the stroma, and the luminal and glandular epithelium, and the myometrium compared to the population of CD4, CD8, and NK cells. At the moment, four studies have used different vaccine formulations targeting E. coli, and T. pyogenes as major pathogens with or without virulence factors (FimH, Leukotoxin, pyolosin), and Bacteroides and streptococcus uberis as secondary bacteria [66-69]. Of the four studies, only one measured the serological response based on blood levels of IgG specific to the antigens utilized in the vaccine formulation [67]. Inoculations of the vaccines were done with whole cells orally, intravaginally, or subcutaneously in heifers or cow. Two out of the four studies succeeded in reducing the incidence of metritis [67,68] and one led to an improvement of reproductive efficiency [67]. In addition, milk production was increased in the first 30 DIM in multiparous cows [68]. The difference in efficacy among these studies may be related to the vaccine formulation, and therefore, more research is warranted to replicate the findings regarding the efficacy of a vaccine against metritis. Another approach to improve the immune defense of cows in peripartum has been the use of Pegbovigrastim. This molecule is a recombinant bovine granulocyte colony-stimulating factor (G-CSF) which is a hematopoietic growth factor that stimulates the production and differentiation of neutrophils by the bone marrow [70]. Subcutaneously administered pegbovigrastim 7 days before the expected calving date and 1 day after calving increased of circulating neutrophils counts but did not decrease the incidence of PUDs [71] forcing its removal from the market. A similar strategy using recombinant IL-8 (rbIL-8) was proposed to reduce PUDs. The IL-8 is a pro-inflammatory cytokine which attracts and activates neutrophils into the inflammatory tissues, stimulates their chemotaxis, and increases phagocytosis and killing ability [72]. Intrauterine infusions of high and low doses of rbIL-8 within 12 h of calving in dairy cows were adequate to decrease metritis incidence and increase milk production compared to control cows [73,74]. If large studies confirm these preliminary results, rbIL-8 could have a promising impact on dairy farms.

The best way to increase efficiency of farms is to prevent diseases. Genomic and genetic studies attempted to validate genomic prediction analysis by taking advantage of the disparity between the worst and the best herds in the incidence of reported diseases [75] and incorporating the data in a selection program. For a long time, practitioners have observed large differences in PUD incidence rate among herds. Nonetheless, the heritability of uterine diseases is low. Even though genetic heritability for metritis (0.05) and endometritis (0.04) is actually very low, geneticists used Bayesian statistical models and high-density SNP panels to estimate genomic predictive values of uterine health traits (PUDs) in Holstein cows in a more efficient way [76]. Taking into account the increase in genomic testing, these tools may soon become part of a preventive program against PUDs.

Conclusion

Despite the documented positive impact of intrauterine infusion of antibiotics for the treatment of PUDs in dairy cows, the global context of antimicrobial resistance compels veterinarians to substitute antibiotics with alternatives to mitigate the impact of PUDs reproductive performance and productivity of cows. Several non-antimicrobial therapies to treat and prevent PUDs have been proposed. However, most of them are still in the early experimental stages.

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The Effect of Nursing Support on Drug Compliance in Inflammatory Bowel Diseases

DOI: 10.31038/IJNM.2021234

Abstract

Background: The main goal of the treatment of inflammatory bowel disease (IBD) is to achieve complete and permanent remission of the disease. A multidisciplinary team approach is also required to make the remission period long-term. IBD nursing in Turkey, Although these patients have begun a new specialization has been made about the pursuit of drug administration, did not find any work. It is thought that this study will provide a well-organized nursing counseling for IBD patients and support patients in drug management.

Objectives: To examine the effect of nurse support on drug compliance in individuals with inflammatory bowel disease.

Method: After selecting the patients who are suitable for the sampling criteria included in the study, the study group was determined, and the patient information form and drug compliance information assessment form were administered to the individuals in the study group as a pre-test (month 0). The information included in the IBD Medical Education Booklet was given by the nurse twice a month in every 15 days on days suitable for the patients in the study group. One month after the training, the patient drug compliance assessment form was applied to the study group again and the scores of the group were analyzed by the nurse.

Results: The average age of the patients is 41.37 years, 53.3% female, 36.67% secondary school graduate and 66.67% married.
Post-training scores of the patients participating in the study increased. It was determined that the drug compliance of individuals with IBD who received nurse support for all other demographic features, except for patients with a maximum disease duration of 2 years, was high.

Conclusion: In this study, it was observed that nurse support given to individuals with IBD in drug management increased the effectiveness of drug use.

Keywords

Inflammatory bowel disease, Inflammatory bowel disease nursing, Nurse support, Drug compliance

Introduction

Inflammatory Bowel Diseases (IBD) is a disease with chronic remission and exacerbations. IBD usually occurs during adolescence or young adulthood, and the etiology of the disease is still unknown [1,2].

There are two types of inflammatory bowel disease, namely ulcerative colitis (UC), which is the continuous involvement of the colon; and crohn disease (CH), which intermittently replaces any part of the gastrointestinal tract from mouth to anus [1-4]. Ulcerative colitis is a bowel disease that is limited to the rectum and colon, has continuous inflammation in the mucosa and generally presents rectal bleeding symptom [1,2]. CH is the most common disease occurring in the ileo-cecal region and then in the colon. Unlike ulcerative colitis, inflammation of the crohn is intermittent and appears as skipped lesions. Although the symptoms vary depending on the location of the disease, the most common symptom is abdominal pain [1,2]. The main goal in the treatment and maintenance of inflammatory bowel disease is to provide complete and permanent remission of the disease [3,4]. In the selection of pharmacological treatment method to be used for the targeted remission period, factors such as the location, intensity and disease activation time of the inflamed area are considered; the choice of a suitable oral, subcutaneous or parenteral drug is decided by healthcare professionals [2,5]. It is expected that the nurse will be included in this decision [1,6]. Drug groups generally applied in drug treatment; 5-aminosalicylic acid (5-ASA) are glucocorticoids and immunosuppressants [6-8]. With the introduction of biological agents in the last few years, progress has been made in the treatment of IBD and there is a need for more nurse support [6-8]. A multidisciplinary team approach is required to make the remission period, which is the main target of the treatment, long-term and to minimize the discomfort caused by the drug side effects [6-10]. In addition, the absence of a specific etiological factor in inflammatory bowel disease caused the lack of protective treatment methods [10-14]. Therefore, comprehensive management of these patients in the clinic should be provided by IBD nurses [10-14].

Purpose of the Research

The research aims to examine the effect of nurse support on drug compliance in individuals with inflammatory bowel disease.

Material and Methods

Type of the Study

The research is a semi-experimental (single-group pretest-posttest), prospective, relational type research.

Place of the Research

The research was carried out in İzmir Katip Çelebi University Atatürk Training and Research Hospital Gastroenterology Unit between 11 September 2017 and 01 January 2018.

Research Universe/Sample

The population of the study was taken between 11 September 2017 and 01 January 2018, individuals with IBH who were hospitalized in İzmir Katip Çelebi University Atatürk Training and Research Hospital Gastroenterology Department, and a diagnosis of inflammatory bowel disease admitted to the IBD outpatient clinic at İzmir Katip Çelebi University Atatürk Training and Research Hospital formed individuals with IBD. Between the dates specified in this universe, n; 30 individuals with IBD, who comply with the criteria of being included in the study, accessible and volunteering, served as the sample of the study.

Data Collection Tools-Validity and Reliability Information

In this study, a Patient Information Form with IBD, a Drug Compliance Information Assessment Form for patients diagnosed with IBD, and a Pharmaceutical Management Booklet for patients with IBD were prepared by the researcher with the opinion of experts to collect data. 9 questions examining the demographic characteristics of the patient such as age, gender, education level in the IBD information form; there are 5 questions about how long the disease has been present, and periods of exacerbation. There are 10 closed-ended questions in the IBD drug compliance assessment form. The questions in the form were evaluated as correct (1), incorrect/unanswered (0). A raw score of 0-10 was obtained for individuals with IBD and scores were evaluated over 100 for ease of interpretation. The fact that the total score obtained from the drug compliance information assessment form in patients diagnosed with inflammatory bowel disease was high, showed that the person with IBD had a high knowledge of their drugs. This form was applied to patients with IBD twice as pre-test (before training) and post-test (after training) and training efficiency was evaluated.

Inflammatory Bowel Disease Medical Management Information Booklet

In the booklet, there are three main topics: Medical Management of Inflammatory Bowel Disease, Purpose of IBD Medical Treatment, Drugs Used in Treatment (5-ASA agents, Sulfasalazine, Corticosteroids, Immunomodulators, Antibiotics) Elements to be Considered in General Medical Treatment of IBD.

Action/Intervention

Before starting the application, the patients were diagnosed in terms of sociodemographic characteristics and drug compliance information, and the training program was applied after the diagnosis was made (mont 0). The main material used in the training program is the IBD Medical Education Booklet prepared by the researcher in line with the current literature. The information included in the IBD Medical Education Booklet was given by the nurse twice a month in every 15 days on days suitable for the patients in the study group. One month after the training, the patient drug compliance assessment form was applied to the study group again and the scores of the group were analyzed by the nurse. The training was given to the patients in a comfortable, quiet, appropriate light, temperature and furniture arrangement in the outpatient clinic environment, protecting the privacy of the patient. The nurse who teaches is doing a master’s degree and has attended trainings on the subject. The trainings were given using a booklet and a slide show prepared on the subject. During the training, patients were encouraged to ask questions. After the training sessions, noncompliance with patients who did not comply was discussed and individual goals were determined and achievement of targets.

Evaluation of the Data

SPSS (Statistical Package for the Social Sciences) 23 program was used to evaluate the findings obtained in the study. While evaluating the study data, Wilcoxon signed rank test was used as a nonparametric statistical test since it does not show normal distribution for demographic properties. Median, one of the descriptive statistical methods, was used while evaluating the study data. Descriptive characteristics of individuals with IBD included in the study were calculated as a percentage. Drug information score averages of patients with IBD were evaluated with pre-test, post-test, appropriate analysis.

Results

Thirty patients treated at our center between 11 September 2017 and 01 January 2018 were included in the study. The characteristics of the patients who received training within the scope of the study are shown in Table 1. The average age of the patients is 41.37 years, 53.3% female, 36.67% secondary school graduate and 66.67% married. 90% of the patients stated that they experienced changes in their normal life due to the disease.

Table 1: Sociodemographic Characteristics of the Participants.

 

n

%

Gender Female

14

46.67

Male

16

53.33

Total

30

100

Marital Status Married

20

66.67

Single

9

30

Divorced

1

3,33

Total

30

100

Educational Status Literature

1

3,33

Primary Education

8

26,67

Secondary education

11

36,67

High education

10

33,33

Total

30

100

Work Status Working

16

53.33

Not working

14

46.67

Total

30

100

Economic Situation Over Income Expense

1

3,33

Income and Expense Equal

21

70,00

Income Less Than Expense

8

26,67

Total

30

100

There is Social Security Yes

26

86.67

No

4

13.33

Total

30

100

Has your normal life changed due to your illness? Yes

27

90

No

3

10

Total

30

100

According to the data obtained from Table 2, the ages of individuals with IBD participating in the study vary between 23 and 60 and the average age is 41.37.

Table 2: Questions marked with multiple answers about the disease.

N

Minimum Maximum Mean

Std. Deviation

Age

30

23 60 41,37

11,226

According to Table 3, patients are among the changes due to the disease; it is most disturbed by changes in the excretory habit. And in the vast majority of patients, working life has changed.

Table 3: Descriptive Statistics of the Age Variable.

 

n

%

Which of the changes caused by the disease bothers you the most? Changes in eating and drinking habits

10

20.83

Changes in daily activities

11

22.92

Changes in excretion

22

45.83

Changes to your skin

4

8.34

Changes in sexual functions

1

2.08

Which or which changes occurred? In family relationships

9

22.22

In working life

9

33.33

In interpersonal relations

4

14.82

All

8

29.63

According to Table 4, the lowest score in the first test is 10, while the highest score is 80. In the last test, it can be seen that the scores received vary between 40 and 100. In addition, although the average of the scores obtained in the pre-test was 49.67, the average of the scores from the post-test was 72.67. This result shows that nurse support increases the effect of drug compliance.

Table 4: Investigation of Drug Compliance Knowledge Level in Individuals Diagnosed with Inflammatory Bowel Disease (pre-test-post-test).

N

Minimum Maximum Mean

P

Total score (pre-test)

30

10 80 49.67

.071*

Total score (post-test)

30

40 100 72.67

0.128*

Total score (first test) – Total score (post test) analysis  

.000**

*One-sample kolmogorov-smirnov test was used. ** Paired samples test was used.

IBD nurse met with patients twice to provide training. It was observed that IBD patients who received nurse support for all demographic characteristics, except for patients with a maximum duration of 2 years, had a high effect on drug compliance (Table 5).

Table 5: First Test And Post Test Point Analysis Showing The Difference Between Sociodemographic Features And Drug Compliance.

Sociodemographic Features

Total Score (Post-Test)

Total Score (Pre-Test) (p)

Gender Female

.002*

Male

.003*

Marital status Married

.000*

Single

.012*

Education Status Primary School Graduate

.024*

Secondary Education Graduate

.006*

Higher Education Graduate

.011*

Economic Situation Income Equivalent to Expenses

.001*

Revenues Less Then Expenses

.016*

Disease Duration

Maximum 2 Years

.223*

3-5 Years

.039*

6-10 Years

.027*

More than 11 years

.004*

Are there any people who get support because of your illness? Yes

.004*

No

.001*

*Wilcoxon marked rank test was used.

Discussion

When we evaluated the data in our study, we found that the pre-education means scores of the individuals with IBD who participated in the study were x = 49.67 after the education mean x = 72.67 (Table 4). Similarly, Nurit et al. (2009) found that patients who received training on their treatment showed higher compliance with the treatment after training [15]. The reason for the increase in the mean scores after the training, which we found in our study, may be the individual trainings planned with the prepared training booklet, videos, and slideshows after the patients have been correctly diagnosed. In some studies, it was found that compliance with treatment was higher in elderly patients than in younger patients [16,17]. This may be due to the increased use of medication due to older patients having more chronic diseases. However, in our study, we did not find a significant difference between treatment compliance and age (Table 4). 73.3% of individuals with IBD who participated in our study stated that they were most disturbed by the changes in the excretory habit due to the changes caused by the disease (Table 2). According to the data of N-ECCO (Nurse-European Crohn Colitis Association) (2013), it was stated that patients complain of the most intestinal control problems during hospitalization. It was determined that drug compliance of individuals with IBD who received nurse support for all other demographic features, except patients with a maximum disease duration of 2 years, was high. In patients with a maximum duration of 2 years, the effect of nurse support on drug compliance was found to be low. This result shows us that in patients newly diagnosed with IBD, nurse support is not effective on drug compliance. Similarly, Erci et al. (2018) found that in their study on hypertensive patients, compliance was lower in patients who had been diagnosed with hypertension for a year or less [18-20]. Based on these data, we comment on the process of accepting the disease of individuals who are new to chronic diseases and changing the behavior after getting the diagnosis of the disease.

Conclusion

In this study, it was observed that nurse support given to individuals with IBD in drug management increased the effectiveness of drug use.

Disclosure

There is no conflict of interest among the authors. In addition, our responsible company comes out with any company in the research.

Ethical Aspect of the Research

In order to conduct the research, the permission of the University’s non-interventional research ethics board numbered E1700080677 and numbered 23.11 of 01.11.2017 was obtained. Written and verbal consents of the patients who agreed to participate in the study were obtained. Research and publication ethics were followed at all stages of the article.

Information

Research idea, design, literature review, data analysis and review EÜA and DA; data collection was carried out by DA. No support was received from any project or firm related to the research. The budget of the research was covered by the researchers. There is no conflict of interest among the authors.

References

  1. M O’Connor, P Bager, Duncan J, Gaarenstroom J, Younge L, et al. (2013) N-ECCO Consensus statements on the European nursing roles in caring for patients with Crohn’s disease or ulcerative colitis. JCC 7: 744-764. [crossref]
  2. Molodecky NA, Soon IS, Rabi DM, Ghali AW, Ferris M, et al. (2012) Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 142: 46-54. [crossref]
  3. Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, et al. (2011) IBD Section of the British Society of Gastroenterology. Guidelines for the management of inflammatory bowel disease in adults. Gut 60: 571-607.
  4. Friedman SL, Mcquaid KR, Greendell JH. (eds) (2007) Current Diagnosis & Treatment in Gastroenterology. Çev.Eds: Sivri B, Gönen Ö. Current. Gastroenterology Diagnosis and Treatment. Oncu Printing, İstanbul pg: 108-129.
  5. Pithadia AB, Jain S (2011) Treatment of inflammatory bowel disease (IBD). Pharmacol Rep 63: 629-642.
  6. Levine JS, Burakoff R (2011) Extraintestinal manifestations of inflammatory bowel disease. Gastroenterol Hepatol 7: 235-241. [crossref]
  7. Golik M, Kurek M, Poteralska A, Bieniek E, Marynka A, et al. (2014) Working Group Guidelines on the nursing roles in caring for patients with Crohn’s disease and ulcerative colitis in Poland. Prz Gastroenterol 9: 179-193. [crossref]
  8. Ozgursoy Uran B, Yıldırım Y (2016) A New specialty: inflammatory bowel disease nursing. İKÇÜSBFD. 1: 27-33.
  9. Green C, Elliott L, Beaudoin C, Bernstein CN (2006) A population-based ecologic study of inflammatory bowel disease: searching for etiologic clues. Am J Epidemiol 164: 615-628. [crossref]
  10. Konduk BT, Gulsen MT (2017)When to start immunosuppressive therapy in inflammatory bowel diseases?. Current gastroenterology 21: 317-327. [crossref]
  11. Stretton JG, Currie BK, Chauhan UK (2014) Inflammatory bowel disease nurses in Canada: an examination of Canadian gastroenterology nurses and their role in inflammatory bowel disease care. Can J Gastroenterol Hepatol 28: 89-93. [crossref]
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  13. Faust AH, Halpern LF, Danoff-Burg S, Cross RK (2012) Psychosocial factors contributing to inflammatory bowel disease activity and health-related quality of life. Gastroenterol Hepatol 8: 173-181. [crossref]
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  15. Nurit P, Bella BC, Gila E, Revital Z (2009) Evaluation of a nursing intervention project to promote patient medication education. J Clin Nurs 18: 2530-2536. [crossref]
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  17. Gurol Arslan G, Eşer I. (2005) Yaşlıların kendi kendine ilaç kullanımına uyumu ve hemşirenin rolü. . EGEHFD. 21: 147-57.
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  20. Ercı B, Elıbol M, Akturk U (2018) Investigation of factors affecting hypertension patients’ compliance to treatment and quality of life. FNJN 26: 79-92.
fig 3

Treatment Planning for Paediatric Exodontia under General Anaesthesia: A Re-Audit

DOI: 10.31038/JDMR.2021424

Abstract

This re-audit of paediatric exodontia under general anaesthetic assessed seventy one patients’ GA records across three boroughs in the directorate – Bury, Oldham and Rochdale between 02/01/2020 to 17/03/2020. It assessed compliance with Pennine Care local guidelines including:

  • The justification for GA
  • Attendance at a dedicated POA
  • Pre-operative radiographs and their justification
  • Pre-operative restorations
  • Were patients caries free following GA?
  • Were guidelines adhered to when extracting FPM’s including orthodontic considerations?
  • Were first permanent molars balanced/compensated where appropriate?
  • Were all poor prognosis deciduous teeth extracted under GA?
  • Was appropriate consideration given to balancing/compensating extractions?
  • Record keeping standards
  • Were patients appropriately discharged/reviewed?

Results were varied and showed good compliance with some parts of the guidelines such as 70/71 (98.6%) patients having dedicated POA in the re-audit.

The percentage of patients with a dedicated oral health appointment rose from 13.9% (11/79) for Cycle 1 to 38.0% (27/71) for Cycle 2 which is a 24.1% improvement.

The percentage of patients without documented justification for a lack of radiographs dropped from 26.5% (9/34) for Cycle 1 to 9.1% (3/33) for Cycle 2. This shows a 17.4% improvement.

There were improvements in the numbers of patients having appropriate balancing extractions for unilaterally carious deciduous canines: 6/9 (66.7%) for Cycle 1 and 11/13 (84.6%) for Cycle 2. This shows an improvement of 17.9%

24/26 of patients (92.3%) in Cycle 2 who had planned extraction of FPM’s had pre-operative x-rays and there were some improvements in the number of patients with documented orthodontic considerations compared to Cycle 1. For example:

The number of patients with documented assessment of crowding rose from 16.7% (4/24) in Cycle 1 to 85.2% (23/27) in Cycle 2. This is a 71.8% improvement.

The percentage of patients who were advised of the risk of future mesial tipping or malocclusion of the second permanent molars rose from 8.3% (2/24) in C1 to 57.7% (15/26) in C2. This is a 49.4% improvement.

94.3% (67/71) of patients were caries free following completion of GA in the re-audit whereas the target is 100%. However, some of these findings appear to be record keeping errors.

Greater consistency is needed regarding record keeping as well as the post-operative review/discharge process. A greater awareness of the guidelines would be helpful.

Introduction

The prevalence of dental decay amongst children is high in England and especially so in the North West.

The Community Dental Services under Pennine Care NHS Foundation Trust (now Bridgewater Community Healthcare NHS Foundation Trust) receive a high number of referrals for paediatric exodontia each year. This treatment under GA is not only costly, but there are ever increasing waiting lists [1-4].

Aim/Objectives

Aims

This re-audit retrospectively evaluated the pre-operative planning process for Paediatric exodontia under GA and the post-operative outcomes against Pennine Care local guidelines.

Objectives

  • Evaluate current practice for treatment planning paediatric patients for exodontia under general anaesthesia and compare this to local guidelines.
  • Determine whether the treatment carried out under GA followed the pre-operative treatment plan.
  • Identify improvements that have been made since the previous audit, and define further areas for change.

Criteria and Standards

The guidelines measured in this Audit are based on local guidelines published on Pennine Care Trust Intranet. These local guidelines were in turn drawn from published national guidelines from the Royal College of Surgeons, British Society of Paediatric Dentistry and a consultant opinion group from the Community Dental Service Section of the BDA. The local guidelines are included in the appendix section of this proposal; these guidelines were published in 2016.

For simplicity and the purpose of this audit we assessed compliance with the local guidelines using the following summarised points:

  1. Was there clear justification for extractions under GA?
  2. Did patients attend a dedicated pre-operative assessment?
  3. Were appropriate radiographs taken and justified if not taken?
  4. Were restorations carried out on teeth prior to GA if to be retained?
  5. Were all poor prognosis deciduous teeth planned for extraction?
  6. Was consideration given to deciduous balancing/compensating extractions? E.g. balancing canines to avoid centre line shift or balancing primary first molars in the absence of spacing?
  7. Was a diagnostic OPG x-ray taken for FPM extraction?
  8. Was an orthodontic assessment carried out for FPM extraction?
  9. Was the patient referred for an orthodontic opinion if indicated? E.g. cases with hypodontia, marked skeletal discrepancy and labial/buccal segment crowding
  10. Were poor prognosis FPM’s extracted at the optimum time?
  11. Was the risk of tipping of the second permanent molars discussed where FPM’s were planned for extraction?
  12. Were FPM’s balanced/compensated?
  13. Did the treatment plan at the pre-operative assessment match the treatment carried out at GA?
  14. Was the patient free of decay following completion of the GA?
  15. Were patients appropriately discharged following GA and/or reviewed appropriately?

Standards

  1. All patients should have a dedicated pre-operative assessment prior to the GA appointment and there should be justification for GA documented in the notes.
  2. If radiographs are not taken pre-operatively for deciduous extractions, there should be documented justification for this in all cases in the clinical notes.
  3. Should a deciduous carious canine require extraction, balancing extraction of the contralateral deciduous canine should be discussed with parents/guardian for preservation of the centre line.
  4. Diagnostic OPG should be carried out for all patients undergoing:
  5. a. Timed elective extractions of poor prognosis first permanent molars to encourage mesial drift of the second permanent molar.

    b. Balancing/compensative extractions of first permanent molars.

  6. An assessment of incisal classification and crowding should be carried out for all patients undergoing elective timed extractions of PFM’s and balancing/compensative extractions of PFM’s to determine whether orthodontic referral is appropriate.
  7. Restorations should be completed for any carious teeth that are planned for retention by the end of the GA session.
  8. All paediatric patients should be caries free by the completion of the GA session.

Methodology

Population

This re-audit assessed patients’ records across three boroughs in the Dental Directorate: Bury Oldham and Rochdale boroughs.

The patients had their dental procedures at either Royal Bolton Hospital or Alder Hey Children’s Hospital under General Anaesthesia.

Inclusion criteria: Paediatric patients (under 16 years) both routine and special care requiring exodontia under GA.

Exclusion criteria: any patients over the age of 16 and patients who do not require GA.

Sample Size/Sampling

This audit included an anonymised sample of patients from each of our different boroughs and only included patients for routine exodontia under GA treated at either hospital.

Cycle 1 assessed 79 records with GA dates ranging from 01/06/2017 to 28/07/2017.

Cycle 2 assessed 71 patients with GA dates ranging from 02/01/2020 to 17/03/2020.

Data Collection

Data was collected retrospectively by I Zaman from the R4 computerised dental clinical records system and the operation notes from the GA appointments which are uploaded onto the R4 software.

A copy of the data collection spreadsheet is included in the appendix.

From this data, we intended to determine the following:

  1. Was there general uniformity in the treatment planning for GA exodontia across the different Boroughs in the Directorate?
  2. Were the treatment plans from the pre-operative assessment in line with the local guidelines?
  3. Was there any discrepancy between the treatment prescribed and the treatment carried out under GA and does this conform to standards?
  4. Is there need for further training/development to consolidate treatment planning for paediatric exodontia under GA and to promote greater compliance with guidance across the Directorate?

Data Analysis

The data was analysed on an Excel spreadsheet by I Zaman.

Data Validity

A sizeable sample of 71 patients was analysed for this audit which is comparable to the first cycle and also helped to ensure validity and consistency of data collection and analysis.

Results

Patient Demographics and Pre-operative Assessments

  • Sample = 71 patients
  • The average age of patients was 7.1 years
  • 39 patients were male, 32 were female
  • The sample included 9 special care patients
  • 6% (70/71) of patients had a dedicated pre-operative assessment (POA). One patients POA was combined with their dental check-up.
  • 0% (27/71) of patients had a dedicated oral health appointment.

Justification for Treatment under GA

The justification for GA at the pre-operative assessment is displayed in Figure 1 below. Multi-quadrant decay was the most frequent justification and three patients had no justification documented. The “other” justifications documented were for 2 patients were “repeated pain” and “decayed teeth”.

fig 1

Figure 1: Justifications for GA as percentages.

Pre-operative Radiographs

Figure 2 below shows the distribution of pre-operative radiographs for patients having deciduous tooth extractions (Table 1).

fig 2

Figure 2: : The distribution of pre-operative radiographs for patients having deciduous tooth extractions.

Table 1: Justifications for unavailability of pre-operative radiographs for patients undergoing deciduous extractions.

Lack of radiographs deciduous extractions – justifications

No. of patients

Lack of co-operation

16 (48.5%)

Attempted – patient could not tolerate

3 (9.1%)

All deciduous molars clinically carious

11 (33.3%)

No documented justification for not taking x-rays

3 (9.1%)

Total number of patients

33

For two patients the notes stated that x-rays were not needed. However, not all the deciduous molars were clinically carious or planned for extraction. Therefore this was not a valid justification.

Patients Undergoing Extraction of Permanent Teeth

2 patients mentioned in Table 2 below were originally planned for primary extractions only but ended up undergoing extraction of permanent molars at GA as they were found to be carious. These 2 patients had no pre-operative radiographs as the permanent molars were added to the plan at GA where there was no x-ray facility for routine exodontia. 100% of patients otherwise had pre-operative radiographs. The distribution of radiographs taken is displayed in Table 2 below (Figure 3).

fig 3

Figure 3: The pre-operative orthodontic assessments that were done before GA.
Percentage of patients with orthodontic assessment prior to extraction of first permanent molars.

Table 2: Distribution of radiographs taken for patients undergoing permanent dental extractions.

Radiographs for permanent extractions

No. of patients

OPG

23 (88.5%)

Per-apical

1 (3.8%)

Bitewing

8 (30.8%)

No Radiographs due to unexpected change in GA plan

2 (7.7%)

Total number of patients

26

Balancing Extractions of Deciduous Canines

13 patients presented with unilateral decay in a deciduous canine, and balancing extraction was carried out in 11 of these cases. Distribution is displayed in Table 3 below

Table 3: Distribution of balancing extractions carried out on deciduous canines.

Deciduous canine balancing extractions

No. of patients

Planned balancing extractions of C’s

11 (84.6%)

Balancing extractions discussed – declined by parents

0

Balancing extractions not carried out – no documentation on justification

2 (15.4%)

Total number of patients with unilateral decay in deciduous canine

13

Balancing Extractions of First Primary Molars

For this re-audit an additional parameter was added. It assessed if unilaterally carious first primary molars (D’s) were balanced in the absence of spacing as per Royal College of Surgeons guidelines3.

1/14 patients with unilateral decay of a “D” had documented assessment of spacing and was spared a balancing extraction (Table 4).

Table 4: Distribution of balancing extractions carried out for first primary molars.

First primary molars balancing extractions

No. of patients

Spacing assessment carried out

1 (7.1%)

Balancing extractions discussed – declined by parents

0

Balancing extractions carried out

0

Balancing extractions not carried out – no documentation on justification

13 (92.9%)

Total number of patients with unilateral decay in first primary molar

14

Extraction of Poor Prognosis First Permanent Molars (FPM)

  • 26/71 patients in this audit underwent extraction of one or more poor prognosis FPM’s.
  • 12 of these patients underwent planned/timed extraction of FPM’s to encourage the mesial migration of the second permanent molar for space closure.
  • 23/26 (88.5%) had a pre-operative OPG to assess dental development. 2 patients had their permanent molars added to the extraction plan at GA where there is no intra-operative x-ray facility.
  • The percentage of patients who had the future risk of 7’s tipping mesially or future risk of malocclusion discussed rose from 8.3% (2/24) in Cycle 1 to 57.7% (15/26) in Cycle 2.
  • A noticeable improvement can be seen especially in the percentage of patients having a crowding assessment. However, the percentage of patients with a skeletal assessment decreased.

Restoration of Teeth

  • 1 special care patient had planned restoration of first permanent molars during GA in this audit.
  • 7/71 patients had enough compliance for permanent restorations prior to GA.
  • The remaining 63/71 patients in this audit were planned for extraction of all decayed teeth.

Differences between Initial Exam and GA Pre-operative Assessment

  • Figure 4 below shows the differences between the initial exam and POA:
  • For 67.6% (48/71) of patients there was no difference between the plan at the exam and POA.
  • 5% (16/71) of patients had additional deciduous teeth added to the extraction plan.
  • For 1 patient a carious deciduous tooth was not included in the plan.
  • 2 patients had a change in the plan with no documented justification for the change.

fig 4

Figure 4: Distribution of the differences between the initial exam and the pre-operative assessment (number of patients out of 71)

Differences between the Pre-operative Assessment Plan and GA

Figure 5 below shows the differences between the POA and GA:

fig 5

Figure 5: Distribution of the differences between the pre-operative assessment and treatment carried out at GA (number of patients out of 71).

  • 7% (41/71) patients had the same treatment at GA as the POA
  • 7% (5/71) patients had fewer teeth extracted due to signs of very early decay or natural exfoliation
  • Additional deciduous extractions were carried out under GA in 26.8 (19/71) patients.
  • 1/71 patient had a change in the plan without documentation.
  • The previous issue in cycle 1 of notes not being available has resolved as we now scan the op notes onto R4.

Patients Who were Caries Free at the Completion of GA

67/71 patients (94.3%) were caries free following completion of GA. According to the clinical records, four patients (may have) been left with decay as follows:

  1. FPM’s noted as being carious at GA. The patient was then re-booked for these teeth to be restored with preventive resin restorations after GA.
  2. It appears that the GA clinician had charted UR5 as extracted at GA on R4 instead of URE in error. Therefore, on the chart carious URE is still present.
  3. The LLD was documented as carious prior to GA, but was not added to the POA extraction plan and was also not extracted at GA. There was no mention in the operation notes about it and LLD is still charted as carious and present on R4.
  4. URE was charted as a retained root in the R4 records, no mention of it at GA if it is present or missing. It is still charted as present on R4 after the GA.

Post-GA Plan and Review

Justification for CDS Review

3 patients with additional special care needs were discharged following GA. For 1 of these patients the POA stated to review after GA, but the patients was discharged with no additional justification (Table 7).

Table 7: Justifications for why patients were reviewed with CDS rather than being discharged.

Justification for CDS review

No. of patients

Medical factors e.g. special care

6 (50%)

Social factors e.g. looked after child

2 (16.7%)

No general dentist

0

Other (high anxiety, previous XGA, poor attendance, poor compliance with OH, high number of teeth extracted at GA/high dental needs, no justification)

4 (33.3)

Total number of patients

12

Table 7.1: Significance of Improvements and compliance with targets

Improvement

Cycle 2 Compliance

Target

There has been a notable improvement (24.1%) in the number of patients with a dedicated oral health appointment prior to GA. However the percentage of patients in the re-audit (38.0%) is still below the target of 100%.

38.0%

100%

A 17.4% improvement in clinicians documenting justifications for not taking radiographs is positive. There were still 9.1% of patients without a documented justification for no x-rays, whereas there should ideally be 0 patients like this.

9.1%

0%

There was a 7.3% improvement in the number of patients with pre-operative OPG radiographs prior to permanent extractions. The target for this is 100%, so the current compliance of 95.8% is good.

95.8%

100%

There was a 17.9% improvement in the number of patients having a balancing extraction of unilaterally carious deciduous canines. Current compliance of 84.6% is significant and shows positive change, but the target for this is 100% (where justified)

84.6%

100%

All patients (100%) having extraction of a unilaterally carious primary first molar should ideally have an assessment of spacing to inform whether a balancing extraction is required. There was a reduction in compliance of 5.4% in the re-audit (overall 7.1% had an assessment of spacing)

7.1%

100%

The percentage of patients who were advised of the risk of future mesial tipping or malocclusion of the second permanent molars after extraction of FPM improved by 49.4%.

57.7%

100%

The patients who underwent assessment of skeletal classification prior to permanent molar extraction showed a reduction in compliance of 6.7%.

30.8%

100%

Patients who underwent assessment of incisor classification prior to permanent molar extraction improved by 10.9%.

69.2%

100%

Patients who underwent assessment of crowding prior to permanent molar extraction improved by 71.8%.

88.5%

100%

There was a 3.7% improvement in C2 regarding the number of patients with changes to their GA plan without documentation compared to C1.

1.4%

0%

1 patient was reviewed due to decay being present at the end of GA, which then required further restoration appointments.

Several patients with high numbers of teeth extracted at GA were not reviewed, for example, one patient had 18 deciduous extractions and was discharged.

1 patient was scheduled for review after GA in the operation note. No reason was given for why the review was needed. Nothing was ever booked in and the patient is still not discharged.

Conclusion

Pre-Assessment

  • C1 100% (79/79) of patients underwent a dedicated pre-operative treatment planning session. This compared to 98.6% (70/71) for C2 as a patient had the initial assessment combined with the POA.
  • The percentage of patients with a dedicated oral health appointment rose from 13.9% (11/79) for C1 to 38.0% (27/71) for C2 which is a 24.1% improvement.

Justification for GA

  • 1 patient had no documented justification for GA in their records for cycle 1 compared to 2 patients for C2. The target for documented justification of GA is 100%.

Pre-operative Radiographs for Deciduous Extractions

  • C1: 63.0% of patients (34/54) undergoing deciduous dental extractions did not have pre-operative radiographs compared to 64.7% (33/51) for C2.
  • For C1 26.5% (9/34) did not have any documented for reason for radiographs not being taken compared to 9.1% (3/33) for C2. This shows a 17.4% improvement.

Pre-operative Radiographs for Permanent Extractions

  • 100% of patients in C1 and C2 who were due for planned FPM extraction had pre-operative x-rays.
  • 5% (23/26) had the recommended OPG for C1 compared to 95.8% (23/24) for C2. This shows a 7.3% improvement.

Balancing Extractions of Deciduous Canines

  • C1: 9 patients presented with caries unilaterally in a deciduous canine. Balancing extraction of the contralateral deciduous canine was planned and carried out in 6/9 cases (66.7%).
  • C2: 13 patients presented with unilateral decay in a deciduous canine, and balancing extraction was carried out in 11/13 of these cases (84.6%).
  • This shows an improvement of 17.9%

Balancing Extractions of First Primary Molars

  • For C1, 12.5% (2/16) patients had an assessment of deciduous molar spacing compared to 7.1% (1/14) for C2.
  • No patients in C1 or C2 had documented balancing extractions of first primary molars.

First Permanent Molar Extractions

  • The percentage with balancing/compensating extractions was C1 29.2% (7/24) and C2 34.6% (9/26)
  • The percentage of patients who were advised of the risk of future mesial tipping or malocclusion of the second permanent molars rose from 8.3% (2/24) in C1 to 57.7% (15/26) in C2. This is a 49.4% improvement.
  • 16/24 patients underwent timed elective extraction of poor prognosis first permanent molars in C1 compared to 12/26 for C2.
  • The patients who underwent assessment of skeletal classification dropped from 37.5% (9/24) in C1 to 30.8% (8/26) for C2. This is a reduction of 6.7%.
  • Patients who underwent assessment of incisor classification rose from 58.3% (14/24) in C1 to 69.2% (18/26) for C2. This is a 10.9% improvement.
  • Patients who underwent assessment of crowding rose from 16.7% (4/24) in C1 to 88.5% (23/26) for C2. This is a 71.8% improvement (Table 5).

Table 5: Information relating to first permanent molar extractions.

Extraction of poor prognosis first permanent molars

No. of patients

Pre-operative OPG radiograph

23 (88.5%)

Balancing or compensating extractions performed

9 (34.6%)

Balancing or compensating extractions not performed despite meeting criteria

5 (19.2%)

Future risk of 7’s tipping mesially or future malocclusion discussed

15 (57.7%)

Total number of patients that had FPM extraction

26

Differences between Initial Exam and GA Pre-operative Assessment

  • C1 60.0% of patients (45/79) had the same number of teeth planned for extraction in the initial charting compared to the POA, compared to 67.6% (48/71) for C2
  • For both C1 and C2, 1 patient had a carious deciduous tooth noted at the initial exam which was not included in the POA plan.
  • For both C1 and C2, 2 patients had a change in the plan with no documented justification for the change.

Differences between the Pre-operative Assessment Plan and GA

  • C1 70.9% of patients (56/79) had the same number of teeth planned for extraction at the POA compared to GA, compared to 57.7% (41/71) for C2
  • C1 5.1% of patients (4/79) had a change in the GA plan without documentation. This compares to 1.4% (1/71) for C2.

Patient Who were Caries Free at the Completion of GA

  • C1 no patients had outstanding restorative treatment to be carried out by the end of the GA session. C2 one patient had outstanding restorative treatment at the end of GA and subsequently had the upper 6’s restored after GA.
  • C1 78/79 patients (98.7%) were caries free following completion of the GA session. According to the clinical chart, a carious deciduous incisor was still retained following treatment under GA.
  • C2 67/71 patients (94.3%) were caries free following the completion of GA. Some of these patients left with decay at the end of C2 may be attributed to record keeping errors.

Post-GA Plan and Review

  • C2, 3 patients with additional special care needs were discharged following GA. For one of these patients the POA stated to review after GA, but the patients was discharged with no additional justification.
  • Several patients with high numbers of teeth extracted at GA were not reviewed, for example, for C2, 1 patient had 18 deciduous extractions and was discharged (Table 6).

Table 6: Post GA plans for all of the patients.

Post GA discharge/review plan

No. of patients

Discharged as per plan

59 (83.1%)

Reviewed with our service

8 (11.3%)

Pending review

4 (5.6%)

Post GA/review plan not documented and not discharged

0

Total number of patients

71

Significance of Improvements and Compliance with Targets

The most significant improvements have been made with the number of patients advised of the risk of future tipping/malocclusion of the second permanent molars after extraction of FPM (49.4%). Also with the patients who underwent assessment of crowding prior to permanent molar extraction (71.8% improvement).

Discussion and Areas for Improvement

  • There is little consistency with whether patients have a dedicated oral health appointment prior to GA. For both cycles the vast majority of patients having these dedicated appointments are from Oldham compared to other boroughs.
  • The justifications recorded for GA aren’t always accurate. For example, some patients were listed as “pre-compliant” when in fact the patients had failed previous treatment attempts under inhalation sedation or local anaesthetic.
  • Listing patients as being “pre-compliant due to age” seems subjective as each clinician appears to interpret this age limit differently. The same appears to stand for patients listed for “high number of extractions”.
  • There also seems to be no consistency with when clinicians try sedation first or when they send the patient for GA directly. This will obviously depend upon the clinician’s assessment of compliance.
  • Lower than expected numbers of patients with pre-operative radiographs may likely relate to compliance issues based on the justifications for patients listed for GA.
  • In order to comply with guidance it is important for clinicians to justify not taking radiographs correctly rather than statements such as “not needed” without further explanation. To avoid unnecessary radiographic exposure it is also important for clinicians to be aware of when images are not required such as when all deciduous molars as clinically carious.
  • Early loss of one deciduous canine is highly likely to lead to a centre line shift in the absence of spacing. Therefore it is positive to see an increase in the percentage of patients having appropriate balancing extractions in these cases. However, there appears to be little to no documentation of clinicians assessing first deciduous molars for balancing extractions (which is recommended in guidelines).
  • The findings show that not all patients having extraction of FPM’s are having the recommended pre-operative assessments. However, improvements have been made such as the number of patients having appropriate balancing/compensating extractions and the percentage of patients advised of the risk of future malocclusion or of the second permanent molars tipping mesially. There was also an improvement in the percentage of patients who underwent incisal classification and an assessment of crowding. These improvements will help patients to avoid future orthodontic complications or avoidable orthodontic treatment.
  • There may be a need for an x-ray facility at GA for all cases and not just special care cases. This will be helpful for routine exodontia cases where additional decay is found which may include permanent teeth.
  • Patients should be caries free at the completion of GA. To a certain extent the discrepancies here seem more likely to be record keeping errors.
  • A patient had their lower FPM’s extracted at GA as per advice from their Paediatric Specialist Dentist. The specialist letter didn’t mention compensating extractions so the clinician did not compensate the lower molar extractions with the upper molars or document an assessment of this. It is useful to still document orthodontic assessments in such instances.
  • The issue from Cycle 1 has been overcome whereby records from Alder Hey Children’s Hospital were not available locally as we are now scanning the op-note to R4 software post-operatively.
  • Several patients with high numbers of teeth extracted at GA or high needs were not reviewed, while others were. We may benefit from a set protocol to improve consistency with this.
  • It may also be beneficial to have a more robust follow-up system after GA. For example, a patient was planned for review after GA in their operation note. A recall was not set and the patient was still not discharged.
  • A greater awareness of the Paediatric Exodontia guidelines amongst clinicians would be helpful. This should also help with pre-operative assessments and record keeping omissions/errors such as clinicians interchanging the terms “compensating” and “balancing” extractions, when these are in fact separate treatments.
  • The number of patients pending review after GA for cycle 2 is impacted by the Covid-19 pandemic.

Dissemination and Action Plan

This audit highlights certain areas for further improvement. The following recommendations have been made:

  1. Present findings locally to the dental directorate for example local clinical governance/audit meeting and local forums.
  2. Present the findings for the research and clinical audit group meeting for the Trust and other interested parties.
  3. Complete a re-audit when GA services resume subject to the Covid-19 pandemic.
  4. Aim to publish the report in a peer reviewed journal, or a poster/oral presentation at a relevant dental conference as appropriate.

All of the following assume there has been thorough discussion of the risks and benefits of each point with documentation in the clinical notes should be clearly recorded with the reasons why:

  1. If possible, bilateral dental bitewing radiographs are performed prior to the General Anaesthetic; unless caries is well established and frank in all Ds and Es, and all Ds and Es are planned for extraction.
  2. If possible, upper anterior occlusal or periapical radiographs are performed for anterior teeth where there is a history of trauma, or caries into dentine in permanent teeth.
  3. When first permanent molars are to be extracted, a DPT is necessary.
  4. All children must be offered and attend a specific Oral Health appointment, with either a nurse with additional training (Oral Health Certificate) or a Dental Hygienist/Therapist. This is to discuss diet and toothbrushing prior to the GA.
  5. Cs and Ds are balanced for orthodontic purposes (BSPD 2002). In a spaced arch, Ds should not be balance (RCS 2006).
  6. Any deciduous tooth that has a poor long-term prognosis, or has been temporarily dressed with a temporary filling material, such as Glass Ionomer Cement, should be extracted at the GA appointment. Prioritise saving Es when possible for orthodontic benefit, extracting Ds can help maintain Es, as it removes the contact point (Consultant opinion, BDA CDS Group).
  7. Any deciduous tooth with two-surface caries/two-surface restoration, must be extracted at the GA appointment, as they pose a high risk for future problems.
  8. Any tooth that is developmentally close to exfoliation, and has a poor prognosis (two-surface caries/two-surface restoration/pulp treatment/mobile), should be extracted.
  9. Any tooth that is very mobile, should be extracted.
  10. Only strategic teeth (Es) with a very good prognosis, or evidence of missing permanent teeth, could be retained. For example, mildly affected hypoplastic Es with adequate composite sealants/restorations or a well-fitting stainless-steel crown, with radiographic evidence of no pathology; or perhaps in a child with missing second premolars, the Es can be considered to be retained after a GA if they have a good long-term prognosis.
  11. If appropriate, an orthodontic opinion should be sought when considering extracting first permanent molars of poor prognosis.
  12. a. Optimum time approximately 9 years of age.

    b. Where a maxillary first permanent molar is planned to be extracted, do not balance with one from the contralateral side.

    c. Where a mandibular first permanent molar is planned to be extracted, do not balance with one from the contralateral side, but do consider a compensating extraction of the opposing maxillary first permanent molar.

    d. Where both mandibular molars are to be extracted, consider extracting all four first permanent molars.

    e. Where contralateral first permanent molars (e.g. upper right & lower left) are to be extracted, consider extraction of all four first permanent molars.

    f. In the majority of cases of Class I Incisors, if radiographic examination shows the furcations of the mandibular second permanent molars to be developing, and all four second permanent molars are present, and the mandibular first permanent molars are to be extracted, the maxillary first permanent molars should also be extracted (RCS 2004).

  13. Children should not be offered GA for orthodontic extractions.
  14. Any caries in deciduous teeth that is planned to be restored, must be restored prior to the GA appointment, and only if the clinical justification is strong. For example, minimal buccal cavities on maxillary Cs restored with composite or early minimal caries/mildly hypoplastic Es restored with composite or a well-fitting stainless-steel crown.
  15. Any caries in permanent teeth planned to be restored, must be restored before the GA appointment. Co-operation cannot be presumed afterwards. Restorations under GA must be the exception (for children with special needs). When carrying out restorations under GA, consent must be sought for the restoration and for all possible extractions if the tooth has deep caries and a poor prognosis.
  16. The child must be dentally fit after the GA appointment and must not wake up from a dental GA with caries.
  17. Any child posing additional medical/social concern (e.g. no GDP, siblings have had dental GA, low income family, poor attendance, poor compliance with prevention advice, LAC, special needs, high number of teeth removed) should be followed-up within the CDS and guided to find a GDP on an individual basis. The person holding Parental Responsibility. If a guideline is not to be followed.

References

    1. Extraction of Primary Teeth – Balance and Compensation (2002) British Society of Paediatric Dentistry.
    2. Consultant Opinion “BDA London, CDS Group, March 2015. Dr Mike Harrison, Consultant in Paediatric Dentistry”.
    3. A Guideline for first permanent molar extraction in children (2004). Royal College of Surgeons.  Williams A, McMullen R.
    4. Extraction of Primary Teeth, Balance and Compensation (2006) by hospi College of Surgeons Faculty Working Party.