Monthly Archives: November 2021

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National Heart Institute (NHI) – Acute Cardiovascular Care (ACVC): One-Month Perspective, a Single-Center Experience

DOI: 10.31038/JCCP.2021425

Abstract

Background: National Heart Institute (NHI), Cairo – Egypt is a tertiary care center serving cardiovascular patients nationwide. In this study, patients admitted to our institute’s cardiac care unit (CCU) with critical acute cardiovascular conditions (ACVC) were included to assess the management strategies and the in-hospital outcome.

Aim: Determine different presenting diagnoses admitted to NHI-CCU with documentation of their primary management strategies and its correlated outcomes.

Methodology: A prospective cohort study of all comers to NHI-CCU for one month duration from 15/7/2020 to 15/8/2020.

Results: This study represents a cohort of all comers admitted to our institute with ACVC during the study period. Total of 445 patients were included. In terms of gender, 301 patients were males (67.8%) and 143 patients were females (32.2%). The mean age of patients in this cohort was 55.8 ± 13.0 years of age. Patients spent a total length of hospital stay of 2250 days, with an average hospital stay per patient of 6 ± 6 days. The overall mortality was 13% (i.e.: 58 patients). Of particular notice patients presenting with cardiogenic shock or pulmonary edema complicating acute coronary syndrome (ACS) had longer hospital stay and higher mortality.

Conclusion: The current strategy for managing ACS or HF at NHI had markedly improved with a high success rate and favorable overall outcome across different age groups. The presence of acute pulmonary edema or Cardiogenic shock on admission to CCU in patients with ACS (STEMI or NSTE-ACS) is strongly correlated with prolonged hospital stay and in-hospital mortality. Reperfusion strategies, either Primary PCI (PPCI) or pharmaco-invasive approach, has a positive impact on short-term outcome and length of hospital stay. This positive impact is blunted in patients complicated with acute pulmonary edema or cardiogenic shock. Device therapy in patients with decompensated HF impacts short-term outcomes and correlates with a shorter hospital stay.

Introduction

ACVCs are a worldwide health issue that affects both industrialized and underdeveloped countries [1]. This is related to increased mortality; more extended hospital stays, and increased healthcare expenditures. The purpose of this study is to evaluate the treatment strategy, and in-hospital outcomes of patients admitted to NHI with ACVC over a one-month duration.

Objectives

Improve the care of ACVC in NHI and provide optimized management plans.

Aim

Determine different presenting diagnoses admitted to NHI-CCU with documentation of their primary management strategies and their correlated outcomes.

Methodology

Study Design

A prospective cohort study.

Study Setting

Cardiac Care Unit – National Heart Institute

Study Period

One month – Mid-July to Mid-August 2021

Study Population

Inclusion Criteria:

  • All comers with ACVC requiring admission to CCU for at least 24 hours

Exclusion Criteria:

  • Incomplete or missing diagnosis or outcome.

Study Procedures

All consecutive patients with ACVC admitted to the CCU at the NHI from mid-July to mid-August 2021 were included in this study. Patients’ data were collected, including personal information, clinical history, diagnoses, plan of management, and status at discharge. Further stratification for each group of patients with a specific diagnosis was done according to the management plan. According to the diagnosis and management plan, patients’ status at discharge was recorded.

Data Collection

Patients’ data were collected using a pre-designed electronic worksheet. Once a patient’s data is submitted, it is backed up to an online database. A double-check was performed before patient discharge to ensure no data was missing. In addition, senior staff continuously monitored, assessed, and revised the data collection process to ensure data integrity and completeness.

Ethical Aspects

Informed written consent was signed by all patients who accepted enrollment in this study. In critically ill patients and patients who died before signing a consent, a next of kin signed in substitute.

Statistical Analysis

The Statistical Package for Social Sciences, version 26.0 – 2018 (SPSS Inc., Chicago, Illinois, USA), was used for statistical assessment. Demographic data, clinical diagnoses, plan of management, and hospital outcome were compared using Chi-squared (χ2) test for categorical variables and the unpaired t-test for continuous variables. Relationships between management plans and hospital outcomes were assessed using logistic regression analysis. Quantitative data were expressed as mean ± SD. Qualitative data were expressed as frequency and percentage, and a P value less than 0.05 was considered significant.

Results

During the study period of 1 month from mid-July to mid-August 2021, a total of 445 patients were admitted to the CCU. Primary diagnoses were ACS, CHF, Pulmonary embolism, aortic dissection, Infective endocarditis, and CHB. Regarding gender, 302 patients were males (67.8%), and 143 patients were females (32.2%). Accordingly, the male-to-female ratio is 2.06:1.

Mortality in this cohort was 13% (i.e., 58 patients). The highest mortality was recorded in patients with aortic dissection; that is 100%.

Patients spent a total of 2250 days, with the mean length of hospital stay per patient being six ± six days. The maximum hospital stay was 46 days. The minimum hospital stay was one day.

The mean age of patients in this cohort was 55.8 ± 13.0 years of age. The youngest patient was 16-year-old, while the oldest patient was 82-year-old (i.e., Range: 16-82)

Primary Diagnosis

Total no. = 445

 
ACS

202

45.39%

High degree AV block

133

29.89%

CHF

78

17.53%

Ventricular Tachycardia

11

2.47%

Pulmonary Embolism

8

1.80%

Atrial Fibrillation

5

1.12%

Aortic Dissection

3

0.67%

Infective Endocarditis

2

0.45%

Device related infection

1

0.22%

Left Atrial Myxoma

1

0.22%

Acute Coronary Syndromes

During the study period, a total of 202 cases of ACS were admitted to CCU. The In-hospital mortality was 6.9%. Most of the cases were STEMI (84.5%) vs. 15.5% NSTE-ACS. 95% of the patients had undergone invasive coronary angiography their admission. The initial strategy for STEMI was PPCI in 67%, while the pharmaco-invasive plan was 22.4%. Rescue PCI needed in 8.1%. Delayed PCI was carried out in 2.5%. The success rate for PCI is 96%—failed PCI in 7 patients (4 planned for CABG, two intended for a second attempt).

Further revascularization was needed in 14% of cases (8% required CABG, 6% staged PCI). Only 10% of patients who needed further revascularization were initially diagnosed with NSTE-ACS, 90% were STEMI (most commonly inferior STEMI). Thrombolytic therapy was used in 22.4% of STEMI cases. Only SK was used and successful in 69% of cases. All patients with failed SK went for Rescue PCI. Length of hospital stay in PPCI was 2.9 days while was 4.5 days inpatient who received thrombolytic therapy. And was 2.5 days for NSTE-ACS patients. The initial management strategy was significantly correlated with length of hospital stay in STEMI cases (P=0.0002), and the use of thrombolysis was significantly related to a more extended hospital stay P<0.0212.

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Presenting Diagnosis as AHF among ACS Patients

Patients admitted with cardiogenic shock and pulmonary edema due to an underlying acute coronary syndrome represents a small fraction of ACS patients admitted to NHI. Fifteen cases showed signs of severe AHF during their initial presentation, either APE or Cardiogenic shock. Analysis of ACS complicated by severe AHF showed that Conservative treatment was the most common therapy for those patients. PCI has done in 33%. CABG is 13.3%. Only one case documented a mechanical complication of STEMI (VSR; percutaneous closure was attempted, and the patient died after the procedure. The mortality was 76% in all cases, 80% for PCI, and 75% for the conservatively treated group and 50% for CABG patients.

The use of hemodynamic support was considered in 2 cases; both had IABP insertion (one during PCI the other during CABG).

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In regression analysis, the presence of severe AHF (APE or Cardiogenic shock) was the only variable that showed a strong correlation with in-hospital mortality Acute decompensated Heart Failure (AHF).

A total of 78 cases were admitted with AHF. 66.7% were males. Various age groups were noticed; the most common decade was 50-60 years, followed by 60-70 years. More than half of the patients’ overall hospital stay was six days. The initial medical strategy was considered in all patients and was directed only toward guidelines-directed medical therapy, and device therapy was considered in the eligible patient. Precipitating factor for decompensation was not documented in admission notes.

50% of the patients have underlying IHD. 50% (39 cases) are NICM the underlying etiology in patients with NICM was identified in 8 cases (20.5%); 3 cases have primary valve disease as underlying etiology (2 cases with rheumatic MS and one case with severe AS and MR), one case with PPCM, two patients with HFpEF and two patients with isolated right-sided HF. The rhythm was AFib in 24.4% of cases. Moderate to severe secondary valve pathology was documented in 8 patients with AHF; 10.2%. The most common valve pathology was Functional Mitral regurge (5 cases), MR and TR (3 cases), and isolated TR (one patient). Rhythm and valve lesions were not correlated with in-hospital outcomes.

Device therapy in HF correlated with a shorter hospital stay (P=0.0045). Devices used were CRT, CRT-D, and ICD.

IHD in a patient with HF is associated with a prolonged hospital stay. AF, valve pathology is not associated with outcome or stay

Non-Ischemic Cardiomyopathy

58 cases admitted with decompensated HF without underlying IHD. 65.5% were males. AF was the rhythm in 44.8%. All patients were managed medically. Mortality was in 3 patients; 1 because of VF and two because of progressive pump failure and multisystem affection. The underlying etiology was not identified in 90% of the cases. The diagnosis of HFpEF was documented only in 2 cases out of 78% with CHF, which indicates a significant challenge in identifying this specific subgroup and possibly missing proper diagnostic criteria for this group of patients. In patients with the underlying etiology of primary valve disease for CHF, the rheumatic pathophysiology is more common than degenerative, reflecting the current challenge in developing countries where RHD is still the most common pathology for VHD.

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Heart Block

During the study period, 133 patients were admitted to CCU with a high degree A-V block. Eight cases with the second degree and 94% with CHB. 52.4% were males, and 47.6% were females. The average age was 61 years; the range was 1-90 years. The average hospital stay was 7.2 days. 131 patients received a PPM. One patient was managed with medical therapy, and one patient died before pacemaker insertion. A dual-chamber pacemaker was used in 53.4% of cases, while a single lead pacemaker was used in 46.6%. In addition, two patients required CRT while eight patients required ICD according to the associated condition.

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Pulmonary Embolism

Eight cases were admitted with pulmonary embolism. Thrombolytic therapy was the strategy in 62.5% of cases. Medical therapy (anticoagulation) was used in 37.5%. No mechanical therapy was used. Mortality in one patient.

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Acute Aortic Dissection

Three patients were admitted with acute aortic dissection; all were Stanford Type A. All were planned for surgical repair. In-hospital mortality 100%. 2 of them died before surgery.

Arrhythmia

Eleven patients were admitted with VT. The most common presenting symptom is syncope. Ten were males, and one was female. The average age was 46 years (range from 19-70 years). Device-based therapy was the default strategy for management in 9 patients. Devices used were DDD-ICD (5 cases), ICD (2 cases), and CRT-D (2 cases). Medical therapy was the strategy in 2 cases. Mortality was 1 case.

Atrial Fibrillation (AF)

AF was the primary diagnosis in 5 cases. 4 were males. Rate control is used in one patient. Electrical cardioversion was used in one patient. Three cases underwent ablation for AF. Mortality in one point, which was in the ablation group.

As a secondary diagnosis, AF was ubiquitous in all cases admitted with CHF. Found in 44.8% of all patients with DCM and 11% of cases with ICM. All patients were managed medically.

SVT

One case was admitted with resistant SVT and underwent ablation successfully.

Cardiovascular Related Infections

Three cases were admitted with infections. 2 had IE; one was native tricuspid, and one was prosthetic valve endocarditis. Both were treated medically. One was device-related (Pacemaker) and required device replacement.

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Others

One case was admitted with left atrial myxoma and went surgery.

Discussion

Our management strategies and outcomes were compared to the internationally available observational data for each subgroup of cases.

ACS

In patients with ACS, the invasive approach was the default method for most patients admitted to NHI. PPCI was the standard treatment for all STEMI patients. However, the pharmaco-invasive plan was an acceptable option in circumstances where ideally timed reperfusion was not achievable. PPCI has a success rate of 96%, which satisfies international standards [2,3]. Thrombolysis was successful in 69% of patients; however, the only thrombolytic agent utilized was SK, the only agent available, and no adverse effects were reported. Newer agents, such as t-PA and TNK, would produce a better result.

In patients with NSTE-ACS, the invasive technique was used in all scenarios; this could be related to the higher risk category of NSTE-ACS referred to NHI, where Invasive strategy should be the standard regimen.

In ACS patients presented by AHF, the consideration of an invasive strategy was considerably lower. The most frequent method was to use medical treatment. This finding could be related to the interventionist perception of the procedural risk or futility of any intervention. In some instances, advanced shock and multisystem affection were the primary causes of this significant caring trend change. The survival in those subgroups of patients who underwent invasive treatment was 20% [4,5], while the survival for conservative strategy was 25%. CABG was considered in few cases; however, the number is too small to make a clear conclusion. It should be noted that IABP was the only hemodynamic support available to those individuals because advanced MCS (Impella® and LVAD) were not available.

Acute Decompensated Heart Failure

As regards decompensated HF, admission criteria were based only on clinical evaluation and radiological findings. As per study protocol, AHF complicating ACS was included in the ACS subgroup but not in the AHF group. The average hospital stay was similar to the international data [6].

Device therapy, including CRT, CRT-D, and ICD, was associated with a shortened hospital stay. However, we cannot make a causal relation between an acute benefit of device therapy and short-term outcomes in those patients.

Pulmonary Embolism

For a patient with PE, more than half the patients received thrombolytic therapy. The decision of thrombolysis was physician dependent and non-standardized. Initial hemodynamic data was missing. SK was the only thrombolytic agent used, as a newer agent was not available. Mechanical thrombectomy was not used in any patient, as mentioned above.

Aortic Dissection

In our snapshot cohort, only 3 cases were admitted over a month duration. All patients were of Stanford type A, and all of them planned for surgical repair. Mortality was 100%. Time to surgery was missed. The small number of cases and the available data limits our capability to provide a clear conclusion. However, it is urgently needed to collect more data over an extended time to verify patient outcomes.

Atrial Fibrillation

A common condition exists either as a primary or secondary diagnosis, especially in patients with CHF, either DCM or IHD. The consideration of ablation in AF is an outstanding achievement. However, it was noticed that conservative medical therapy was the default strategy for all patients with CHF and AF. The consideration of device therapy targeting LV dysfunction was much less when AF was associated. Moreover, concern for rhythm control or ablation for AF was underutilized with CHF.

Heart Block

Our Success rate in device therapy is meeting the international standards [7,8]. A dual-chamber in almost half of the patients is an excellent achievement in a big volume center with limited resources. Thirty patients stayed in hospital more than eight days, up to 88 days, with an average of 22 days. There is no clear explanation for the underlying reason for their prolonged hospital stay and whether the delay was because of delayed intervention or procedure-related. A follow-up registry is needed to evaluate long-term outcomes and reflect our practice on functional class and quality of life [9].

Conclusion and Recommendations

  • Although it is a single-center experience, NHI is a high-volume cardiac center with a CCU admission rate of around 400 patients per month.
  • NHI has established a successful 24/7 PCI service with a high success rate. Accordingly, invasive reperfusion methods, whether PPCI or pharmaco-invasive, have a beneficial influence on short-term results and hospital stay length.
  • The present method for addressing ACS or HF at NHI has significantly improved, with a positive overall result across all age categories.
  • Strategies that result in a shorter hospital stay and reduced readmissions should be seriously explored in such a high-volume institution.
  • Accurate monitoring of timed reperfusion goals for various ACS reperfusion methods is urgently required to tackle all time delay components.
  • Complicated ACS patients with AHF have a very high risk of poor outcomes and are significantly associated with more extended hospital stays and in-hospital deaths. In this group of patients, invasive strategies -in our local experience-provided a muted benefit, indicating the need for further development in treatment measures. Well-established methods like ventricular unloading devices or MCS should be considered urgently to support successful mechanical reperfusion and improve prognosis.
  • Available Device therapy (CRT, DRT-D, and ICD) in patients with decompensated HF impacts short-term outcomes and correlates with a shorter hospital stay. Follow-up data reflecting the impact on long-term effects is needed.
  • Poor outcomes noticed in specific diagnoses like cardiogenic shock and Aortic dissection mandate the generation of an institute-specific registry for more precise data collection over a more extended period to guide further management optimization.
  • Creating an electronic health record for mega data collections will offer a clearer picture of healthcare quality rather than analysis of snapshot data. As a result, more comprehensive recommendations regarding areas for improvement will be implemented.

References

  1. Savarese G, Lund LH (2017) Global Public Health Burden of Heart Failure. Cardiac Failure Review 3: 7-11. [crossref]
  2. Shehab A, Al-Dabbagh B, Almahmeed W, et al. (2012) Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates. BMC Res Notes 5: 534. [crossref]
  3. Peter J McCartney, Colin Berry (2019) Redefining successful primary PCI. European Heart Journal – Cardiovascular Imaging 20: 133-135. [crossref]
  4. Nieminen MS, Harjola VP (2005) Definition and epidemiology of acute heart failure syndromes. Am J Cardiol 96: 5G-10G. [crossref]
  5. Cannon CP, Battler A, Brindis RG, Harrington RA, Krumholz HM, et al. (2001) American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol 38: 2114-2130. [crossref]
  6. Cowie MR, Anker SD, Cleland JGF, Felker GM, Filippatos G, Jaarsma T, et al. (2014) Improving care for patients with acute heart failure: before, during and after hospitalization. ESC Heart Fail 1: 110-45. [crossref]
  7. Armstrong PW, Pieske B, Anstrom KJ, Ezekowitz J, Hernandez AF, et al. (2020) Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. The New England Journal of Medicine 382: 1883-1893. [crossref]
  8. Lee TC, Kon Z, Cheema FH, et al. (2018) Contemporary management and outcomes of acute type A aortic dissection: an analysis of the STS adult cardiac surgery database. J Card Surg 33: 7-18. [crossref]
  9. Rajaeefard A, Ghorbani M, Babaee Baigi MA, Tabatabae H (2015) Ten-year Survival and Its Associated Factors in the Patients Undergoing Pacemaker Implantation in Hospitals Affiliated to Shiraz University of Medical Sciences During 2002 – 2012. Iranian Red Crescent Medical Journal 17: e20744. [crossref]

To Mask, or Not to Mask?

DOI: 10.31038/AWHC.2021451

 

Wearing facemasks is recommended as part of personal protective equipment and as a public health measure to prevent the spread of coronavirus disease 2019 (COVID-19) pandemic. However, new mask guidance is suggesting vaccinated people take their mask off in countries such as the U.S., where more than one third of their population is vaccinated [1]. But after the trauma of the past year, and given that we are still nowhere near the roughly 80 percent needed to reach herd immunity, are we ready to uncover our faces yet?

Over one year into the pandemic, among the variety of public health and hygiene measures that have been gradually adopted worldwide, the most visually noticeable is the wearing of face masks. Different, mandatory or voluntary, practices, and contradictory indications about the utility of facemask wearing were introduced across affected countries. Across Europe, face masks have been adopted as one of the measures to reduce the COVID-19 spread, despite the fact that wearing masks in Europe is not common or familiar, and it is often only associated with some Asian or Middle East countries [1], where its use is deeply connected to social and cultural practices, as well as political, ethical, and health-related concerns, personal, and social meanings [2]. At the beginning of the pandemic, there was a lack of consistency among political leaders and experts, who advised against the use of facemasks by the public due to a sense that their potential risks, such as self-contamination, could outweigh the potential benefits, and that public use, would lead to depletion of the supply needed for healthcare workers. Experts then shifted their thinking about potential benefits of masks to include protecting others against infection with SARS-CoV-2 (source control), similar to how surgical masks in the operating room protect patients. However, self-protection is the main reason why infection prevention and control experts recommend healthcare workers to wear a facemask when entering a patient’s room who may have a viral respiratory infection. With COVID-19, however, facemasks have proven to be beneficial for protection of both healthcare workers and the public. This has since been backed up by empirical observations. Epidemiological evidence from Cochrane [3] or the World Health Organization [4] point out that, for population health measures, we should not generally expect to be able to find controlled trials, due to logistical and ethical reasons, and should therefore instead seek a wider evidence base. Therefore, we should not be surprised to find that there are no randomised clinical trials for the impact of masks on community transmission of any respiratory infection in a pandemic.

While there remains much uncertainty around the true effectiveness of face masks-especially when factoring in differences in mask types, levels of adherence, and patterns of human behavior-there is evidence to confirm that masks can provide a measure of protection and containment for respiratory viruses [3]. Systematic reviews of facemask use suggest relative risk (RR) reductions for infection ranging from 6-80%, including for betacoronavirus infection (e.g., COVID-19, SARS, MERS). For COVID-19, this evidence is of low or very low certainty because it is derived from observational studies with important risk of various biases, or indirect evidence from randomised studies of other (non-betacoronavirus) respiratory viruses with methodological limitations. Only one observational study has directly analysed the impact of mask use in the community on COVID-19 transmission that looked at the reduction of secondary transmission of SARS-CoV-2 in households by facemask use [5]. It found that face masks were 79% effective in preventing transmission, if all household members used them prior to symptoms occurring. The study did not look at the RR of different types of mask. In a systematic review sponsored by the World Health Organization [6], physical distancing, facemasks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 were studied, observing that facemask use could result in a large reduction in risk of infection. However, the review included only three studies of mask use outside healthcare settings, all of which were of SARS, not of SARS-CoV-2, and were too underpowered to draw any conclusions [7-9]. Another study found the use of masks was strongly protective, with a risk reduction of 70% for those that always wore a mask when going out [11-13], but it did not look at the impact of masks on transmission from the wearer. It is not known to what degree analysis of other coronaviruses can be applied to SARS-CoV-2. None of the studies looked at the RR of different types of mask [2,12].

Laboratory studies have demonstrated the efficacy of masks and other fabrics as a barrier to small particles and microbes. Surgical and N95 masks limit and redirect the projection of airborne whereas filtration efficiency, which may correlate with containment, has been estimated to be 80% for fitted surgical masks against small particles, or up to 96% against microbes [3,12]. Surgical masks were three times more effective than homemade masks, though droplet transmission from infected individuals wearing the latter was nevertheless reduced. Generally, however, the theoretical protective effect of masks may be diminished by a number of factors: compliance and effective use may be inadequate, masks may not be replaced frequently enough to prevent contamination, and finally, COVID-19 infection may even occur via alternative routes, such as ocular transmission. Nevertheless, the best evidence for airborne (or aerosol) transmission of COVID-19 is from outbreaks and through the detection of virus in air samples [10]. What is meant by airborne or aerosol transmission is the inhalation of the smallest droplets by exposed individuals. This is the case whether the virus is contained in “ballistic” droplets emitted at close range from an infected person or in aerosolized particles over longer distances, minutes or more after leaving the source. Coughing has been associated with the highest aerosol emissions, with a peak concentration at least 10 times greater than the mean concentration generated by speaking or breathing.

Consequently, the wearing of masks-in addition to vigilant hand hygiene-has been put forth as a means to mitigate disease transmission, especially in healthcare settings [10,11]. Much research has indicated that masks can provide significant protection to the wearer, although proper mask fitting is critical to realizing such benefits [7-9]. Alternatively, masks can potentially reduce outward transmission by infected individuals, providing protection to others [10].

From a public health perspective, it is important to emphasise the importance of other risk mitigation strategies, aimed at reducing the number, proximity, and duration of interpersonal contacts, respiratory and hand hygiene measures, and engineering measures in built environments. No single intervention, therefore, seems to give invulnerability to SARS-CoV-2.

Therefore, future steps should include conducting high quality studies, including use of standardised cloth masks, for both the estimates of effects and contextual factors in tandem with ongoing evidence synthesis. Current best evidence includes the possibility of important relative and absolute benefits of wearing a facemask. As no intervention is associated with affording complete protection from infection, a combination of measures will always be required, now and during the next pandemic.

Individual and collective responsibility and trust in the institutions and in the official assessment of recommendations as to the adopted measures are crucial to build up a degree of epistemic agreement [7]. However, this relies on communicating certainty [9], of which very little has been seen during COVID-19 pandemic. Hence, the acceptance of official advice varied among countries, cultures, and political contexts, with some degree of contradiction.

Which is why the general public can’t help but wonder, with or without a mask? It’s a confusion exacerbated by changing rules that vary by countries, states, provinces or even neighborhood, all while the very real threat of infection remains, in some places more than others. However, recent observations directly demonstrate that wearing of surgical masks or KN95 respirators, even without fit-testing, substantially reduce the number of particles emitted from breathing, talking, and coughing [10]. While the efficacy of cloth and disposable masks is not as clear and confounded by shedding of mask fibers and the importance of regular changing of disposable masks and washing of homemade masks is mandatory for its correct use, observations indicate it is likely that they provide some reductions in emitted expiratory particles, in particular the larger particles (> 0.5 μm).

In the case of being fully vaccinated, the Centres for Disease Control and Prevention in the U.S. recently recommended that people vaccinated against the coronavirus resume wearing masks in schools and in public indoor spaces in parts of the country where the virus is surging, marking a sharp turnabout from their advice just a few months ago.

On the other hand, the World Health Organization recommends on wearing masks, especially indoors, and making its use as a normal part of being around people. Vaccines are effective against the worst outcomes of infection, even with variants, and conditions have clearly improved since last year [12]. However, being in an area with a high number of new COVID-19 cases wearing a mask indoors in public and outdoors in crowded areas or when you are in close contact with unvaccinated people is highly recommended, especially in patients with other conditions [13].

In summary, it is therefore indisputable that mask wearing will reduce emission of virus-laden aerosols and droplets associated with expiratory activities and help in mitigating pandemics associated with respiratory disease such as COVID-19. Parallel to the principle of herd immunity for vaccines, the greater the extent to which the intervention-mask wearing-is adopted by the community, the larger the benefit to each individual member. The prevalence of mask use may be of greater importance than the type of mask worn. Recovery of the countries from the COVID-19 pandemic requires the combined efforts of their populations working together in unified public health action. When masks are worn and combined with other recommended mitigation measures, they protect not only the most vulnerable population, but the whole community. Recommendations for masks will likely keep varying as more is learned about various mask types and as the pandemic evolves. With the emergence of more transmissible SARS-CoV-2 variants, it is even more important to adopt widespread mask wearing until effective levels of vaccination are achieved.

References

  1. Martinelli Lucia, Kopilaš Vanja, Vidmar Matjaž, Heavin Ciara, Machado Helena, et al. (2021) Face Masks during the COVID-19 Pandemic: A Simple Protection Tool with Many Meanings. Frontiers in Public Health 8: 947. [crossref]
  2. Jeremy Howard, Austin Huang, Zhiyuan Li, Zeynep Tufekci, Vladimir Zdimal, et al. (2021) An evidence review of face masks against COVID-19. Proceedings of the National Academy of Sciences 118: e2014564118. [crossref]
  3. Worby CJ, Chang HH (2020) Face masks use in the general population and optimal resource allocation during the COVID-19 pandemic. Nat Commun 11: 4049. [crossref]
  4. Stutt ROJH, Retkute R, Bradley M, Gilligan CA, Colvin J (2020) A modelling framework to assess the likely effectiveness of facemasks in combination with ‘lock-down’ in managing the COVID-19 pandemic. Proc R Soc A476: 20200376.
  5. Li JO, Lam DSC, Chen Y, Ting DSW (2020) Novel coronavirus disease 2019 (COVID-19): the importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol 104: 297-298. [crossref]
  6. Science in Emergencies Tasking – COVID-19 (SET-C). Face masks and coverings for the general public: Behavioural knowledge, effectiveness of cloth coverings and public messaging.
  7. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, et al. (2020) Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet 395: 1973-1987. [crossref]
  8. Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, et al. (2020) The socio-economic implications of the coronavirus pandemic (COVID-19): a review. Int J Surg 78: 185-193. [crossref]
  9. Greenhalgh T, Schmid MB, Czypionka T, Bassler D, Gruer L (2020) Face masks for the public during the covid-19 crisis. BMJ 369: m1435. [crossref]
  10. Torjesen I (2021) Covid-19: Risk of aerosol transmission to staff outside of intensive care is likely to be higher than predicted. BMJ 372: n354. [crossref]
  11. Asadi S, Cappa CD, Barreda S, et al. (2020) Efficacy of masks and face coverings in controlling outward aerosol particle emission from expiratory activities. Sci Rep 10: 15665.
  12. Jeremy Howard, Austin Huang, Zhiyuan Li, Zeynep Tufekci, Vladimir Zdimal, et al. (2021) An evidence review of face masks against COVID-19. Proceedings of the National Academy of Sciences 118: e2014564118. [crossref]
  13. Catching A, Capponi S, Yeh MT, Bianco S, Andino R (2021) Examining the interplay between face mask usage, asymptomatic transmission, and social distancing on the spread of COVID-19. Sci Rep 11: 15998. [crossref]

Improving Adherence of Infection Prevention Standards in Health Facilities: The Role of Competition Approach from Four Regions of Tanzania Mainland

DOI: 10.31038/PEP.2021246

Abstract

Introduction: Implementation of infection prevention and control in health facilities faces several barriers. We conducted quality competition activities amongst health facilities as a model of Improving compliance to Infection Prevention and Control (IPC) standards in four regions of Tanzania.

Methodology: The quality competition activities’ implementation design was held in sixty (60) health facilities. Before the competition, healthcare workers from facilities were taken through a thorough capacity building on IPC as a continued essential health services project post first wave of COVID-19. The sampled facilities were informed that the competition was going to be held based on adherence to IPC principles. Two tools were used, i.e., the IPC national checklist tool and the star rating assessment tool. Both tools focused on the Reproductive, Maternal, Newborn and Child Health. The assessments, using both tools, were done independently and then the mean score was developed.

Results: A substantial improvement in adherence to IPC in all the participating facilities was observed. The top three health facilities from each region were selected as winners for a non-monetary gift. The gifts were given based on the level of health facility, that is hospitals, health centers and dispensaries receiving an award worth 13,043.5USD (Tshs. 30,000,000/=) for hospitals, 10,869.6.0USD (Tshs. 25,000,000/=) for health centers and 6521.7USD (Tshs.15,000,000/=) for dispensary. The funder was Catholic Relief Services (CRS).

Conclusion: Completion was found to be facilitator for the adherence of infection prevention principles amongst healthcare facilities.

Keywords

Infection prevention control; Quality of care; Maternal and newborn health

Introduction

The World Health Organization (WHO) advocates that Infection prevention and control (IPC) is a practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infection and helps to mitigate antimicrobial resistance [1]. Unfortunately, the implementation of IPC in the health facilities of developing countries has been jeopardized by number of barriers and facilitators [2].

The awareness of IPC principles continues to affect the endeavors to improve IPC implementation in most of sub-Saharan African countries. Normally, interventions are required to be done by all hospital staff as part of their duties. However, limited knowledge on IPC guidelines, lack of formal feedback on performance, lack of resources, and staff hierarchy issues, continue to hamper IPC enforcement at facility level [3]. Health Care Workers believe that patients pose no health risks especially when there is an asymptomatic presentation. Little awareness of infection existence or following IPC recommendations coupled with unavailability of adequate resources, high workload, and time limitation interferes with providing good patient care [4].

Compliance to IPC guidelines, standards, and standard operating procedures in Tanzania has been shown to be inadequate. Compliance to IPC standards between 2010 and 2017 was found to be 32% in 2010, then improved to 53% in 2014, and dropped to 34% in 2017 [5]. Implementation of IPC principles in primary healthcare facilities, as assessed through star rating implementation in 2015/2016 and 2017/2018, found that “median adherence to IPC principles increased from 31 percent in 2015/16 to 57 percent in 2017/18” [6]. In outpatient settings, in 2018, adherence to hand hygiene was found to be 6·9%, for glove use 74·8%, disinfection of reusable equipment 4·8%, and waste management 43·3%  [7].  For example, according to a study conducted in Dodoma by Wiedenmayer, et al, (2020), only 6.1% and 3.0% of assessed units in intervention and non-intervention facilities respectively were able to reach the recommended World Health Organization compliance rate of ≥81% in Water, Sanitation and Hygiene [8].

Conceptually, the integration of Care for Child Development (CCD) into Management of Possible Severe Bacterial Infection (PSBI) and Neonatal Survival Program [9] is hinged in “The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals (SDG) reports [10]. The report proposed four actions that require: (i) commitment of health system leaders to govern for quality of care and continuous learning; (ii) countries to redesign service delivery to maximize health outcomes; (iii) transform the health workforce by adopting competency-based clinical education and performance; (iv) governments working with the civil society to hold systems accountable and actively seek high-quality care [10].

The main aim of the study was to translate the Lancet Global Health Commission on High Quality Health Systems report in health system improvement for IPC in Tanzania and strategize to understand what works, why, and in what contexts” [10]. Hence, the main aim of this study was to highlight quality competition activities amongst health facilities as a model of improving IPC compliance in Health Facilities in four regions of Tanzania.

Methodology

The quality competition activities implementation design was held in sixty (60) health facilities of Iringa (16), Mbeya (15), Njombe (14) and Songwe (15) regions. The facilities included regional referral and district hospitals (19), health centres (36) and dispensaries (5). Before implementation of the quality competition activities, healthcare workers from these facilities had a thorough capacity building on IPC as a continued essential health services (CES) project post first wave of coronavirus disease of 2019 (COVID-19) which ended in June 2020. The CES project was designated as a response towards prevention, detection and early containment of outbreaks, that has been developed jointly by the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) and President’s Office – Regional Administration and Local Government (PO-RALG) in collaboration with AMREF Health Africa – Tanzania under the financial support of UNICEF. The implementation started in August 2020 and ended in October 2021. The project’s goal was to increase capacity of health facilities to continue to provide essential health services through strengthening IPC during the COVID-19 pandemic in 17 regions of Tanzania; Mainland (12) and Zanzibar (5). The regions in Tanzania Mainland were: Arusha, Dar es Salaam, Dodoma, Iringa, Kilimanjaro, Manyara, Mbeya, Morogoro, Mwanza, Tanga, Njombe and Songwe.

The CES project deployed a blended cascading mode to train health care workers on IPC to ensure that there is CES even during pandemic time. The project physically trained 40 national level master trainers who then trained virtually 237 regional and district level trainers. These then trained virtually and physically 1,172 facility-based trainers called facility champions who finally trained their fellow health care workers in their facilities. These facilities champions then provided training and mentorship to their fellow health care workers physically. A total of 5,172 health care workers both medical and non-medical, had been reached from 297 health facilities. To ensure a good practice of IPC standards by health care workers information, education and communication (IEC) materials on IPC were developed and distributed to facilities in the Mainland and Zanzibar side.

In order to strengthen the implementation of the IPC standards, the MoHCDGEC and PO-RALG in partnership with Catholic Relief Services (CRS), and with financial support from UNICEF, conducted a quality competition on IPC implementation to the purposefully sampled health facilities which were reached by the CES project that is implemented under AMREF Health Africa – Tanzania. Improving adherence of IPC in the selected health facilities design also fits well with the “behaviour change wheel” fitting with communication and motivation components and of the “source of behaviour (capability, opportunity and motivation – producing a behaviour [COM-B])” involving some aspects of policy and intervention functions [11], as shown in Table 1. The quality competition is conceptualized to be a behavioural change technique in a form of material incentive to winning facility valued at 13,043.5usd (Tshs. 30,000,000/=) for hospitals, 10,869.6.0usd (Tshs. 25,000,000/=) for health centers and 6521.7 (Tshs.15,000,000/=) for dispensary. The expected mechanism of action of the quality competition is by triggering an attitude towards improving IPC practices (which is the intended behaviour change in the project implementing facilities [12].

Table 1: Behavior change wheel [11] fit with quality competition for improving IPC practices in four regions of Tanzania Mainland.

Behavior Change Wheel (BCW) – components, categories and intervention functions

Interventions planned in the quality competition for improving implementation of IPC in Iringa, Mbeya, Njombe and Songwe

BCW– Policy & COM-B system

BCW – Intervention functions

 

Policy categories

Guidelines
  • Planning meetings at national level both consultative and technical involving key stakeholders for deigning on its implementation (assessment and mentorship modalities) and involvement of sub-national levels.
 

 

 

 

 

COM-B system

Capability – physical Training

Enablement

  • Training of health workers in the selected facilities on the use of the SBM-R tool for self-assessment and improvement.
Capability – psychological Education

Training

Enablement

  • Mentorship of health care workers in the health facilities by two members from the Council Health Management Team (CHMTs) aiming at: promoting self-reflection and quality improvement; data use for individual quality improvement; and encourage self-monitoring and evaluation of IPC indicators at unit and facility level.
Motivation – reflective Incentivization

 

  • Self-assessment by individual facilities and working unit which aims at stimulating accountability towards quality improvement.
  • Process of benchmarking against peer facilities and work towards a public award.
  • Use of monitoring system to rate facilities on the implementation of appropriate IPC and WASH.
  • Awarding the highest-ranking facilities with material awards that will be used towards further quality improvement in their respective facilities
Motivation – automatic Incentivization

 

  • External-assessment by National Quality Assessors which aims at stimulating accountability towards quality improvement.  through quality competitions between facilities in the target regions in which facilities will compete with other facilities of the same type in each of the four target regions.
  • Process of benchmarking against peer facilities and work towards a public award.
  • Awarding the highest-ranking facilities with material awards that will be used towards further quality improvement in their respective facilities.

The sampled facilities were informed that, the competition was going to be held based on adherence of IPC and quality improvement principles. The exact timing of the competition was not disclosed to the participating facilities as they would change behavior in response to the knowledge that they are being evaluated. They were informed of the existence of competition for ethical purposes only. Two assessment tools were used, i.e., the IPC Standards Assessment Tool (which uses the Standard Based Management and Recognition (SBM-R) approach) to check for IPC adherence and star rating tool (SRT) to check for quality of health services provision. Both tools focused the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH). The tools are in the Afya Supportive Supervision system. This system was developed by the ministry to ease the supervision and assessments. The tools can be accessed by using phones, tablets, computers, etc. The assessment using the tools was done independently, scores were autogenerated and the mean score was developed.

Data Analysis

Scores (%) of the facilities were extracted from Afya Supportive Supervision System (afya SS) after assessment using SRT for RMNCH Services and IPC – SBM-R tool for department/functional areas related to RMNCH Services and exported to the excel spread sheet. The average score of the facility was computed using excel. The top three best performers on the aspects/domains/variables of SBMR / IPC Score – RMNCH related Departments (%) and Star rating assessment in the reproductive health departments were selected as winners from each region

Results

Average Score (%) of the facilities of Iringa Region after assessment using SRT for RMNCH Services and IPC–SBM-R tool for department/functional areas related to RMNCH Services are shown in Table 2.

Table 2: Average scores for facilities in Iringa Region.

Name of Health Facility

Council SBMR/IPC Score – RMNCH related Departments (%) SRT Score (%) Final Score (%)

A. Hospitals

1 Frelimo District Hospital (CH) Iringa MC

71.00

93.50

82.25

2 Iringa Regional Referral

Hospital (RRH)

Iringa MC

68.10

90.00

79.05

3 Mafinga Town Hospital (TH) Mafinga TC

64.00

68.00

66.00

4 Kilolo District Hospital Kilolo DC

67.00

50.50

58.75

B. Health Centers

1 Ipogolo HC Iringa MC

78.20

81.00

79.60

2 Kidabaga HC Kilolo DC

67.00

80.50

73.75

3 Mlowa HC Iringa DC

61.10

86.00

73.55

4 Nzihi HC Iringa DC

55.60

91.00

73.30

5 Kiponzelo HC Iringa DC

55.13

86.00

70.57

6 Ngome HC Iringa MC

51.70

86.00

68.85

7 Malangali HC Mufindi DC

53.00

82.50

67.75

8 Ihongole HC Mafinga DC

54.00

78.00

66.00

9 Mgololo HC Mufindi DC

60.00

70.00

65.00

10 Mgama HC Iringa DC

43.20

86.50

64.85

11 Ismani HC Iringa DC

35.00

89.00

62.00

12 Sadani HC Mufindi DC

57.00

54.50

55.75

Average Scores (%) of the facilities selected from Mbeya Region after assessment using SRT for RMNCAH Services and IPC – SBM-R tool for department/functional areas related to RMNCAH Services are shown in Table 3.

Table 3: Average scores for facilities in Mbeya Region.

SN

Name of the Facility Council SBMR/IPC Score –RMNCAH related Departments (%) SRT Scores (%)

Average score (%)

Health Centres

1. Igawilo HC Mbeya CC

68.29

96.14

82.22

2. Utengule Usangu HC Mbarali DC

63.06

95.18

79.12

3. Ipinda HC Kyela DC

54.29

100

77.15

4. Ilembo HC Mbeya DC

60.43

93.81

77.12

5. Chalangwa HC Chunya DC

56.31

94.32

75.32

6. Ntaba HC Busokelo DC

54.27

87.82

71.05

7. Ikuti HC Rungwe DC

39.80

90.42

65.11

Hospitals

1. Chunya Council Hospital (CH) Chunya DC

68.84

100

84.42

2. Mbarali (CH) Mbarali DC

53.41

100

76.71

3. Mbeya Zonal Referral Hospital Mbeya CC

56.31

95

75.66

4. Mbeya (CH) Mbeya DC

46.13

100

73.07

5. Tukuyu (CH) Rungwe DC

43.24

95.15

69.20

6. Kyela (CH) Kyela DC

38.14

100

69.07

7. Busokelo (CH) Busokelo DC

48.21

88.50

68.36

8. Mbeya Regional Referral Hospital (RRH) Mbeya CC

32.91

95

63.96

Average Score (%) of the facilities Njombe Region after assessment using SRT for RMNCAH Services and IPC–SBM-R tool for department/functional areas related to RMNCAH Services are shown in Table 4.

Table 4: Average scores for facilities in Njombe Region.

SN

Name of the Facility Council SBMR/IPC Score –RMNCAH related Departments (%) SRT Average Score Overall Score (%)
 

HOSPITALS

1. Ludewa CH Ludewa DC

50.1

100

75.1

2 Makete CH Makete DC

49.3

100

74.7

3 Njombe RRH Njombe TC

40

100

70

4 Njombe TCH Njombe TC

31.8

100

65.9

 

HEALTH CENTERS

1. Lupembe HC Njombe DC

69.7

100

84.9

2. Njombe HC Njombe TC

60.3

100

80.2

3. Lupila HC Makate DC

49.4

100

74.7

4. Ihalula HC Njombe TC

49.7

100

74.9

5. Matamba HC Makete DC

48

100

74

6. Wanging’ombe HC Wanging’ombe DC

46.4

100

73.2

7. Manda HC Ludewa DC

38.5

100

69.3

8. Ipelele HC Makete DC

42.5

100

71.3

9. Makambako HC Makambako DC

36.4

100

68.2

10. Mlangali HC Ludewa DC

30.6

100

65.3

Average Score (%) of the facilities of Songwe Region after assessment using SRT for RMNCAH Services and IPC – SBM-R tool for department/functional areas related to RMNCAH Services are shown in Table 5.

Table 5: Average scores for facilities in Songwe Region.

SN

Name of the Facility Council SBMR/IPC Score -RMNCAH related Departments (%)   SRT Score (%) Average Score (%)

HOSPITALS

1. Vwawa Desinated RRH Mbozi DC

47.8

94.5

71.1

2. Mwambani CDH Songwe DC

44.2

90.5

67.3

3. Itumba CH Ileje DC

20.5

88.5

54.5

HEALTH CENTERS

1 Itaka HC Mbozi DC

62.4

93

77.7

2 Tunduma HC Tunduma TC

17.9

83

50.4

3 Ibaba HC Ileje DC

12

87

49.5

4 Kamsamba HC Momba DC

18.1

79

48.5

5 Nanyala HC Mbozi DC

19.2

72

45.6

6 Mbuyuni HC Songwe DC

11.9

74.5

43.2

7 Lubanda HC Ileje DC

9.0

66

37.5

DISPENSARIES

1 Isongole Ileje DC

42.5

100

71.2

2 Katete Tunduma TC

31.2

90.5

60.8

3 Ngwala Songwe DC

22.8

90

56.4

4 Mlowo Mbozi DC

21.4

71.5

46.4

5 Ivuna Momba DC

24.7

65.6

45.1

Three Winners in Every Region

The top three health facilities from each region were selected as winners for the gift. The gifts were given based on the level of health facility. That is 13,043.5USD (Tshs. 30,000,000/=) for hospitals, 10,869.6.0USD (Tshs. 25,000,000/=) for health centers and 6521.7USD (Tshs.15,000,000/=) for dispensary. The facilities were not given cash but rather to choose an in-kind award worth of the amount. CRS procured the awards as proposed by the winner facilities. The facilities that won are shown in the table 6 below.

Table 6: Facilities which won the competition.

Region

Winners
Facility Name SRA average score Average SBMR RMNCAH related Department’s score (%)

Overall score (%)

Mbeya Chunya CH

100.0

68.8

84.4

Igawilo HC

96.1

68.3

82.2

Utengule Usangu HC

95.2

63.1

79.1

Iringa Frelimo Hospital

93.5

71.0

82.3

Ipogolo HC

81.0

78.2

79.6

Iringa RRH

90.0

68.1

79.1

Njombe Ludewa CH

100.0

50.1

75.1

Lupembe HC

100.0

69.7

84.9

Njombe HC

100.0

60.3

80.2

Songwe Vwawa Designated RRH

94.5

47.8

71.1

Itaka HC

93.0

62.4

77.7

Isongele Dispensary

100

42.5

71.2

Discussion

The main aim of our study was to highlight quality competition activities amongst health facilities as a model of improving IPC compliance in Health Facilities in four regions of Tanzania. Our data have shown this model of competition is effective in fostering IPC compliance. The highest average score was 84.4%.

Training of Infection Prevention and Control to Health Care Workers

The WHO recommends that IPC education should be in place for all health care workers by utilizing team- and task-based strategies that are participatory. This should include simulation training to reduce the risk of Health Associated Infection and Anti-Microbial Resistance. IPC education and training should be a part and parcel of an overall health facility education strategy, including new employee orientation and the provision of continuous educational opportunities for existing staff, regardless of level and position (for example, including also senior administrative and housekeeping staff) [15]. Taking that into account, the training was taken as critical to the facilities. There was engagement of stakeholders that is, government officials, partners and the participating facilities. The engagement was enhanced so as to cultivate the culture of ownership of IPC in the facilities and the government. The cascaded training used both physical and virtual approaches to maximize usage of available resources. The national trainers were responsible to designing the training package based on the selected topics that captured all standard and transmission-based precautions. The development of the training package led to all the trainers to be conversant and own the training package. The national trainers trained the reginal and district trainers virtually. Likewise, the reginal and district teams trained the facility-based trainers. The facility-based trainers trained the health care workers at facility level.

Infection Prevention and Control Mentorship : Facilities Based and External Based

The health facility-based mentorship was done by the health facility-based mentors who were also the trainers. This approach of using the facility-based mentors ensured the ownership. The ownership of any approach facilitates long term sustainability. We need sustainability of compliance of the IPC by all health workers in all health care settings. We find this approach of giving ownership to the health care workers to take lead in the training and mentorship of their fellow healthcare workers to be more successful than depending on the external trainers and mentors.

The external mentors also took part in the mentorship after when the internal mentors had finished mentoring session. The external mentors main obligation was to further emphasize what the internal mentors had done but also to mentor areas where the internal mentors did not mentor as well as to further mentor the health facility mentors. The external mentoring also created motivation to the facility-based mentors and health workers. In addition, the external mentoring created smooth means of communication between health facility workers and upper levels that’s, district, region and the MoHCDGEC of health as well as the implementing partners.

Internal Assessment Using National IPC Checklist

The health facility-based assessors also assessed the health care workers and the facility as a whole to check out how far do they comply with the IPC standards. The internal assessors had assessed themselves to identify the gaps and plan for the interventions to correct the gaps. This approach worked well because the facilities were able to identify the gaps based on the IPC checklist and plan the measures by themselves. Again, this way promoted ownership to the gaps identified and hence the facilities felt that the gaps were theirs and thus, they were responsible to correct them. This approach therefore was successful to improve the compliance of IPC.

Competition by External Assessment Using National IPC Checklist

When the process of preparing the facilities in terms of training, mentorship and internal assessment were done, it was the time to conduct health external assessment and compare health facilities. The facilities that had scored higher were rewarded. As the facilities were told before that, those facilities that scored higher got the gift. The fact that the facilities knew there would be a gift fostered competition amongst health workers from different health facilities. The healthcare workers took self-initiatives to improve IPC by complying to the standards put by the MoHCDGEC. Though overall improvements were noted at inter-facility level, variations in results were observed during the external assessment. These variations are attributable to the overall performance of health facilities in the regions.

The implementation of the project applied a multi-pronged strategy in order to be able to improve IPC in at targeted facilities. Accountability was instituted through quality competitions between facilities in the target regions. This was based on the fact that quality competitions have been used in a variety of settings and gained recognition as a potential approach for increasing accountability and building a culture of quality in health facilities [10]. Therefore, facilities competed with other facilities of the same type (dispensary vs. health center vs. hospital) in each of the three target regions namely Mbeya, Njombe and Songwe.

The process of benchmarking against peer facilities and work towards a public award has been shown to be motivating, as demonstrated in a recent study of a national quality improvement program in Tanzania [13]. Monitoring system to rate facilities on the implementation of appropriate IPC and WASH was used. The highest-ranking facilities received public awards that will be used towards further quality improvement in their respective facilities. In order to ensure fair and just competition, this activity involved: formation of team of judges, orientation of health facilities on selected indicators, selection and orientation of external health facilities, data collectors from each region, from Regional Health Management Team (RHMT) and/ Council Health Management Team (CHMT), data collection; and judges spot check of HF implementation of IPC/ WASH activities and selection of winning HF and award celebrations per regions.

Limitations

The was no control group of health facilities where CES project was not implemented so as to compare with the facilities where CES project was implemented. The scores achieved by these facilities might also be achieved by facilities where there were not implementing CS.

Conclusion

Overall, quality Competition on the adherence of IPC best principles and standards for maternal and child health was found to be a facilitator for the adherence of infection prevention principles amongst healthcare workers. It is envisaged that subsequent efforts in this field will gain insights from the approach to comprehensively address key obstacles that prevent adherence of IPC best principles. By using competition to trigger improvement in IPC practices in the health facilities, the CRS project has been able to show that it is possible for Tanzania to use the approach as a way of further elevating and incentivizing quality of care in health facilities and thus accelerating attainment of what Nimako and colleagues have referred to as “a survival-focused universal health coverage agenda” [14].

Acknowledgement

The team would like to acknowledge the support of the MoHCDGEC of Tanzania.  The team acknowledges UNICEF’s financial support rendered through the CES and PSBI projects which enabled implementation of the competition exercise among the health facilities. The team would also like thank AMREF Health Africa and CRS for their contribution in the development of this publication. Finally, we thank WHO country office Tanzania for generously funding the costs of publication of this article.

Funding

This publication is part of a three years project titled: “Integrating Care for Child Development (CCD) into Management of Possible Severe Bacterial Infection (PSBI) and Neonatal Survival Program which is funded by the United Nations Children Fund (UNICEF) and implemented by Catholic Relief Services (CRS) in four regions of Tanzania Mainland (Iringa, Mbeya, Songwe and Njombe) as well as in Unguja and Pemba in Zanzibar.

Disclaimer

The contents of this article represent the views of the authors and do not necessarily reflect the views of the organizations where the authors are affiliated.

Author Contribution

All authors contributed to designing the manuscript, oversaw the implementation, conducted the literature review, and wrote the first and final draft. Amref Africa and CRS led the implementation of the program in the country.

Conflict of Interest

There was no conflict of interest amongst authors

Ethical Considerations

This work does not require ethical clearance because IPC is part of the routine patient care. There is therefore no requirement of the formal ethical clearance for publication of these data.

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  15. Storr J., Twyman A., Zingg W., et al. (2017) Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations. Antimicrob Resist Infect Control 6, 6  https://doi.org/10.1186/s13756-016-0149-9 [crossref]
fig 1

Innovative Two-Stage Seamless Adaptive Clinical Trial Designs

DOI: 10.31038/JPPR.2021441

Abstract

In recent years, the use of a two-stage seamless adaptive design in clinical research has become popular, which combines two separate clinical studies into a single study that can address the study objectives of two separate studies. The design cannot only reduce the lead time between the two separate trials and consequently shorten the development process, but also increase the probability of success of the intended clinical trial because critical decisions or adaptations can be made after the review of interim data at the end of the first stage. Depending on study objectives, study endpoints, and target patient populations at different stages, two-stage seamless adaptive designs can be classified into “k-D” designs (k is the number of different dimensions). A primary assumption that the study endpoint at the first stage is predictive of the study endpoint at the second stage, consideration of using two sets of hypotheses to account for different study objectives at different stages, and an assessment of a sensitivity index for possible population shifts are proposed for valid statistical analyses for a given type of “k-D” design. Examples concerning a hepatitis C virus (HCV) infection clinical study and a non-alcoholic steatohepatitis (NASH) clinical trial are presented.

Keywords

Two-stage phase 1/2 (2/3) seamless adaptive design; The “k-D” design; Population shift; NASH clinical trial

Introduction

In recent years, the use of seamless adaptive designs in clinical trials has become very popular in clinical research and development. A seamless trial design is defined as a design that combines two separate (independent) trials into a single study [1]. The single study is able to address the study objectives that are normally achieved through the conduct of the two trials. An adaptive seamless trial design is referred to as a seamless design that applies adaptations during the conduct of the trial. A seamless adaptive design would use data collected from patients enrolled before and after the adaptation in the final analysis. A typical example is a two-stage phase 2/3 seamless adaptive clinical trial which consists of two stages, namely a learning (or exploratory) stage (e.g., phase 2 for dose finding or drop the lowers) and a confirmatory stage (e.g., phase 3 study for efficacy confirmation). See also, EMA (2014) [2]; FDA (2019). A two-stage seamless adaptive trial design has the following characteristics: (i) it combines two separate and independent trials into a single trial, (ii) the single trial consists of two stages, namely a learning (exploratory) stage and a confirmatory stage, and (iii) it offers opportunities for adaptations based on accrued data at the end of learning stage [3]. A two-stage seamless adaptive design provides an opportunity for saving because it allows stopping a trial early for safety and/or futility/efficacy. In addition, it can reduce the lead time between the learning stage and the confirmatory stage. Furthermore, data collected at the learning stage can be combined with those data obtained at the confirmatory stage for a final analysis for obtaining a more accurate and reliable assessment of the treatment effect under study. However, the use of a two-stage seamless adaptive trial design also suffers from the following limitations (or regulatory concerns): (i) it may introduce operational bias (e.g., adaptations relate to dose, hypothesis, and endpoint, etc), (ii) it may not be able to control the overall type I error rate, (iii) statistical methods for combined analysis are not well established especially when the study objectives and study endpoints are different at different stages, and (iv) the complexity of the two-stage seamless adaptive design depends upon the adaptations apply [4,5]. Depending upon whether the study objectives, study endpoints, and target populations at different stages are the same, two-stage seamless adaptive designs can be classified into several categories. Statistical methods for data analysis including power calculation for sample size calculation and allocation are different for seamless adaptive designs in different categories. In the next section, these types of seamless adaptive designs are defined. Section 3 describes the analysis methods of these types of seamless adaptive clinical trials with one or more differences in study objective, endpoint, and/or target patient population. Section 4 discusses primary assumptions and statistical considerations for analysis of a general “K-D” design”. Two examples concerning a hepatitis C virus (HCV) infection clinical study and a non-alcoholic steatohepatitis (NASH) clinical trial are presented to illustrate the application of a “2- D” design and a “3-D” design, respectively. Some concluding remarks are given in the last section of this article.

Types of Two-Stage Seamless Adaptive Design

Generally, a seamless adaptive design has three key dimensions: study objective, study endpoint, and target patient population. As is described in Table 1, in practice, a seamless adaptive design may combine two separate (independent) trials with similar but different study objectives into a single trial, e.g., a phase 2 trial for dose selection and a phase 3 study for efficacy confirmation. In addition, the study endpoints considered at the two separate trials may be different, e.g., a biomarker or surrogate endpoint versus a regular clinical endpoint. In some cases, such as non-alcoholic steatohepatitis (NASH) clinical trials, the target patient populations may have been shifted due to disease progression at different stages (e.g., fibrosis, cirrhosis, and liver transplant). Thus, the three dimensions may be the same or different in a particular two stage seamless adaptive design. We can classify two-stage seamless adaptive designs into eight categories depending upon whether the study objectives, study endpoints, and target patient populations at different stages are the same (Table 2).

Table 1: Three Key Dimensions of a Seamless Adaptive Design.

Dimension

Example

Study objective Dose selection versus efficacy confirmation
Study endpoint A biomarker or surrogate endpoint versus a regular clinical endpoint
Target patient population It may be shifted due to disease progression at different stages (e.g., fibrosis, cirrhosis, and liver transplant).

Table 2: Types of Two-Stage Seamless Adaptive Designs (Depending upon Objective, Endpoint, and Target Population)

Study Objective

Target Patient Population

Same (S)

Different (D)
Study Endpoint

Study Endpoint

Same (S) Different (D) Same (S)

Different (D)

Same (S)

SSS

SDS SSD

SDD

Different (D)

DSS

DDS DSD

DDD

Table 3 indicates that there is one “0-D design”, three “1-D design”, three “2-D design”, and one “3-D design”. These “K-D” designs, where K is the number of differences in objective, endpoint, and target patient population are briefly described below.

The “0-D” design is a two-stage seamless adaptive design with the same study objective and same study endpoint at different stages under the same target patient population, which is similar to typical group sequential design with a planned interim analysis.

For the “1-D” designs, there are three different types: (i) the study objective is different at different stages (e.g., dose selection versus efficacy confirmation), (ii) the study endpoint is different at different stages (e.g., biomarker or surrogate endpoint or clinical endpoint with shorter duration versus clinical endpoint), and (iii) the target patient population is different at different stages (e.g., population shift before and after adaptations applied based on the review of interim analysis at the end of the first stage).

For the “2-D” designs, there are three different types: (i) both study objective and endpoint are different at different stages (e.g., dose selection versus efficacy confirmation and biomarker or surrogate endpoint or clinical endpoint with shorter duration versus clinical endpoint), (ii) both study objective and  target  patient  population are different at different stages (e.g., dose selection versus efficacy confirmation and population shift before and after adaptations applied based on the review of interim analysis at the end of the first stage), and (iii) both study endpoint and the target patient population are different at different stages (e.g., biomarker or surrogate endpoint or clinical endpoint with shorter duration versus clinical endpoint and population shift before and after adaptations applied based on the review of interim analysis at the end of the first stage).

For the “3-D” designs, in addition to differences in study objective and study endpoint at different stages, the target patient population  is also different at different stages. A typical example is a two-stage NASH seamless adaptive clinical trial, which will be further discussed in a later section.

Table 3: Types of Two-Stage Seamless Adaptive Designs (Depending upon the Number of Differences in Objective, Endpoint, and Target Population). Depending on the number of differences in study objective, endpoint, and target population, Table 2 can be summarized as the following table.

Two-Stage Seamless Design

The “0-D” design The “1-D” design The “2-D” design

The “3-D” design

SSS

DSS

DDS

DDD

SDS

DSD
SSD

SDD

Note: S = Same, D = Different

Analysis of Seamless Adaptive Trial Design

Analysis for Seamless Design with Different Objectives

In this section, we will focus on statistical inference for the scenario where the study objectives at different stages are different (e.g., dose selection versus efficacy confirmation) and study endpoints at different stages are different (e.g., biomarker or surrogate endpoint versus regular clinical study endpoint). As indicated earlier, one of the major concerns when applying adaptive design methods in clinical trials is probably how to control the overall type I error rate at a pre-specified level of significance. It is also a concern that how the data collected from both stages should be combined for the final analysis. Besides, it is of interest to know how the sample size calculation/allocation should be done for achieving individual study objectives originally set for the two stages (separate studies). In this article, a multiple-stage transitional seamless trial design with different study objectives and different study endpoints and with and without adaptations is proposed. The impact of the adaptive design methods on the control of the overall type I error rate under the proposed trial design is examined. Valid statistical test and the corresponding formulas for sample size calculation/allocation are derived under the proposed trial design. As indicated earlier, a two- stage seamless trial design that combines two independent studies (e.g., a phase 2 study and a phase 3 study) is often considered in clinical research and development. Under such a trial design, the investigator may be interested in having one planned interim analysis at each stage. In this case, the two-stage seamless trial design becomes a 4-stage trial design if we consider the time point at which the planned interim analysis will be conducted as end of the specific stage. In this article, we will refer to such a trial design as a multiple-stage transitional seamless design to emphasize the importance of smooth transition from stage to stage. In what follows, we will focus on the proposed multiple-stage transitional seamless design with (adaptive version) and without (non- adaptive version) adaptations.

Consider a clinical trial comparing k treatments groups, consider 1 with a control group C. One early surrogate endpoint and one subsequent primary endpoint are potentially available for assessing the treatment effect. Let consider 2 and consider 3 be the treatment effect comparing consider 4 with C measured by the surrogate endpoint and  the primary endpoint, respectively. The ultimate hypothesis of interest is

(1)

which is formulated in terms of the primary endpoint. However, along the way, the hypothesis

(2)

In terms of the short-term surrogate endpoint will also be assessed. Cheng [1,3] assumed that interms 1 is a monotone increasing function of the corresponding interms 2. The trial is conducted as a group sequential trial with the accrued data analyzed at 3 stages (i.e., stage 1, stage 2a, stage 2b, and stage 3) with 4 interim analyses, which are briefly described below. The timeline of the trial is depicted in Figure 1. For simplicity, consider the case where the variances of the surrogate endpoint and the primary outcomes, denoted as interms 3 and interms 4 are known.

fig 1

Figure 1: Timeline of a Seamless Trial of Different Objectives and Different Endpoints with 4 Interim Analyses.

At Stage 1 of the study, (k +1)n1 subjects will be randomized equally to receive either one of the k treatments or the control. As the result, there are n1 subjects in each group. At the first interim analysis, the most promising treatment will be selected and used in the subsequent stages based on the surrogate endpoint. Let at stage 1 1 be the pair wise test statistics, and at stage 1 2, then if at stage 1 3 for some c1, then the trial is stopped and H0,1 is accepted. Otherwise, if at stage 1 4, then the treatment Esis recommended as the most promising treatment and will be used in all the subsequent stages. Note that only the subjects receiving either the promising treatment or the control will be followed formally for the primary endpoint. The treatment assessment on all other subjects will be terminated and the subjects will receive standard care and undergo necessary safety monitoring.

At Stage 2a, 2n2 , additional subjects will be equally randomized to receive either the treatment Es or the control C. The second interim analysis is scheduled when the short-term surrogate measures from these 2n2 Stage 2 subjects and the primary endpoint measures from those 2n1 Stage 1 subjects who receive either the treatment Es or the control C become available. Let at stage 2a 1 and at stage 2a 2 be the pairwise test statistics from Stage 1 based on the surrogate endpoint and the primary endpoint, respectively, and at stage 2a 3 be the statistic from Stage 2 based on the surrogate. If

T2.1

then stop the trial and accept H0,1. If T2.1 > C2.1 and T1.2 > C1.2, then stop the trial and reject both H0,1 and H0,2. Otherwise, if T2.1 > C2.1 but then stop 1, then we will move on to Stage 2b.

At Stage 2b, no additional subjects will be recruited. The third interim analysis will be performed when the subjects in Stage 2a complete their primary endpoints. Let

T2.2

where where 1 is the pair-wise test statistic from stage 2b. If T2.2 > C2.2, then stop the trial and reject H0,2 . Otherwise, we move on to Stage 3.

At Stage 3, the final stage, 2n3 additional subjects will be recruited and followed till their primary endpoints. For the fourth interim analysis, define

T3

where us3 is the pair-wise test statistic from stage 3. If T3 > C3, then stop the trial and reject H0,2; otherwise, accept H0,2. The parameters in the above designs, n1, n2, n3, c1.1, c1.2, c2.1, c2.2 and c3 are determined such that the procedure will have a controlled type I error rate of α and a target power of 1−β. The determination of these parameters will be given in next section.

Analysis for Seamless Design with Different Endpoints

For illustration purpose, consider a two-stage phase 2/3 seamless adaptive trial design with different (continuous) study endpoints. Let xi be the observation of one study endpoint (e.g., a biomarker) from the ith subject in phase 2, i 1,…, n and yj be the observation of another study endpoint (the primary clinical endpoint) from the jth subject in phase 3, j=1,…, m. Assume that xi‘s are independently and identically distributed with Exi=v and var(xi); and yj′s are independently and identically distributed with E(yj)=μ and var(yi). Chow, Lu (2007) proposed using the established functional relationship to obtain predicted values of the clinical endpoint based on data collected from the biomarker (or surrogate endpoint). Thus, these predicted values can be combined with the data collected at the confirmatory phase to develop a valid statistical inference for the treatment effect under study. Suppose that x and y can be related in a straight-line relationship

y = β0 + β1x + ε (3)

where ε is an error term with zero mean and variance ς2. Furthermore, ε is independent of x. In practice, we assume that this relationship is well-explored and the parameters β0 and β1 are known. Based on (3), the observations xi observed in the learning phase would be translated to β0 + β1xi (denoted by yi cap ) and are combined with those observations yi collected in the confirmatory phase. Therefore, yi cap‘s and yi‘s are combined for the estimation of the treatment mean μ. Consider the following weighted-mean estimator,

4

where where after It should be noted that u cap is the minimum variance unbiased estimator among all weighted-mean estimators when the weight is given by

5

if β1, interms 4 and interms 3 are known. In practice, interms 4 and interms 3 are usually unknown and ω is commonly estimated by

6

where S12 and yi cap are the sample variances of yi cap’s and yj’s, respectively. The corresponding estimator of μ, which is denoted by

7

Is referred to as the Graybill-Deal (GD) estimator of μ. The GD estimator is also known the weighted mean in metrology. An approximate unbiased estimator of the variance of the GD estimator, which has bias of order O(n−2 + m−2) is given as

is referred

For the comparison of the two treatments, the following hypotheses are considered

8

Let yij cap be the predicted value bob1xij, which is used as the
prediction of y for the jth subject under the ith treatment in phase 2. From (7), the Graybill-Deal estimator of ui is given as

9

where 4page wher 1 and 4page where 2 with 4page where 3 and 4page where 4 being the sample variances of 4page where 5 respectively. For hypotheses (8), consider the following test statistic,

10.

is an estimator of is an 1,2 Using arguments similar to those in section 2.1, it can be verified that t1 cap has a limiting standard normal distribution under the null hypothesis H0 if

is an after

Consequently, an approximate 100(1-α)% confidence interval of μ1 − μ2 is given as

11

where vt Therefore, hypothesis H0 is rejected if the confidence interval (9) does not contain 0. Thus, under the local alternative hypothesis that h1 u1, the required sample size to achieve a 1−β power satisfies

zb

Let mi for Then, denoted by NT the total sample size for two treatment groups is (1+ρ)(1+γ)n1 with n1 given as

12

where and with

For the case of testing for superiority, consider the following local alternative hypothesis that

for the case

The required sample size to achieve 1−β power satisfies

zb2

Using the notations in the above paragraph, the total sample size for two treatment groups is (1+ρ)(1+γ)n1 with n1 given as

13

where D where For the case of testing for equivalence with a significance level α, consider the local alternative hypothesis that that The required sample size to achieve 1−β power satisfies

zb 3

Thus, the total sample size for two treatment groups is (1+ρ)(1+γ) n1 with n1 given

14

Note that following similar idea as described above, statistical tests and formulas for sample size calculation for testing hypotheses of equality, non-inferiority, superiority, and equivalence for binary response and time-to-event endpoints can be obtained.

Analysis of Seamless Adaptive Design with Different Target Patient Population

In clinical research, it is often of interest to generalize clinical results obtained from a given target patient population (or a medical center) to a similar but different patient population (or another medical center). Denote the original target patient population by (μ0, σ0), where μ0 and σ0 are the population mean and population standard deviation, respectively. Similarly, denote the similar but different patient population by μ1, σ1. Since the two populations are similar but different, it is reasonable to assume that μ10 + ε and σ1 =Cσ0 (C > 0), where ε is referred to as the shift in location parameter (population mean) and C is the inflation factor of the scale parameter (population standard deviation). Thus, the (treatment) effect size adjusted for standard deviation of population (μ1, σ1) can be expressed as follows:

15

where triangle and E0 and E1 are the effect size (of clinically meaningful importance) of the original target patient population and the similar but different patient population, respectively. Δ is referred to as a sensitivity index measuring the change in effect size between patient populations [6].

As it can be seen from (1), if ε = 0 and C = 1, E0 = em>E1. That is, the effect sizes of the two populations are identical. In this case, we claim that the results observed from the original target patient population (e.g., adults) can be generalized to the similar but different patient population (e.g., pediatrics or elderly). Applying the concept of bioequivalence assessment, we can claim that the effect sizes of the two patient populations are equivalent if the confidence interval of |Δ| is within (80%, 120%) of E0. It should be noted that there is a masking effect between the location shift (ε) and scale change (C). In other words, shift in location parameter could be offset by the inflation or deflation of variability. As a result, the sensitivity index may remain unchanged while the target patient population has been shifted.

As indicated by [7], in many clinical trials, the effect sizes of the two populations could be linked by baseline demographics or patient characteristics if there is a relationship between the effect sizes and the baseline demographics and/or patient characteristics (e.g., a covariate vector). In practice, however, such covariates may not exist or exist but not observable. In this case, the sensitivity index may be assessed by simply replacing ε and C with their corresponding estimates [7]. Intuitively, ε and C can be estimated by

big c down

where uocaps are some estimates of (μ0 σ0) and (μ1 σ1), respectively. Thus, the sensitivity index can be estimated by

formula

In practice, the shift in location parameter (ε) and/or the change in scale parameter (C) could be random. Chang [8] studied possible shift in target patient population. If both ε and C are fixed, the sensitivity index can be assessed based on the sample means and sample variances obtained from the two populations. In real world problems, however, ε and C could be either fixed or random variables. In other words, there are three possible scenarios: (1) the case where ε is random and C is fixed, (2) the case where ε is fixed and C is random, and (3) the case where both ε and C are random.

Analysis of k-D seamless adaptive design

When there are differences in study objective, endpoint, and/or target patient population in seamless adaptive designs, some primary assumption and/or statistical considerations are necessarily applied for deriving valid statistical methods for data analysis collected from a given seamless adaptive design. These assumptions and/or considerations are described below.

Primary Assumption and/or Considerations

The “0-D Design” (SSS Design). As indicated in Table 2, SS Design is a two-stage seamless adaptive design with the same study objective and same study endpoint at different stages, which is similar to typical group sequential design with a planned interim analysis. Thus, standard statistical methods such as MIP (method of individual p-values), MSP (method of sum of p-values), and MPP (method of product of p-values) for group sequential design can be directly applied [1,9]. It should be noted that if additional adaptations such as change in primary study endpoint or hypotheses after the review of interim data, the standard methods have to be modified for the control of the overall type I error rate.

The “1-D Design” (DSS, SDS, or SSD Design). Since a “1-D design” could be an SD design or a DS design. Statistical analyses for an SD design and a DS design are different. To have a valid statistical analysis, some assumptions are necessary. For example, for an SD design (i.e., study objectives at different stages are the same but the study endpoints are different at different stages), it is assumed that study endpoint (e.g., a biomarker, a surrogate endpoint, or a clinical endpoint with a short duration) at the first stage is predictive of the study endpoint (i.e., regular clinical endpoint) at the second stage [10]. On the other hand, for a DS design (i.e., study objectives at different stages are different but the study endpoints at different stages are the same), we have to consider testing two sets of hypotheses at different stages [3].

The “2-D Design” (DDS, DSD, or SDD Design). For the “2-D” design (i.e., both study objectives and study endpoints at different stages are different), the following primary assumption and consideration are necessarily made for obtaining a valid statistical test using different endpoints for achieving study objectives at different stages: (i) study endpoint at the first stage is predictive of the study endpoint at the second stage, and (ii) considering testing two sets of hypotheses at different stages.

Chow and Lin (2015) illustrated statistical analysis for a DD design using an example concerning a clinical trial for evaluation of safety, tolerability and efficacy of a test treatment for patients with hepatitis C virus (HCV) infection. In the HCV study, a two-stage seamless adaptive design is considered. The trial design was to combine two independent studies (one phase 2b study for treatment selection and one phase 3 study for efficacy confirmation) into a single study. Thus, study objectives at different stages are similar but different. For the study endpoint, the well-established clinical endpoint is the sustained virologic response (SVR) at week 72 (i.e., 48 weeks of treatment plus 24 weeks of follow-up). Since the PI or sponsor is interested in making early decision for treatment selection at Stage 1. The clinical endpoint of early virologic response (EVR) at week 12 is considered as a surrogate endpoint for treatment selection at Stage 1. Thus, the study endpoints at different stages are different. Statistical test was ten derived based on the primary assumption and consideration for addressing the study objectives at different stages [3].

The “3-D Design” (DDD Design). For the “3-D” design (i.e., study objectives, study endpoints, and target patient populations at different stages are different), the following primary assumption and considerations are necessarily made for obtaining a valid statistical test using different endpoints for achieving study objectives at different stages: (i) study endpoint at the first stage is predictive of the study endpoint at the second stage, (ii) considering testing two sets of hypotheses at different stages, and (iii) the assessment of sensitivity index indicates that there is no significant shift in target patient population from stage to stage.

Examples

Hepatitis C Virus (HCV) Study

A pharmaceutical company was interested in conducting a clinical trial for evaluation of safety, tolerability and efficacy of a test treatment for patients with hepatitis C virus infection. For this purpose, after consulting with regulatory reviewers, it was decided that a two-stage seamless adaptive design would be used for the intended study. The proposed trial design was to combine two independent studies (one phase 2b is study for treatment selection and one phase 3 study for efficacy confirmation) into a single study. Thus, the study consists of two stages: treatment selection (Stage 1) and efficacy confirmation (Stage 2). The study objective at the first stage was for treatment selection, while the study objective at Stage 2 was to establish the non-inferiority of the treatment selected from the first stage as compared to a treatment of standard of care (SOC). Thus, the proposed trial design is a typical “2-D” design, i.e., a two-stage adaptive design with different study objectives at different stages with the same target patient population.

Figure 2 shows the timeline of the “2-D” HCV study. For genotype 1 HCV patients, the treatment duration is usually 48 weeks of treatment followed by a 24-week follow-up. The clinical endpoint is the sustained virologic response (SVR) at week 72. The SVR is defined as an undetectable HCV RNA level (< 10 IU/mL) at week 72. Thus, it will take a long time to observe a response. The pharmaceutical company was interested in considering the same clinical endpoint with a much shorter duration to make early decision for treatment selection of the four active treatments under study at Stage 1. As a result, the clinical endpoint of early virologic response (EVR) at week 12 is considered as a surrogate endpoint for treatment selection at Stage 1. The resultant “2-D” seamless adaptive design is briefly outline below (see also Chow and Lin, 2015) [3]:

fig 2

Figure 2: Timeline of the “2-D” HCV study

Stage 1. At this stage, the design begins with five arms (4 active treatment arms and one control arm). Qualified subjects were randomly assigned to receive one of the five treatment arms at a 1:1:1:1:1 ratio. After all Stage 1 subjects have completed Week 12 of the study, an interim analysis was performed based on EVR at week 12 for treatment selection. Treatment selection was made under the assumption that the 12-week EVR is predictive of 72-week SVR. Under this assumption, the most promising treatment arm was selected using precision analysis under some pre-specified selection criteria that the treatment arm with highest confidence level for achieving statistical significance (i.e., the observed difference as compared to the control is not by chance alone) was selected. Stage 1 subjects who have not yet completed the study protocol continued with their assigned therapies for the remainder of the planned 48 weeks, with final follow-up at Week 72. The selected treatment arm was then proceeded to Stage 2.

Stage 2. At Stage 2, the selected treatment arm from Stage 1 was test for non-inferiority against the control (SOC). A separate cohort of subjects was randomized to receive either the selected treatment from Stage 1 or the control (SOC) at a 1:1 ratio. A second interim analysis was performed when all Stage 2 subjects have completed Week 12 and 50% of the subjects (Stage 1 and Stage 2 combined) have completed 48 weeks of treatment and follow-up of 24 weeks. The purpose of this interim analysis was two-fold. First, it was to validate the assumption that EVR at week 12 is predictive of SVR at week 72. Second, it was to perform sample size re-estimation to determine whether the trial will achieve study objective (establishing non-inferiority) with the desired power if the observed treatment preserves till the end of the study. Statistical tests as described in the previous section was presented to test non-inferiority hypotheses at interim analyses and at end of stage analyses. For the two planned interim analyses, the incidence of EVR at week 12 as well as safety data, were reviewed by an independent data safety monitoring committee (iDMC). The commonly used O’Brien-Fleming type of conservative boundaries was applied for controlling the overall Type I error rate at 5%. Adaptations such as stopping the trial early, discontinuing selected treatment arms, and re-estimating the sample size based on the pre-specified criteria were applied as recommended by the iDMC.

Non-Alcoholic SteatoHepatitis (NASH) Clinical Trials

For development of drug products for treating patients with NASH, after having consulted with regulatory agency, it is suggested the following clinical trials utilizing seamless adaptive designs may be useful to shorten and speed up the process of NASH drug product development: (i) proof-of-concept/dose ranging adaptive trial design,(ii) phase 3/4 adaptive trial design, and (iii) phase 2/3/4 adaptive design [11].

Table 4 illustrates the objectives, endpoints and target patient populations in NASH clinical trials. For illustration purpose, consider a single seamless phase 2/3/4 adaptive trial design allows adaptations, continuous exposure, and long-term follow-up (Figure 3). Endpoints at interim analysis are (i) reduction of at least 2 points in NAS, (ii) resolution of NASH by histology without worsening of fibrosis, and/or (iii) improvement in fibrosis without worsening of NASH [12-15]. One (the most promising dose) or two doses may continue to the next phase. A post-marketing phase 4 with demonstration of improvement in clinical outcomes will lead to final marketing authorization.

Because only one trial would lead to approval, a very small overall alpha (i.e., <0.001) is recommended to ensure proper control of a type I error.

Although the above seamless phase 2/3/4 appears to be reasonable, regulatory agency such as FDA [16-18] emphasizes that the designs must be supported by a sound rationale and scientific justifiable for integrity, quality and validity. Protocol should address the following typical issues:

(i) Provide detailed information regarding how the overall type I error rate is controlled or preserved;

(ii) Provide a detailed strategy or plan for preventing possible operational biases that may incur before and after the adaptations are applied;

(iii) Provide justification regarding the validity of statistical methods used for a combined analysis;

(iv) Provide justification for the chosen alpha spending function (e.g., O’Brien-Fleming) for stopping boundaries;

(v) Provide justification regarding criteria used for critical decision-making at interims;

(vi) Establish an independent data safety monitoring committee (IDMC) and provide IDMC charter;

(vii) Provide justification for power analysis for sample size calculation and sample size allocation especially where the study objectives, endpoints, and populations are different at different stages;

(viii) Provide justification if sample size re-estimation is performed in a blinded or unblended fashion in the seamless adaptive trial design.

Table 4: Objectives, Endpoints and Target Patient Populations in NASH Clinical Trials.

Objective

Primary Endpoint

Target Patient Population

Trials to support a marketing application Composite endpoint: complete resolution of steatohepatitis and no worsening of fibrosis –

Composite endpoint: At least one point improvement in fibrosis with no worsening of steatohepatitis (no increase in steatosis, ballooning or inflammation)

Biopsy confirmed NASH patients with moderate/advanced fibrosis (F2/F3)
Clinical outcome underway by the time of submission:

Histopathologic progression to cirrhosis

MELD score change by >2 points or MELD increase to >15 in population enrolled with ≤ 13

•Death

•Transplant

•Decompensation events

–Hepatic encephalopathy – West Haven ≥ grade 2

–Variceal bleeding – requiring hospitalization

–Ascites – requiring intervention

–Spontaneous bacteria peritonitis

 

Dose ranging/Phase 2 Improvement in activity (NAS)/ballooning/inflammation without worsening of fibrosis can be acceptable

Include a subpopulation with moderate/advanced fibrosis (F2/F3) to inform PhIII

Biopsy proven NASH (NAS ≥ 4)

–Include patients with NASH and liver fibrosis with any stage of fibrosis

Include patients with NASH and ≥ Fibrosis stage 2 to inform PhIII

Early phase trials/Proof of concept Endpoints should be based on mechanism of drug

Consider using improvement in NAS (ballooning & inflammation) and/or fibrosis

Reduction in liver fat with a sustained improvement in transaminases

 

Ideal to use patients with biopsy proven NASH, but acceptable to use patients at high risk for NASH (fatty liver + type 2 diabetes, the metabolic syndrome and high transaminases are acceptable

fig 3

Figure 3: Phase 2/3/4 Seamless Adaptive Design.

The NASH clinical trial design is a typical “3-D” design. The analysis of a “3-D” seamless adaptive trial design requires (i) a primary assumption that the study endpoint at the first stage is predictive of the clinical endpoint at the second stage to account for different study endpoints at different stages, (ii) a consideration of testing two sets of hypotheses to account for different study objectives at different stages, and (iii) a sensitivity analysis to account for a possible shift in target patient population from stage to stage.

Conclusion

In this article, depending upon whether the study objectives, study endpoints, and target patient populations at different stages are different, two-stage seamless adaptive designs are classified into eight different categories, namely, “0-D” design, “1-D” design, “2-D” design, and “3-D” design. For a given type of two-stage seamless adaptive trial design, the following proposal is made for a valid statistical analysis. First, a primary assumption that the study endpoint at the first stage is predictive of the study endpoint at the second stage is made to account for different study endpoints at different stages. Second, a consideration of testing two sets of hypotheses is suggested to account for different study objectives at different stages. Third, it is suggested that an assessment of a sensitivity index should be performed for possible shift in target patient population from stage to stage. Two examples concerning a hepatitis C virus (HCV) infection clinical study (a typical “2-D” design) and a non-alcoholic steatohepatitis (NASH) clinical trial (a typical “3-D” design) are presented to illustrate the proposed methods. From regulatory perspectives, the innovative seamless adaptive trial designs discussed in this article cannot only offer great flexibility of identifying any signal, trend, or optimal benefit of the test treatment under investigation, but also improve the relative efficiency (e.g., shorten the development process). However, these can only be achieved at the risk of controlling the overall type I error rate and/or the validity and integrity of the intended clinical trials. From statistical perspectives, on the other hand, for most innovative seamless adaptive trial designs, statistical methods are not fully established. Although clinical simulation may provide a solution, it is not “the” solution because the model used for simulation is difficult, if not impossible, to verify. A wrong model could lead to biased conclusion and hence may be misleading. Never misuse or abuse the use of complex seamless adaptive trial design in clinical research and development. From clinical perspectives, it is suggested that an “investigator’s wish list” approach should be considered when applying complex innovative design in clinical research. In other words, clinician should always be in the driver seat and biostatistician should development statistical tests with optimal statistical properties to accommodate the investigator’s wish list without undreaming the validity and integrity of the intended trial.

References

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  3. Chow SC, Lin M (2015) Analysis of two-stage adaptive seamless trial design. Pharmaceutica Analytica Acta 6.
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Introduction to Vital Biological and Regenerative Factors Myxocyprinus asiaticus

DOI: 10.31038/AFS.2021343

Abstract

It will not be possible to get the biological course and to know the biological species without a comprehensive knowledge of different species, especially their important species from different landscapes. Chinese high-fin banded shark is a species of biological and geogeological importance about which little resources and research have been done. This fish is also of special importance from an evolutionary point of view. The present article tries to examine the general characteristics, general needs, and methods required.

Keywords

Biological, Geogeological, Evolution

Introduction

Myxocyprinus asiaticus is a freshwater fish native to China and the only member of the family, Catostomidae, in Asia [1]. This species is an important commercial fish and has an important role in archaeological and geogeographical studies [2]. It is also used as an ornamental fish due to its colorful body. However, the wild population of this fish has decreased tragically in recent decades due to overfishing, water pollution and other anthropogenic effects [3]. Chinese sucker is an endangered species that is the second most endangered species in China [4].

Systematic and Morphological

It is the only member of the Catostomidae family in Asia [5]. A large freshwater fish with a slightly long and compact body on both sides, small and short head, short snout, and curved mouth upwards, full lateral line, lack of Barbel on jaw and smooth abdominal surface 48-53 scales on lateral line, long base of dorsal fin Which is close to the second fin. It has three stripes on the sides and a panda-like dark spot on the edge of the eye in adult species [6].

Distribution

They are distributed only in the Yangtze and Min Jiang rivers in China [7].

Maintain and Expand Reserves

This species is an endangered fish, which is in the second category of endangered aquatic and terrestrial animals in China [8].

Controlling abandoned populations and preventing population decline through factors such as disease is inevitable. One of the most reliable methods of disease control in aquaculture is the preventive use of immune stimulants [9]. Immune stimuli can increase survival against pathogens by enhancing the nonspecific defense mechanism [10]. Also, in a study on thermal marking of fish pebbles, which was performed by exposing Chinese high-fin banded shark larvae to temperature regimes from hot water 28°C to cold water 16°C, it was found that the incremental patterns of pebbles were different in each group. In this way, by controlling the duration of presence in hot water, narrower or wider incremental patterns could be obtained. A deep and positive relationship between the width of the incremental pattern and the duration of cultivation in hot water in each cycle of water temperature fluctuation could be seen. Unusually, it is proposed as a solution to distinguish breeding people from species grown in nature [11]. Studies have also shown that those in the 24-hour temperature cycle provided clear, high-contrast patterns compared to constant-temperature findings [12].

Genetics

The Catostomidae family is thought to have evolved from a cyprinid-like ancestor in Asia [13]. Although most members of this family of about 60 species are now confined to North America, only two species include Catostomus catostomus rostarus (a subspecies of C. c. Catostomus in North America; sometimes both of these fish as a subspecies). Single species are classified as C. c. Catostomus in eastern Siberia and Myxocyprinus asiaticus in China, native to Eurasia. Tetraploidy has been confirmed in North American suckers [14,15]. A study also found that tetraploidy of this family was found in Asia and not in North America [16].

Nutrition

The Chinese high-fin banded shark actively collects food from the floor and seems to need 30 minutes to complete one dimension [17]. Chinese high-fin banded shark is an omnivorous species that is bred in China due to its delicious meat and uniform growth. These resources are difficult to store and easily reduce water quality and even spread diseases [18]. It is important to know the sources and principles of fish nutrition in their impact on various factors such as growth, productivity, survival and fertility, as well as providing alternative or complementary methods and food sources. Some important sources of nutrition will be listed.

Phosphorus

Phosphorus is an important component of the internal skeleton of fish, with more than one-third found in phospholipids, nucleic acids, cell membranes, and energy-rich compounds [19]. Although fish have the ability to absorb minerals from water [20], food is the main source of phosphorus due to its low concentration in salt and fresh water. Analyzes have shown that the minimum amount of phosphorus for optimal growth of this species of fish is 7.4 grams per kilogram of body mass [21]

Protein

Knowing the amount of protein needed is a necessity for formulating balanced diets. So far, only a few studies have been performed on Chinese suckling infants. Information [22,23] about the protein required in the diet of this fish is scarce. According to a study, about 460 grams per kilogram of body weight of protein fish in a diet Food can be the optimal level for the maximum growth of M. asiaticus [24]. In general, one of the main components of fish mixed foods is fish meal or fish meal, although recently the price of fish meal has increased sharply with a decrease in resources [25-28]. Therefore, the need to look for sustainable alternatives is felt. For decades, aquatic nutritionists have evaluated plant protein sources to replace some or all of fishmeal [29-32]. One of these alternatives is Soybean meal (SBM). According to research, fermented soybean meal (FSBM) is a plant protein suitable for replacing up to 35% of the protein in fish diet without significant adverse effects on growth, survival, FCR, PER and body composition [33].

Vitamin C

Vitamin C, also known as L-ascorbic acid, is a powerful reducing agent that facilitates iron absorption [34]. Vitamin C is also a cofactor in the hydroxylation of proline and lysine to hydroxyproline and hydroxy-lysine [35]. Research has shown that growth factors for nutritional survival and nutritional productivity are improved by adding vitamin C to food at a maximum of 2.125 mg per kilogram of fish body weight. Also, the minimum amount of vitamin C for optimal growth of M. asiaticus is 84.6 g/kg body weight of fish [36].

Conclusion

The importance and danger of this species makes it a species of interest. The importance of nutrition and disease prevention and policy for the population of this fish is well known. It is also noteworthy that this fish is a creature to follow the evolutionary path.

References

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  13. Miller RR (1959) 0rigin and affinities of the fresh Water fish fauna of western North America. 187-222 in C. L. Hubbs, ed. Zoogeography. Ameri- Can Assoc. For the Advancement of Science.
  14. Beamish RJ, Tsuyuki H (2011) A biochemical And cytological study of the longnose sucker (Calostomus calostomus) and large and dwarf forms of the white sucker. J Fish Res Bd Can 28: 1745-1748.
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  16. Ueno K, Nagase A, Yun-Juan Ye (1988) Tetraploid Origin of the Karyotype of the Asian sucker, Myxocyprinus asiaticus. Japanese Journal of Ichthyology 34: 512-514.
  17. Yuan YC, Gong SY, Yang HJ, Lin YC, Yu DH, et al. (2011) Effects of supplementation of crstalline or coated lysine and/or methionine on growth performance and feed utilization of the Chinese sucker, Myxocyprinus asiaticus. Aquaculture 316: 31-36.
  18. Yuan YC, Gong SY, Yang HJ, Lin YC, Yu DH, et al. (2010) Apparent digestibility of selected feed ingredients for Chinese sucker, Myxocyprinus asiaticus. Aquaculture 306: 238-243.
  19. Vajargah MF (2021) A Review on the Effects of Heavy Metals on Aquatic Animals. J Biomed Res Environ Sci 2: 865-869.
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  21. Yuan YC, Yang HJ, Gong SY, Luo Z, Yu DH, et al. (2011) Dietary phosphorus requirement of juvenile Chinese sucker, Myxocyprinus asiaticus. Aquaculture Nutrition 17: 159-169.
  22. Wan Q, Lai NY, Liu YB, Shen BP, Sun WX, et al. (2006) Study on intensive cultivation of Myxocynricus asiaticus fingerling fed with mixed feed. Anhui Agri. Sci 18: 4605-4606.
  23. Sattari M, Bibak M, Bakhshalizadeh S, Forouhar Vajargah M (2020) Element accumulations in liver and kidney tissues of some bony fish species in the Southwest Caspian Sea. Journal of Cell and Molecular Research 12: 33-40.
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  25. Forouhar Vajargah M, Imanpoor MR, Shabani A, Hedayati A, Faggio C (2019) Effect of long‐term exposure of silver nanoparticles on growth indices, hematological and biochemical parameters and gonad histology of male goldfish (Carassius auratus gibelio). Microscopy research and technique 82: 1224-1230. [crossref]
  26. Forster IP, Dominy W, Smiley S, Bechtel P, Hardy R, et al. (2004) Recent advances in utilization of fish by-prod-Ucts in aquaculture feeds. Abstracts Book. Aquaculture 1–5 Honolulu, Hawaii, USA.
  27. Samocha T, Davis DA, Saoud IP, DeBault K (2004) Sub-Stitution of fish meal by co-extruded soybean poultry by-product Meal in practical diets for the Pacific white shrimp, Litopenaeus Vannamei. Aquaculture 231: 197-203.
  28. Kristofersson D, Anderson JL (2006) is there a relationship between fisheries and farming Interdependence of fisheries, ani-mal production and aquaculture. Marine Policy 30: 721-725.
  29. Vajargah MF, Yalsuyi AM, Hedayati A (2018) Effects of dietary Kemin multi-enzyme on survival rate of common carp (Cyprinus carpio) exposed to abamectin. Iranian J of Marine Sciences 17: 564-572.
  30. Montajami S, Vajargah MF, Hajiahmadyan M, Zarandeh HAS, Mirzaie FS, et al. (2012) ASSESSMENT OF THE EFFECTS OF FEEDING FREQUENCY ON GROWTH PERFORMANCE AND SURVIVAL RATE OF TEXAS CICHLID LARVAE (CYANOGUTTATUS HERICHTHYS). J of Fisheries International 7: 51-54.
  31. Hajiahmadian M, Vajargah MF, Farsani HG, Chorchi MM (2012) Effect of Spirulina platensis meal as feed additive on growth performance and survival rate in golden barb fish, Punius gelius (Hamilton, 1822). Journal of Fisheries International 7: 61-64.
  32. Montajami S, Hajiahmadyan M, Forouhar Vajargah M, Hosseini Zarandeh AS, Shirood Mirzaie F, et al. (2012) Effect of symbiotic (Biomin imbo) on growth performance and survival rate of Texas cichlid (Herichthys cyanoguttatus) larvae. Global Veterinaria 9: 358-361.
  33. Yuan YC, Lin YC, Yang HJ, Gong Y, Gong SY, et al. (2012) Evaluation of fermented soybean meal in the practical diets for juvenile Chinese sucke, Myxocyprinus asiaticus. Aquaculture Nutrition 19: 74-83.
  34. Hsu T, Shiau S (1998) Comparison of vitamin C require-Ment for maximum growth of grass shrimp, Penaeus mon-Odon, with L-ascorbyl-2-monophosphate-Na and L-ascorbyl-2-monophosphate-Mg. Aquaculture 163: 203-213.
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fig 1

A Breast Pump with a Compression Component is the Breast Pump of the Future

DOI: 10.31038/IGOJ.2021441

Introduction

Breastfeeding, due to its nutritional and immunological aspects, is the best source of food for the newborn [1]. In situation where is not possible to breastfeed a baby, for example, where the mother has returned to work or is otherwise temporarily separated from her baby, it is necessary for her to express breast milk for storage period of separation using a breast pump. Also, if an infant is unable to effectively draw out the milk, for example, due to premature birth, illness, or underdeveloped nursing reflex, it may be necessary to express the milk from the mother’s breast using a breast pump [2]. To achieve lactation success before a baby’s suckling can ensure the effective extraction of milk, breast pumps must meet specific physiological and mechanical requirements. In particular, breast pumps:1) must effectively stimulate the mechanoreceptors in areola to promote maternal secretion and milk-ejection reflex, 2) must effectively remove milk from the breast, at the same time, pumping should not be painful or lead to damage to the nipples and areola 3) should remove high quality milk.

It should be noted here that milk excretion by the baby is studied in detail [1,3-5]. It is shown that the baby, creating a pulsating vacuum in the mouth, additionally performs mechanical compression of the areolar region of the breast with gums and tongue. However, during the operation of the vacuum breast pump, these mechanical effects on the nipple-areolar region of the mammary gland are not used, and until recently there was no experimental data on the role of such compression in the process of milk excretion. Based on the assumption that the mechanical compression plays an important role in the milk excretion process, a breast pump has been developed that performs mechanical squeezing of the areolar region during milk excretion, along with exposure to pulsed vacuum (the device was called “Lactopuls”). Currently, a number of important advantages of the Lactopuls apparatus over modern vacuum breast pumps have been proved. These data are presented in this article.

Materials and Methods

Thirty lactating women 25-34 years old, 5-8 weeks lactation who volunteered to be included in this study were examined. Six of them were primiparous breastfeeding mothers and three were multiparous mothers. All infants were born in term. The informed consent of the women was obtained according to the Declaration of Helsinki.

Breast Pump with Compression Stimuli

Just like vacuum electric breast pumps, the breast pump “Lactopuls” consists of a control unit with a compressor and a removable funnel-shaped cup that is placed on the breast of a woman. Schematically, the removable funnel-shaped cup is shown in Figure 1A. It consists of conical and cylindrical part (3). However, unlike vacuum breast pumps, the cup is made an elastic material, such as silicone rubber. The cone part is placed on the breast (1). On two opposite external sides, rigid plates (4) are contact with the elastic cone, which are fixed at the front ends of the levers (5). The rear parts of the levers are connected to the movable membranes (9) of the pneumatic piston (8), to which excessive pressure pulse are supplied from control unit through the pneumatic hoses (10). The pneumatic piston is placed in the rigid body (7), to which a cylindrical part of the cup is attached on the outside on special movable ledge (6). The pump works as follows. Vacuum and compression (overpressure) stimuli are applied in certain sequence to the removable funnel-shaped cup from the control unit. Just as when milk is excreted by a child, at the beginning a vacuum acts on the mammary gland, which enters the cup via a pneumatic hose and the areola of the breast (2) begins to stretch, stimulating the skin stretching receptors. At the same time, under influence vacuum, milk begins to flow out of the ducts. After the same amount vacuum inside the elastic cone tube reaches the maximum value, positive pressure stimuli are applied to the piston. The movement of the piston membrane is transmitted to the levers (Figure 1B), and the rigid plates compress the conical part cup and areola, area where milk located. It is important to note here, that just as a child, the amplitude of compression and vacuum stimuli can independently regulate.

fig 1

Figure 1: Action of the compression and vacuum component in the milk breast pump.
A. Positive pressure pulse is not turned on. B. Positive pressure pulse is on.
1- mammary gland, 2- breast areola, 3-elastic cone, 4- rigid plates, 5- levers, 6- movable ledge, 7-solid body, 8- pneumatic pistons, 9- pneumatic pistons membranes, 10- pneumatic hose.

Recording the Intraglandular Pressure

In 11 women, the intraglandular pressure was recorded during expressing in the breast not being expressed. The breast was washed with anticeptic solution and one of the ducts was dilated with a special duct dilator. A metallic catheter with an outside diameter 0.5mm was introduced into the duct as far as 2 cm approximately. The catheter was connected to the pressure gauge by means of polyethylene tube 0.7mm in diameter. Before measuring, the whole system was filled with sterile saline (0.9% NaCl) solution. The electric signal from the pressure gauge was conveyed to the amplifier and then to polygraph H-338 (Russia).

Milk Analysis of Macronutrients

Milk analysis of macronutrients (fat, proteins, carbohydrates) and energy value in the samples was performed 1-1.5 hours after milk ejection with a mid-infrared human analyzer Miris AB Uppsala, Sweden.

Statistical Analуsis

Student s t-test was used for statistical analysis. In milk analysis experiments statistical analуsis was performed using test two-way ANOVA. Large differences in nutrient concentrations in milk were found in women. Therefore, data for each woman were normalized relative to the concentration value of the first sample ejected from the breast by vacuum stimuli. Statistical significance was set as p<0.05

Results

Breast Pumps with Compression Component Effectively Stimulate the Mechanoreceptors in Areola to Promote Maternal Milk-ejection Reflex

The normal functioning of the breast pump «Lactopuls» that is when vacuum and compression stimuli are applied to the nipple and areola resulted in milk flow in all the women. This could be clearly observed. Once the funnel attachment of the breast pump was applied to the breast milk began drip from the other breast after 0.5-1 min. Where the other breast was catheterized, an increase in intraglandular pressure occurred (Figure 2A). It should be noted that throughout the experiment visual observation revealed the pulsed character of milk removal in women. The periods of the absence of milk removal could be as long as 0.5-1 min. Yet graphically the pulsed character of milk removal was evident only when recording the milk volume with intervals of less than 1 min (Figure 2B). It was thought interesting to compare the pulsatory character of milk removal with intraglandular pressure. On comparing the graph Figure 2A and 2B it can be seen that the maximum milk removal rate coincides with the intraglandular pressure. Switching off the compression stimuli changed the dynamics of milk expression. The influence on milk removal of switching off the compression stimuli in women, who had difficulty expressing breast milk manually, was especially noticeable. The data from one woman presented in Figure 3 serves as an example. In the normal mode of the breast pump, that is when vacuum and compression stimuli are applied to the nipple and areola, the first peak of milk removal was reached in approximately 1.5 min. During expression 6 peaks of milk flow were recorded in one woman (Figure 3A). When the compression stimuli were switched off milk did not appear for 4 min (Figure 3B(V)).When compression was again switched on milk removal began in 0.5 min (Figure 3B(PV)), the maximum rate of the first peak reached 16 ml/ 0.5 min, as it had been in the first case (Figure 3A).

fig 2

Figure 2: The change in intramammary pressure (A) and the rate of milk removal (B) Pressure in mm Hg, time in min.

fig 3

Figure 3: The change in volume of milk removed under different operating conditions of the breast pump. For A and B, the rate of milk removal ml/ 0.5 min; time in min. In each graph the horizontal line shows the period of milk removal by means of the breast pump. PV, breast pump action in normal mode with both compression and vacuum stimuli; V, breast pump action with compression stimuli switched off (vacuum only).

Compression stimuli increase the efficacy of the breast pump which is not only due to the effective formation milk ejection reflex, but also directly to an additional squeezing the milk from the breast. At the same time, breast pump does not cause pain and does not damage the nipple and the areola of the breast.

Mechanical stimulation of mechanoreceptors of the areola releases oxytocin from the central nervous system into the bloodstream, which produces periodic increases in the intraductal mammary pressure. These serve to increase the rate of milk ejection (Figure 2). Evidently it is difficult to comparatively evaluate the effects of vacuum and vacuum–compression stimuli in milk ejection. We work out the method that allows us to reveal the difference in volume of milk expressed by applying purely vacuum and by applying vacuum-compression stimuli in relation to changes in intraductal pressure. This method will allow us to assess how the compressive force imposed on the mammary glands directly correlates with the volume of expressed milk.

According to the method, the nipple and areola were alternately affected by short (4s) series of 0.5 s vacuum stimuli with compression pulse of 0.27 s. The amplitude of the vacuum pulses was within -120 and -140 mm Hg, i.e. less than the maximum comfortable vacuum amplitude of -191,3 ± 6,5 mm Hg [6]. Accordingly, the milk ejected to various milk collectors: (a) when pumping together with vacuum and compression stimuli and (b) when pumping only with vacuum stimuli (Figure 4A).

When pumping milk alternatively with vacuum pulses and vacuum with compression pulse, the volume of milk expressed together with the help of vacuum and compression exceeded the amount of milk expressed single vacuum. However, the difference in volume varied in different patients in the range of 10%-46%. On average , as follows from histograms (Figure 4B), the amount milk of expressed by one vacuum was 40.5±5%, and the vacuum with compression stimuli was 59,5±5%.

fig 4

Figure 4: Influence of compression components on the amount milk removal.
A. Scheme of effects of vacuum and compressive stimuli on the mammary gland. (a) Simultaneous action of vacuum and compression stimuli, the milk enters the milk collectors (a); (b) action of vacuum stimuli, milk enters the milk collector (b). Ordinate, P (positive pressure), V (vacuum); abscissa, time (s). (B) The amount of milk as a percentage of the total volume of milk removal together by means of vacuum and compression pulses and by means of vacuum only (B). The ordinate: the amount of milk as percentage.

In addition, according to Figure 5B, the volume of expressed milk equals40.5-1.03% at vacuum milking and 59.5-1.07% at vacuum–compression milking. In this series of experiments, we additionally conducted comparative experiments on the expression milk of breast pump “Lactopuls” and one of the best vacuum breast pump Medela Symphony. It was found that the average values of the volume milk expressed with “Lactopuls” were 14% higher, than volume of milk expressed with «Medela Symphony».

Milk ejection with vacuum and compression stimulus in breast pump increases amount of fat and protein in breast milk.

During observations among women, marked variations were found in the amount of milk ejected and in the concentration of milk nutrients studied. At the same time, the dynamics of nutrient concentrations in the process of milk ejection did not depend on the mode of operation of the apparatus and was similar for all women. Figure 5А shows graphs of changes in fat concentrations as well as the protein of milk (B) in 10 ml samples during the ejection milk during the whole session of milk ejection. The largest changes in milk samples were observed in fat concentration (Figure 5A). The fat content in milk increased in each subsequent sample and in the latter samples exceed its content in the initial samples by 2-3,5 times. The total amount of ejected fat was about 25% more when milk ejected by vacuum with compression, than when milk ejected only by vacuum. When determining the protein concentration in milk samples, an increase in its concentration was also found during milk ejection, but on 10-20% (Figure 5B). The increase in protein concentration occurred evenly during the entire ejection time. In contrast to the dynamics of fat and protein concentrations, the concentration of carbohydrates did not change in all women during of the milk ejection (Figure 5C).

The energy of milk is determined by the content of fat, protein, carbohydrates. It is easy to note that the graphs of changes in the energy value of milk (Figure 5D) have a great resemblance to the graphs of changes in the fat content of milk (Figure 5A).

fig 5(1)

fig 5(2)

Figure 5: Change in the amount fat (A), protein (B), carbohydrates (C), and energy value (D) in woman in samples throughout the milk ejection session.

Discussion

Рresented experimental material shows that breast pump with compression component more effectively removes milk, and the quality of milk is also higher than milk extracted using vacuum. It can be assumed that one of the main reasons is the effective stimulation of the milk ejection reflex in a woman due to more adequate stimulation of the areola mechanoreceptors and, accordingly, an increase in oxytocin output [1]. An increase in the concentration of oxytocin will cause a more intensive сontraction of the myoepithelial cells of the alveoli, which will “squeeze” more milk from the alveoli, including more caloric, i.e. with an increased fat and protein content, “hind milk”. In addition to increasing the rate of milk excretion by increasing the pressure of milk in the ductal system of the gland (Figures 2 and 3) compression stimuli increase milk volume by compressing the expanded sections of the milk: “milk sinuses” located in the area of the areola mammary gland.

Observation during pumping indicate that the difference in the volume of expressed milk depend on anatomical characteristics of the breast. According to ultrasound studies, 6-14 milks ducts are suitable for the nipple, which at a distance of 8-9 mm from the base of the nipple have a maximum diameter of 1-5 mm (“milk sinuses”) [7]. However, when the milk ducts pass into the milk ducts of the nipple, they narrow by five to ten times [8]. Moreover, the diameter of the milk ducts along the length of the nipple varies. So, when approaching the tip of the nipple (1mm from the tip), the diameter of the ducts is the smallest and about 0.1mm. To the outlet, the ducts in most cases expand in the form of funnel with an increase in diameter by 1,5-3 times. When moving deep into the nipple (3.5-4mm from the tip) in different women, the diameter of the ducts increases and reaches 0.4-0.8 mm. Then the diameter decreases again to an average of 0.4mm [9,10]. Since the resistance to the movement of liquid in the tube is inversely proportional to the area of its cross-section, nipples with thin milk ducts will inhibit the output of milk to a greater extent, and in this case, the mammary glands are classified as “tight”. In addition, in the first 4 days after birth, when colostrum is present in the ductal system, the viscosity of which is higher than that of transitional and mature milk, difficulties with milk excretion are aggravated. To overcome the “tightness” of the gland, it is necessary to increase the pressure difference between the environment and the milk inside the milk ducts, for example, to increase the vacuum. However, as clinical studies have shown, high vacuum causes pain in the nipple, which inhibits the formation of the milk ejection reflex and consequently slows down the milk output. The child gets out of position by adding compression impulses to the vacuum stimuli so that the overall pressure difference between the environment and the milk inside the milk ducts increases markedly. In particular, when removing milk, the child can create a maximum vacuum of 197±10 mm Hg. The maximum amplitude of the compression pulses could reach 70 mm Hg. Thus, when added together, the total pressure difference will be about 270 mm Hg, which will significantly increase the efficiency of removing milk from the “tight” gland. At the same time, the woman will not experience discomfort, since when the child creates vacuum and compression stimuli, the values of vacuum and compression for the woman will be comfortable. The combination of vacuum and compression stimuli in the executive mechanism of the pump was also effective. Surveys have shown that compression stimuli against the background of vacuum stimuli -120, -140 mmHg can increase the output of milk from the gland by 46%. Compression stimuli made a particularly noticeable contribution when pumping “tight” mammary glands and mammary glands in the first days of lactation filled with colostrum. Here it is interesting to note the results of surveys of Morton J [11]. In this work, against the background of sucking milk using a Medela Symphony breast pump, the fingers were additionally compressed in the area of the breast in front of the edge of the hard cup. As a result of the combination of vacuum and compression, the amount of milk produced increased significantly (up to 48%). This method was especially effective when removing colostrum from the gland.

However, in the case of equal volume of milk expressed by vacuum and vacuum with compression pulses, examinations showed that the patient’s breast was very “light”. Through the transparent cover, it was clearly visible that the milk began to be released from the breast in trickles already under the influence of a vacuum of 60-70 mm Hg, i.e. half the established amount. Moreover, the milk as a result of the reflex of milk excretion began to drip quite intensively from the neighboring breast. In this case, the milk ducts in the nipple probably had a maximum diameter (0.6-0.8 mm) and a vacuum stimulus, before the compressing stimulus took effect, removed most of the milk. In this regard, it is interesting to note the results of a study of the process of removing milk from bottles, the nipples of which have holes for the exit of milk of different diameters (Eishima, 1991). It was discovered that the child had the greatest compressive effect tongue and gums on the nipples without holes or nipples with a very small diameter exit hole, which when you turn the bottle in vertical position water is dripping at a speed of 0.04 ml/h. If the whole diameter was increased so that water dripped at a rate of 0.1ml/sec, the nipple compression was significantly weakened.

Here it should also be noted that when the milk was removed by a breast pump with a compression component, there was no compaction and puffiness of the areolar area of the breast. Massage of the areola with compressive stimuli as the milk is withdrawn, as well as in the case of milk withdrawal by a child, did not allow for compaction and puffiness of the areola. Therefore, the use of the breast pump in clinical practice with a compression component was effective in eliminating postpartum breast engorgement, as well as in the case of elimination of edema in lactostases. Thus, the use of milk-removing devices and especially devices with a compression component is an effective non-drug means of increasing the productivity of lactating women and increasing their lactation period.

References

  1. Alekseev NP (2019) Physiology of human female lactation. Springer
  2. Fewtrell MS, Lucas P, Collier S, Singhal A, Ahluwalia JS, et al. (2001) Randomized trial comparing the efficacy of a novel manual breast pump with a standard electric breast pump in mothers who delivered preterm infants. Pediatrics 107: 1291-1297. [crossref]
  3. Ardran GM, Kemp FH, Lind J (1958) A сineradiographic study of breast feeding. Br J Radiol 31: 156-162. [crossref]
  4. Mizuno K, Ueda A (2001) Development of sucking behavior in infants with Down’s syndrome. Acta Paediatr 90: 1384-1388. [crossref]
  5. Elad D, Kozlovsky P, Blum O, Laine AF, Po MJ, et al. (2014) Biomechanics of milk extraction during breast-feeding. Proc Natl Acad Sci USA 111: 5230-5235. [crossref]
  6. Mitoulas LR, Lai CT, Gurrin LC, Larsson M, Hartmann PE (2002) Effect of vacuum profile on breast milk expression using an electric breast pump. J Hum Lact 18: 353-360. [crossref]
  7. Prime DK, Geddes DT, Spatz DL, Robert M, Trengove NJ, et al. (2009) Using milk flow rate to investigate milk ejection in the left and right breasts during simultaneous breast expression in women. Int Breastfeed J 4: 1-10. [crossref]
  8. Ramsay DT, Kent JC, Hartmann RA, Hartmann PE (2005) Anatomy of the lactating human breast redefined with ultrasound imaging. J Anat 206: 525-534. [crossref]
  9. Going JJ, Mohun TJ (2006) Human breast duct anatomy, the ‘sick lobe’ hypothesis and intraductal approaches to breast cancer. Breast Cancer Res Treat 97: 285-289. [crossref]
  10. Rusby JE, Brachtel EF, Michaelson JS, Koerner FC, Smith BL (2007). Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications. Breast Cancer Res Treat 106: 171-179. [crossref]
  11. Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, et al. (2009) Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 29: 757-764. [crossref]
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Phoenix Tree, Phoenix and Empress: Empress Historical-Cultural Symbol of Phoenix Tree and its Good Environmental Civilized Value

DOI: 10.31038/AFS.2021342

Abstract

This paper is intended to analyze the interrelation, mutual influence and integration of phoenix tree, phoenix and empress in ecological and cultural terms. The study indicates the historical-cultural symbolical meaning of Empress Wu of phoenix tree, and the ecological value. Empress Wu is the incarnation of dragon, rebirth of Maitreya Buddha with godship. From aspect of theology, phoenix stays at phoenix tree that is a myth by means of phoenix tree; phoenix and dragon keep abreast, phoenix represents outstanding woman, and Empress Wu is the incarnation of phoenix (super holy bird). Phoenix liked to stay on phoenix tree (super sacred tree), therefore, phoenix tree represents the body of empress. In Buddhism, phoenix tree’s imagery being the sacred tree of Chinese Buddhism is its feature, which is formed when the tree is cultivated in religious temple. Empress Wu is a human with humanity. In forest culture, imagery of phoenix tree is of aesthetic culture which represents pure love subjective intention by means of phoenix tree in gardens planting of past dynasties and composition of poetry. Love imagery of phoenix tree and phoenix symbolizes human emotion of Empress Wu. Lofty imagery of phoenix tree symbolizes the only one empress in China. That falling leaves of phoenix tree shows autumn comes symbolized Empress Wu lost her Kingship and became queen for the rest of her life. Aesthetic cultural connotation, consisting of nobleness and hope of phoenix and misery and sad of phoenix tree, symbolized people’s comment to Empress Wu in the past one thousand and three hundred years. Ecological value of phoenix imagery: nine holy birds which perch at bronze divine trees of Sanxingdui, and Sunbird of the Jinsha Site gives an impression that golden bird carries the sun to soar in the universe; in human’s mental concept, phoenix tree symbolizes habitat for humanity of ecological civilization, and phoenix symbolizes human’s dream of flying. Phoenix likes to stay on phoenix tree, which symbolizes harmonious civilization of human and human’s earnest hope for good life.

Keywords

Phoenix tree; Phoenix; Sacred tree of Chinese Buddhism; Empress culture

Phoenix tree and phoenix culture are well-known in China. It is of profound practical significance to associate the phoenix tree and phoenix with Empress Wu, the only empress in Chinese history, and thus to study the empress culture. The composite image of phoenix tree and phoenix contains Empress Wu’s divinity, emperor and female humanity as a “the incarnation of dragon” and “rebirth of Maitreya Buddha with godship”, full of mystery, solemnity, humanity and historical and cultural sense. Phoenix tree and phoenix culture and the empress culture are integrated with each other, so that the phoenix tree blends into people’s subjective sentiments and aesthetic ideals of Empress Wu [1], and becomes an aesthetic image to examine the empress culture.

Phoenix Tree, Phoenix and the Empress

The Phoenix Tree

The phoenix tree, also known as Qingtong, Chinese phoenix tree, Biwu, Qingyu, and Tingwu, belongs to the deciduous tree of the Sycamonaceae family. “The fertile soil is suitable for planting phoenix trees.” Phoenix trees have long become garden ornamental trees and important greening trees in China. They are suitable for lawns, courtyards, front houses, slopes, roadsides, solitary planting around lakes or cluster planting. The phoenix tree, collocated with palm, bamboo, plantain, etc. could convey a sense of harmony. “A tranquil house may have phoenix trees planted in the front, and green bamboos at the back. The front eave provides space to take a leisure walk under it. Covert windows are set in the north, which are closed in spring and winter to protect the room from wind and rain. While in summer and autumn, they are opened to get the room ventilated. Planting phoenix trees is full of joy: in spring and winter, sunlight fall through the sparse branches, bathing the people sitting against the trunk in the warmth, while in summer and autumn, the dense branches form a canopy for people to seek shade from the scorching sun.” [2] There are extremely abundant scientific culture and poetry creations about the phoenix tree, forming a unique phoenix tree culture [3].

The Phoenix

The oldest phoenix pattern found in China has a history of 7,400 years. Dragon and Phoenix are the two totem systems of the Chinese nation. The ancients used an animal, a plant, or a creature in the nature as a symbol to represent the lineage of a clan or group, and respected it as a patron to worship. Such a symbol is called a “totem”. The phoenix is a totem image evolved from the patron imagined by the ancients. It is said that the Shang tribe among the descendants of the Yellow Emperor used to be the bird totem tribe, and this bird was called the “Phoenix Bird”. The Book of Songs · Song of Shang · Xuan Niao says, “The emperor ordered Xuan Niao (another name of phoenix in ancient times) to come to the world and give birth to Qi, who later established the Shang Dynasty.” The ancestor of the Shang Dynasty, Qi, was born by Xuan Niao, who later established a powerful Shang Dynasty. Xuan Niao is the Phoenix. From the bronzes unearthed in the Shang and Zhou dynasties, we can see the carved phoenix pattern. “The singing phoenix in Qishan mountain heralds a prosperous era of Zhou” “Blowing flute to attract the phoenix.” So the phoenix bird became the holy bird that blessed the people of Zhou. The allusion of “the phoenix sings in Qishan mountain” made the phoenix a symbol of Zhou’s prosperity. This is why there are a lot of phoenix patterns in the bronzes of the Western Zhou Dynasty. There is a sentence in The Book of Songs · Daya, “The phoenix flies to the sky in the wind…The phoenix sings on the high hills, heralding auspiciousness.” It also talks about the allusion about “the phoenix sings in Qishan mountain”. Therefore, in the Western Zhou Dynasty, the phoenix was regarded as a mystical mascot. Later, as the tribes united or annexed each other, various totems were compounded for many times, thereby resulting in totems with strange images such as dragons and phoenixes. The phoenix and the dragon are always inseparable till today. The holy bird, phoenix, is beautiful, auspicious, kind, peaceful, virtuous, and blessing of the nature. For Chinese, worshiping phoenixes is a strong national complex in that the phoenix is a symbol of nobility and dignity.

As the incarnation of the royal woman’s mascot, “Phoenix” was first seen in an allusion. According to the legend, when Yao abdicated to Shun, and Shun abdicated to Yu, all of people celebrated and all the beasts also came to congratulate, including the phoenix. The “Dragon and Phoenix Pattern” painted pottery flask was unearthed at the Yangshao Cultural Site in Beishouling, Baoji, Shaanxi. This shows that both the dragon and the phoenix originated in the Neolithic period, which is seven to eight thousand years ago. The phoenix and the dragon have gradually become a pair in the legend, and they complement each other. The dragon has many changes while the phoenix has good virtues. From the Neolithic Age to the Spring and Autumn and the Warring States Periods when the theory of Yin and Yang and the Five Elements (metal, wood, water, fire and earth, held by the ancients to compose the physical universe) was popular, the phoenix almost appeared as something “yang”. While in the early stages of its formation, the dragon is basically something “yin”. The combination of dragon and phoenix reflects the view of yin and yang of the ancients. During the Warring States Period, a group of patterns that the dragon and phoenix entangle appeared. Later, the dragon symbolized the sun, and the phoenix, which was originally divided into yin and yang, gradually became a representative of yin after being contrast with the dragon. The emperors call themselves dragons, the queens call themselves phoenixes. Throughout the ages, the queen’s appearance has been called “Feng Zi” and “Feng Yi”(that is the posture of phoenix); the crown worn by the queen is called “phoenix clothes with superb power”; the children born are called “the sons of the phoenix”; the edict issued by the queen is called “phoenix edict”; the cart used by the queen is called “fengche” or “fengnian”(that is the cart taken by the phoenix); the pavilion in the imperial palace is called “phoenix pavilion”; in the imperial room, the executive secretariat, which is the closest to the emperor’s central institution in charge of the imperial court, is called “phoenix pool”.

The Empress

Although Empress Wu is a woman, she took the throne successfully. For 1,380 years after her death, she has become the focus of attention and research by later generations. Just like the mausoleum with no inscription, there’re no definite conclusions for her whole life. Hence, a unique historical and cultural phenomenon of the empress was derived.

Empress Wu’s father, Wu Shiyue, run timber business, thereby the family of Wu gained fame and fortune. Later, Wu Shiyue got to know Li Yuan, and followed him closely with his whole heart. After the founding of the Tang Dynasty, he was named the founding earl, and rose to the official ranking of minister of the Ministry of Works [4,5]. Emperor Li Yuan designated Yang, the daughter of a prominent family in the Sui Dynasty, to marry Wu Shiyue. Later, Wu Shiyue was promoted to the governor of Lizhou (now Guangyuan, Sichuan). His wife, Yang, was pregnant with Empress Wu while boating on the Jiangtan Lake. Later, she gave birth to the baby in Lizhou [6]. Empress Wu’s nickname was Yuanhua and Meiniang. When she was born, “the golden phoenix came to congratulate.” Empress Wu entered the imperial palace at the age of 14 as a Cairen(a rank of ladies-in-waiting), and later became Zhaoyi(a kind of concubines of the emperor in ancient China), queen, empress dowager, and eventually became the emperor. She collected a treasure map in Luoshui River and claimed it as a gift given by the God, and described herself as the reincarnation of Maitreya Buddha in Mahamegha Sutra. Relying on the historical condition, specific marriage, and personal talents, Empress Wu wrote a glorious empress history. From the nomination of the queen in 655 AD, to 690 when she enthroned herself emperor, she audited politic affairs behind the curtain (historically known as two emperors in the imperial court) for 35 years. From 690 to 705 AD, Empress Wu changed the dynasty and enthroned herself emperor, ruling for 15 years. During her half-century rule, she was in charge of all over the country, maneuvered among various political groupings. She made the profound achievements that could be on a par with the rule of Zhenguan and lay a solid foundation for the prosperous rule of Kaiyuan [7,8].

The Historical and Cultural Symbol of the Empress of the Phoenix Tree

Phoenix Symbolizes Empress Wu

Phoenix Tree and the Phoenix

Firstly, legend has it that mankind has a dream of flying to the sky, the phoenix bird is the holy bird, and the bronze is the holy tree. The phoenix tree is regarded as a holy tree by the ancients. The bronze holy tree unearthed in Sanxingdui is a holy tree with compound characteristics. Its branches are divided into three layers, and there are 9 holy birds in it. It is just like the situation that “nine suns live on the branches below” (From the Book of Mountains and Seas). At the top of the bronze holy tree that was broken when it was unearthed, it is speculated that there should also be a holy bird symbolizing “a sun on the top branch” (The author believes that “the bronze” pronounces the same with the word “phoenix tree”, the holy bird living in the holy tree is exactly the symbol of the phoenix living in the phoenix tree.).

Secondly, the ancients used the woods of phoenix trees to make the musical instrument. The ancients believed that music was related to the wind and the wind (Feng in Chinese pronunciation) sounds like the word “phoenix” (feng in Chinese pronunciation). Hence, it is believed that the phoenix lives in the phoenix tree.

Thirdly, since the phoenix is a bird, it must be connected with the tree, that is, the phoenix tree. The image of the phoenix is a synthesis of several natural objects. The roc mentioned in ancient books is also a phoenix. The Book of Mountains and Seas says, “There is a bird, shaped like a chicken, with colorful feathers all over its body, and its name is Phoenix.”—The phoenix, the king of birds, governs the birds all over the world. The phoenix trees are luxuriant, densely shaded, and extremely tall, which have accumulated rich cultural connotations. The phoenix knows the rise and fall of a nation, boasts good virtues, and dwells exclusively on phoenix trees, thereby the phoenix trees are regarded as auspicious trees in the past dynasties. The well-off family in history often planted phoenix trees in their yards because the phoenix trees are not only vigorous, but also the symbol of auspiciousness. There is a saying in The Book of Songs that the phoenix tree grows luxuriantly, causing the phoenix to sing. During the Spring and Autumn period, King Wu, Fuchai, built a phoenix garden in the yard. “The phoenix garden is in the Wu Palace. It’s the old garden of King Wu, also named Qinchuan.”(A Wonder and Tangle Wood Tales, Liang Renfang). During the Warring States Period, in Zhuangzi · Waipian · Qiushui, there is “The phoenix sets off from the South Sea and flies to the North Sea. It only inhabits when it encounters phoenix trees. It only eats bamboo and only drinks sweet springs”, which reflects the phoenix does not live with the common birds, and shows the nobleness of the phoenix tree. The Zhou dynasty has been crowned the first place among the dynasties for it lasts 800 years. And the reason for that is also related to the phoenix tree. Shuyu is the younger brother of King Zhou Cheng. One day, Shuyu played with King Cheng. King Cheng cut a leaf of the phoenix tree into the shape of a Jade Tablet and said to Shuyu: “I will give you the seal of Jade Tablet.” Shuyu was happy and told this to Zhou Gong. …Therefore, King Zhou Cheng bestowed Jin as a fief to Shuyu (Springs and Autumns of Master Lü · Zhongyan) The ancient kings valued the phoenix tree, which was called the gentleman of the book. King Zhou Cheng planted the phoenix trees in the courtyard, and cut the leaf and bestowed a fief to his brother [9].

After observation, the author believes that phoenix living in the phoenix tree is a human association of the ecological pictogram of the phoenix tree. The phoenix tree belongs to the terminal panicle. In late June, flowers of phoenix trees appear in temples, royal palaces, parks, courtyards, roadsides, and jungles. They are calm and noble, indisputably beautiful. They are like phoenixes living in the top of the tree, or holy birds flying into the sky, with both spiritual charm and royal temperament, which makes people stunned and respectful. Perhaps this is the original ecological image of “Planting a phoenix tree and attracting the phoenix”!

Phoenix and the Empress

Empress Wu described herself as a phoenix, and was the incarnation of phoenix, so she enthroned herself emperor. There are also many images, myths and legends of Empress Wu as a phoenix. The memorials and cultural customs of later generations also regard her as a phoenix.

  1. From the analysis of natural geomantic omen in Lizhou where Empress Wu was born, the dragon is in the Wulong Mountain and phoenix is in the Phoenix Mountain, and both of them are auspicious. The author observes that the water of the Jialing River flows between the Wulong and Phoenix mountains, through the Wulong Lake, and then joins with the two waters of the Nanhe River. The whole view is just like the picture of Yin-Yang Fishes, which integrates the spirit of heaven and earth, and presents a magical golden triangle, namely the beautiful ancient city of Lizhou. When the phoenix flew out of here, it was named Phoenix Mountain.
  2. From the legend that Empress Wu was born “from the reincarnation of the phoenix”, this story was first spread in Empress Wu’s hometown, Lizhou (Guangyuan), and was included in writings by some literati after the Mid-Tang Dynasty. The following is about the legend: At that time, his parents and some people were having fun on the river boating. Suddenly, a dragon jumped into the sky from the Xishan Mountain, rushed straight to their boat, and flew around the ship and then flew to Chang’an. After that, Ms. Yang became pregnant. The legend has been passed down to today. After Li Shangyin, a poet of the late Tang Dynasty, came to Lizhou in 851 AD, he visited the place where Ms. Yang was pregnant and wrote the poem “Lizhou Jiangtan Lake” and noted that it was “the place where Ms. Yang was pregnant with Empress Wu”. The poem vividly depicts the scene of the dragon and man mingling and becoming pregnant with Empress Wu. Empress Wu was deeply affectionate with her hometown. So Wu’nu Mountain was changed into Wulong Mountain, and Jiangtan Lake into Wulong Lake.
  3. Yuan Tiangang made an astrology. Yuan Tiangang, a master of astrology, concluded that there would be the emperor of the new dynasty born in Langzhong. Therefore, he cut into the mountain at the dragon neck of Panlong Mountain where the image of the dragon was formed, so as to stop this omen. It is said that after the dragon neck was sawed off, the omen went to Guangyuan. In the early years of the Tang Dynasty, he went south from the capital of Chang’an to Shu (Sichuan), and arrived at Lizhou City on the day of Dragon Boat Festival. Suddenly, a dragon sprang from the depths of the river and flew towards the Xishan Mountain; at the same time, a phoenix sang on the top of the Dongshan Mountain, and then flew to the north. Yuan Tiangang said, “This is called the prosperity brought by the dragon and the phoenix, and there must be an important man born here.” In the first month of the next year, the wife of Governor Wu gave birth to a girl. Governor Wu asked Yuan Tiangang to look up the physiognomy for her. At that time, Empress Wu was wearing a boy’s costume and held by a wet nurse. After looking at her for a while, Yuan Tiangang exclaimed, “The center of the frontal bone shows some emperor’s temperament. Her eyes are similar to those of a dragon and the neck is like that of a phoenix, which is the look of the most distinguished person.” When he learned that it was a girl, he exclaimed and asserted, “This girl may become the ruler of the country!”
  4. Yuan Tiangang met a phoenix at Chaotian Pass. On the Double Ninth Festival, Yuan Tiangang saw a woman with a red ribbon fluttering around her transformed into a colorful phoenix surrounded by nine golden dragons, and the colorful phoenix changed into an emperor wearing a golden crown and holding an imperial jade seal. Astonished, Yuan Tiangang fallen off and shouted, “Your Majesty, Heaven’s order is hard to violate!” It turns out that it is Meiniang on the plank road. Decades later, Empress Wu enthroned herself on the Double Ninth Festival and changed the Tang Dynasty to Zhou Dynasty, and the reign title was “Tianshou”.
  5. The imagination of Empress Wu when she entered the imperial palace for the second time. When Empress Wu entered the palace for the second time, she seemed to see a colorful phoenix singing and there were other birds singing around the phoenix. So being the empress in the palace became her goal.
  6. Empress Wu’s calligraphy is “Feibai calligraphy with phoenix figure” [7]. She used to be “Wu Zhaoyi”. Her mother Yang’s Shun Mausoleum is called “Wangfengtai”, and its mausoleum is called “Wangfengtai Stele” in history.
  7. Empress Wu was the queen first, then the empress dowager, and finally took the throne. She referred to herself as the phoenix. The empress dowager met the petition team that supported her as the emperor in the gate tower. According to legend, something auspicious was observed. Someone saw a phoenix flying out of Mingtang and landing on the phoenix tree on the Suzhengtai (the supervisory agency in Tang Dynasty) of Shangyang Palace in Luoyang. Empress Wu hurriedly led the crowd to Mingtang and watched this scene. The phoenix flew southeast once it saw Empress Wu. But the rosefinches gathered in the hall, dancing for a long time and refused to leave…. Seeing this, a minister immediately knelt down, and explained to Empress Wu, “The phoenix symbolizes you, and these rosefinches just represent us. It flies to the Suzhengtai and leaves as soon as seeing you, which is to imply that you should be enthroned. If you still do not take the throne, it will go against the will of God, the rosefinches will not leave, and we will kneel down forever!” Finally, Empress Wu conformed to the so-called will of God. On September 9th, 690, Wearing the imperial robe, she boarded the Zetian Gate Tower and announced the start of the enthronement ceremony. Later, she ordered an amnesty for the country. And rosefinches flew away as expected [10-12]. The model that a phoenix controls nine dragons in Mingtang symbolizes her Wu Zhou regime, which is exactly the portrayal of Empress Wu.

Phoenix Tree and the Empress

Guangyuan is the birthplace of Empress Wu where verdant phoenix trees are widely planted. The phoenix tree contains Empress Wu’s nostalgia complex. 1,380 years ago, the story from Mrs. Yang’s “Being Pregnant on the Jiangtan Lake” to “Golden Phoenix Brings Good Fortune” and “Paranormal Things Echo” took place here. From the standpoint of historical materialism, myths and legends are spread by later generations. They describe that Empress Wu took the throne as “the unity of Heaven and Humanity”. It is this legendary and paranormal story that makes this place fascinating. The phoenix brings auspiciousness and peace and Empress Wu brings safe and sound. Although the phoenix had gone, today we can still see the phoenix trees in the Five Buddha Towers in Huangze Temple in Guangyuan where Mrs. Yang was pregnant with Empress Wu. The phoenix trees on the Phoenix Mountain are verdant and tall, with legends of immortality. Based on Empress Wu’s nostalgia complex, the phoenix tree in Guangyuan embodies the profound historical and cultural implication of the empress.

Phoenix Tree Symbolizes the Body of the Empress as a Sacred Tree of Buddhism

Phoenix Tree—Sacred Tree of Chinese Buddhism, Phoenix—Chinese Buddhist Bird

Phoenix tree becomes the sacred tree of Chinese Buddhism because Chinese Buddhist disciples have chosen this tree, which adapts to the local climate and has many similarities with the bodhi (“pu ti” in Pinyin) tree, to replace the bodhi tree.

According to history, in 502 AD, the monk Zhiyue Sanzang brought the bodhi tree back from Xizhu (India) and planted it in Guangzhou. Real bodhi trees are only planted in the tropics and subtropics, but in the temperate zone and the vast northern regions of China, it is difficult for bodhi trees to survive the winter [13]. In China, only the south and southeast coastal areas are suitable for growth. Therefore, in history, Chinese Buddhist disciples had to choose some tree species that could adapt to the local climate instead of bodhi trees. The phoenix tree is tall and straight with big and green leaves and deep shade. It has been widely planted in various provinces and regions in China for more than 2,000 years, so it has become the best choice for the replacement.

On the other hand, because the phoenix tree has many similarities with the bodhi tree, so it becomes one of the sacred trees of Chinese Buddhism with the ginkgo and horse chestnut trees. First of all the similar religious connotations of the phoenix tree and the bodhi tree. “Pu ti” is the transliteration of the ancient Hindi language “Bodhi”, which means enlightenment and wisdom. In plant taxonomy, the Latin name of bodhi tree is “Ficus religiosa”, which means sacred religion. The phoenix tree also has the meaning of nobility and enlightenment. Second, the temporal and spatial distribution. Bodhi trees are widely planted in jungle temples in India, Sri Lanka and Myanmar. Devout Buddhists regard them as sacred trees and admire them very much. Phoenix trees are also widely distributed in China’s courtyards, palaces and jungle temples, and are regarded as sacred and auspicious trees. Third, the individual characteristics. The bodhi tree is a tall tree with smooth or slightly angled bark. The crown is round or obovate, and the ground was covered by the luxuriant branches and leaves. The leaf base is heart-shaped, ark green, with clear net-like veins called “Bodhi yarn”, which is regarded as a sacred tree. The phoenix tree is a tall tree with the green bark, the luxuriant branches, and the round crown. The petiole is nearly the same length as the leaf, the broad leaf is like a lotus, and the heart-shaped leaf base is like the heart of the Buddha, which is elegant and delightful. The clear net-like veins are especially like “Bodhi yarn.” Fourth, the plant characteristics. The trunk of bodhi tree and phoenix tree is stout and majestic. The crown is like a pavilion, which is huge. The leaf is heart-shaped, and the surface is smooth. Fifth, the cultivation methods. Both bodhi trees and phoenix trees can be cultivated by cuttings with beautiful appearance and gorgeous leaves. Finally, the similar uses of the two. Their leaves, flowers, and bark can be used in medicine [14].

In ancient Chinese legend, the phoenix was formed by the golden-winged bird of Buddhism. In addition, it is said that the peacock once swallowed the Tathagata, and the Tathagata came out of her back. The Tathagata wanted to kill her, but was discouraged by the Lantern Buddha, saying that since you came out of her body, and you killed her like killing your mother. So the Tathagata forgave the peacock and named her “Mahā-mayūrī-vidyā-rājñī” (means the Great King of the Peacock). This shows that phoenix is also a Buddhist bird in Chinese myths.

Empress Wu — Buddhist Body

  1. Empress Wu has been inextricably bound to Buddhism since she was a child. Her mother, Yang, believed in Buddhism since she was young, and even prayed for her father in Buddhism for more than a decade, so that she didn’t get married until she was in her forties. It is said that when Wu was born, in Zhengjia Mountain (Lotus Village) outside Lizhou, the withered lotus leaves in late autumn regenerated new leaves, and golden lotus blossomed out, and large tracts of beautiful auspiciousness suddenly floated in the sky. Further research shows that Empress Wu’s real name is “Wu Yuanhua” [7]. “Yuanhua” is the meaning of the initial light and unique youth. “Yuanhua” is close to “Mahavairocana”, which reminds people of the Buddhist scene that the sun and the moon are in the sky and the light is so bright.
  2. Wu believed in Buddhism from an early age, facing the ancient Buddha with a lantern, chanting and worshiping. In her youth, she also used to be a nun with “Mingkong” as her Buddhist name. When she was 21, Wu worked as a nun at a Buddhist temple. Her name was “Ming Kong”, which means the Dharma and all void space-directions, which is very similar to the Buddhist situation. This is also the reason why she created the words “Ming and Kong” into the word “Zhao” after she became empress. The meaning of Yuanhua-Ming Kong-Zhao is same.
  3. When she was queen, Wu donated 20,000 pieces of private storage to carve a “Locanabuddha” at Fengxian Temple in Longmen, Luoyang, and personally attended the opening ceremony of it. Locanabuddha totally has the facial features of oriental women and is known as “the most beautiful Buddha in the world”. After research, the “Locanabuddha” of Fengxian Temple is Wu’s appearance when she was in Xianheng for three years (672) and was about 4 years old [7]. The Buddha, also known as “Maha^vairocana”, is a transformation of the Buddha. In China, it is often regarded as “sambhogakaya”, meaning the “prevailing light”. Locana means vast wisdom and prevailing light, and its image is a vivid embodiment of Buddhist teachings and an example of the perfect combination of divinity and human nature.
  4. Wu is the rebirth of Maitreya Buddha. As a politician, Wu is a theist. She highly values Buddhism, not only believing in it, but also making use of it. She was favored, murdered people to obtain the position, coerced into resignation, and served the imperial power with the help of theocracy. The Buddhist theory of reincarnation found the basis for Wu as a female emperor. Under the banner of Maitreya Buddha, the Queen Wu instructed to annotate and promote Dayun Scriptures which said that “the Buddha tells a heavenly maiden named “Jingguang” that she will transform the Bodhisattva, that is, the female will be the king.” In Dayunjing Shu, Feng Xiaobao directly stated that Wu was the reincarnation of Maitreya Buddha, transforming the Tang Dynasty into Zhou. “She was the ruler of the world”, and then finally became a Buddha.
  5. The stone statue of the Queen Wu of Huangze Temple in Guangyuan is a Bodhisattva statue carved according to Wu’s face in her old age, implying the historical fact that she was the rebirth of Maitreya Buddha and ascended to the throne in her later years.

Phoenix Tree Symbolizes the Only Female Emperor

  1. The trunk of Phoenix tree is straight and tall, with few branches, symbolizing that Wu has taken a firm step towards the ultimate goal of life since her parents named “Yuanhua”. Phoenix tree symbolizes the only female emperor in the era of patriarchal rule, with a woman as the system and the emperor. It can be said that she was the only person in ancient and modern times, walking alone for thousands of years. From entering the palace to becoming the empress, Wu basically relied on personal struggle and continuous self-improvement along the way. She had an indomitable will to do everything, the lofty words of “enforcing justice on behalf of heaven”, and an ambition to achieve a great cause. She is aggressive, resourceful, resolute, decisive, unafraid, and indomitable, and has a fierce personality that is not afraid of everything. At that time, the focus of the political struggle in the Tang Dynasty focused on the interior of the imperial court. Empress Wu encountered very strong opposition forces in the process of her uproar in the Tang Dynasty. Liu Shuang, Changsun Wuji, Han Yi, Yu Zining, Pei Yinjian, Laiji, Shangguan Yi and so on hurt Wu before, Xu Jingye in Yangzhou, Li Yuanjia in Jiangzhou, and Li Zhen in Runan [7] armed against Wu later, however, they all failed to defeat her.
  2. The phoenix tree is tall and straight, with a graceful posture and the natural and imposing demeanor. Its magnificent beauty is just what Empress Wu likes. The phoenix tree with green branches is lush and elegant, and the shade of dense leaves relieves the heat of summer, symbolizing Empress Wu’s life of benefiting the world and the people. Empress Wu had “a wisdom of knowing people and a heart of loving talent.” She employed the right people, listened to the right words, used civil and military methods, and made great achievements, which can be called an iron-handed monarch in Chinese history [7,15]. Empress Wu’s attitude towards the Manifesto Against Wu Jao in the mutiny in Yangzhou shows her capacity; the opening of disciplines to select scholars reflects her wisdom of knowing people; and her control of villains and gentlemen embodies her skill of employing people.
  3. The phoenix tree stands in the wind, not afraid of the cold, symbolizing that the life of Empress Wu is a vigorous life, a rebellious life, and a life of subverting patriarchal political thought. Mr. Lu Xun once said “who dares to say men are superior to women when Wu became the emperor?” In the feudal society in which men were superior to women, Empress Wu was stigmatized as “a hen crowing in the morning”, which always belittled the empress consciously [16,17]. Today, history has objectively evaluated this great woman.

Phoenix Symbolizes the Affection of the Empress

Phoenix symbolizes love which refers to the affection of the empress. Empress Wu was a ruthless monarch who murdered countless people, but she was also an affectionate woman who loves so much. She went to the palace at the age of 14 to be a talented scholar for Emperor Taizong, Li Shimin, but was not spoiled by Taizong. “The leaves of the phoenix tree by the well are getting yellow, and you can know the frost in the night without rolling the pearl curtain. The smoked cage and jade pillow looks like a haggard face, lying down and listening to the voice from the South Palace.” (The Poem of the Changxin Palace by Wang Changling). “The rain drenched on the leaves of the phoenix tree at the night, full of autumn, and beat on the plantains, making people sorrowful. In the middle of the night, I returned to my hometown in my dream.” (Double Tone · Water Fairy · Night Rain by Xu Zaisi). This poem cannot stopping the melancholy thoughts of young Wu in the palace. In the period of loss and loneliness, Wu was dressed in court dress and wrote a love poem Set to the Tune Ruyi Niang in Ganye Temple: “Watching red turn to green, my thoughts entangled and scattered. I am disheveled and torn from my longing for you, my lord. If you fail to believe that of late I have constantly shed tears, open the chest and look for the skirt of pomegranate-red.” [10] This poem is so sorrowful, even Li Bai had a lot of emotion after reading it, and felt inferior to himself. Empress Wu, who trained a steed with a dagger, missed her lover day and night, and her eyes were dim with tears, regarding the red flowers as green phoenix tree leaves.

“The autumn rain in the midnight falls on the phoenix tree leaves, and the sound of the leaves tells of separation.” (Zhegutian · A Little Bit of Red is Dying by Zhou Zizhi). The pronunciation of “Wu (means phoenix)” and “Wu (means I), and “Tong (means phoenix)” and “Tong (means together)” is similar. The tall phoenix tree symbolizes that the emperor Gaozong, Li Zhi, and Wu Yuanhua made an oath to weep when they met under the phoenix tree in Ganye Temple. Because of missing Li, Wu was awakened by the rain of phoenix tree in autumn night after falling into a dream. There is no doubt that the phoenix tree becomes a symbol of love between Li and Wu. At the age of 27, Wu became the queen of Li. The green leaves and branches of Phoenix tree symbolize her good relationship with Li. When she was 55 years old, Li died of illness in Zhenguan Hall in Luoyang. Before his death, he wrote in the edict that “if there is anything that cannot be decided on military and national affairs, listen to the decision of the empress.” The final decision-making power of the empire was handed over to Empress Wu. At the age of 62, she became the emperor of the Great Zhou Dynasty and still had her own emotional world in the cruel political struggle. The empress, who was over 70, was still alone, and she was eager to be a “Ruyi Niang” again. Thus, the Phoenix tree symbolizes her complex emotional life.

The Falling Leaves of Phoenix Tree in Autumn Shows that Empress Wu Lost Her Kingship and Became Queen

The leaves of phoenix tree are luxuriant, but they fall earliest in autumn. “One leaf of phoenix tree falls, the whole world knows autumn to come.” (Erruting Qunfangpu by Wang Xiangjin). Fallen leaves are not declining, which is a natural response of plants to adapt to the environment, so the phoenix tree is a symbol of the autumn. Empress Wu, who abdicated from the throne in Shangyang Palace in Luoyang, stood in the cold autumn wind and looked at the shade of sparse phoenix trees under the moonlight in the deep courtyard. She sighed her glorious past and returned Zhou to Tang Dynasty. When she was dying, she removed to the Kingship and said she was still the queen. That is to say, Empress Wu finally gave up the independence of women and returned to the male power society, which was inevitable at that time, and was what she had to do. The leaves of phoenix tree fall to know autumn, and the leaves return to their roots. Although Empress Wu conquered numerous challenges, she could not escape the secular convention in the end.

Ecological Significance of the Images of Phoenix Tree, Phoenix, and Empress

The interpretation of the ecological significance of the images of phoenix tree, phoenix and empress can guide people to deepen the study of the empress culture in the forest culture. The image of phoenix tree and empress culture does not exist alone, it can form a compound image with phoenix, or it can be used individually. At the same time, when we interpret the image of phoenix tree and empress culture, we must put it in the whole historical and cultural atmosphere, and combine other images to grasp it as a whole. Only in this way can we better interpret the image of phoenix tree, which has the connotation of empress culture [18]. At the same time, we can carry forward phoenix culture and empress culture to create a characteristic forest cultural creative park, build a forest cultural city, and promote their ecological civilization value [19]. We can plant phoenix trees in the countryside of Guangyuan, in front and back of the courtyard, on both sides of the road, and in urban gardens. The green lines of roads, railways and rivers make up the phoenix, and the large green areas around the city set off the flying phoenix, which can enhance the image of the city. Phoenix tree symbolizes ecological civilization, and phoenix symbolizes human dream of flying into the sky, so phoenix tree and phoenix share a harmonious and wonderful life desire. In this beautiful city, as the king of birds, phoenix is the embodiment of truth, goodness and beauty. As its only habitat and auspicious tree species,phoenix tree can bring happiness and good luck to residents and tourists, so as to enhance the tourism charm of Guangyuan City.

Acknowledgment

Professor Chen Jiancheng and Professor Zheng Xiaoxian of Beijing Forestry University, Director Jiang Dayong of Sichuan Forestry Department, Director Chen Yang of Guangyuan City Library, Director Bai Chaomao of Fenghuangshan Park Management Office of Guangyuan City, Pu Zhitian, a senior engineer from the Landscape Department of Guangyuan Construction Bureau, Director Bai Jian of Guangyuan Culture Bureau, Li Qianxiu, the chairman of the Lizhou District of CPPCC and Writers’ Association, etc. Thank all of you for your help!

References

  1. Jiang Kongyang, Zhu Liyuan (1999) Aesthetic Principles [M]. Shanghai: East China Normal University Press.
  2. Chen Jiru (2007) Sketches by the Little Window [M]. Tianjin: Baihua Literature and Art Publishing House.
  3. Guan Chuanyou (2007) Historical and Cultural Implication of Planting Phoenix Trees in China. China Urban Forestry 5: 40-41.
  4. Xin Mo (1988) Wu Zetian and Huangze Temple [M]. Chengdu: Sichuan Art Publishing House 36-39.
  5. Ma Yunhuan (2000) Guangyuan Trip to Shu Road, Jianmen [M]. Xi’an: Taibai Literature and Art Publishing House 11: 12.
  6. Hu Ji (1986) Biography of Wu Zetian [M]. Xi’an: Sanqin Publishing House.
  7. Chen Yang (2009) Decrypt of Wu Zetian [M]. Beijing: Popular Literature and Art Publishing House.
  8. Li Qianxiu (2000) Wu Qianqiu [M]. Chengdu: Sichuan People’s Publishing House 2-4.
  9. [9] Liu Zongyuan (1987) Discrimination of Giving Leaves of Phoenix Tree to Brother [M]. Changsha: Yuelu Book Society 1987: 203-205.
  10. Meng Man (2008) Meng Man Talking about the Tang Dynasty: Wu Zetian [M]. Nanning: Guangxi Normal University Press 2, 3, 27, 185, 186.
  11. Zhang Wendi (2006) Poems about the Empress’s Hometown [M]. Beijing: Popular Literature and Art Publishing House 175.
  12. Shi Yongtao (2007) From Daming Palace to Luoyang Mingtang [N]. Urban Economic Bulletin 5: 6-26.
  13. Yu Liangxiu (2002) Chengdu Landscape Plants [M]. Chengdu: Sichuan Science and Technology Publishing House.
  14. Chen Youmin (1990) Landscape Dendrology [M]. Beijing: China Forestry Publishing House 400-403: 570, 571.
  15. Hui Huanzhang, Wu Qiao (2002) 100 Secrets of Wu Zetian [M]. Xi’an: Xi’an Publishing House 75-78.
  16. Li Daming (2005) Twenty-five Histories [M]. Chengdu: Bashu Publishing House 511-514.
  17. He Kaisi (2008) The Light of Women under the Five-ring Flag” [N]. Sichuan Daily 08-15 (B4).
  18. Su Zurong (2001) Introduction to Forest Aesthetics [M]. Shanghai: Xuelin Publishing House 275: 316.
  19. Wu Zhiwen (2008) Development of Forest Culture, Forestry Creative Industry and New Forestry Economic Growth Point. World Forestry Research 9: 184-192.
fig 1(1)

Proficiency Monitoring of Allergen-Specific IgE macELISA – 2021

DOI: 10.31038/IJVB.2021541

Abstract

The purpose of this study was to evaluate the reproducibility of results yielded using a macELISA for detection of allergen specific IgE in dogs and cats when run by eleven different individuals in seven separate affiliated laboratories. Samples of 24 different sera samples were independently evaluated in each laboratory by differing operators in a single blinded fashion. For evaluations completed by multiple operators in a single laboratory, the average intra-operator variance was calculated to be 4.6% (range=0.8%-8.7%) while the average inter-operator variance was 5.7% (range=1.4%-7.8%). The average intra-assay variance among reactive assay calibrators in all laboratories was 5.3% (range=0.8%-12.6%). The overall inter-assay inter-laboratory variance evident with reactive calibrators was consistent among laboratories and averaged 10.1% (range=4.4%-12.8%). All laboratories yielded similar profiles and magnitudes of responses for replicate unknown samples; dose response profiles observed in each of the laboratories were indistinguishable. Correlation of EAU observed for individual allergens between and among all laboratories was strong (r>0.90, p<0.001). Collectively, the results demonstrated that ELISA for measuring allergen specific IgE is reproducible, and documents that consistency of results can be achieved not only in an individual laboratory, but among different operators and between laboratories using the same ELISA.

Keywords

IgE, ELISA, Proficiency, Atopy, Allergy, Immunotherapy, Cross-reactive carbohydrate

Introduction

Stallergenes Greer maintains a proficiency monitoring program for laboratories that routinely run macELISA [1] for evaluation of allergen specific IgE in serum samples. The foundation for this program is based on the desire for inter-laboratory standardization and quality control measures that ensure the uniformity, consistency, and reproducibility of results among laboratories that perform the assays. This program is designed to evaluate the proficiency of laboratories and ensures that individual operators yield consistent and reproducible results. The inaugural proficiency evaluations, initiated in 2009 and repeated in 2010, in six different laboratories documents that inter-laboratory standardization and quality control measures in the veterinary arena are on the immediate forefront and that uniformity, consistency, and reproducibility of results between laboratories is achievable [2]. Similarly, reproducibility of results among different laboratories was documented in the subsequent proficiency evaluations completed in 2013 [3], 2016 [4], 2018 [5], 2019 [6], and 2020 [7]. The results presented herein summarize the comparative results observed in the affiliate laboratories for the most recent proficiency evaluations that were completed in August 2021. The 2021 proficiency evaluation is the third documentation of the assay reproducibility since adopting a cross-reactive carbohydrate inhibitor in the sample diluent [7,8].

Materials and Methods

All serum samples, buffers, coated wells, calibrator solutions, and other assay components were aliquants of the respective lots of materials manufactured at Stallergenes Greer’s production facilities (located in Lenoir, NC, USA) and supplied as complete kits to the participating laboratories along with the exact instructions for completing the evaluations.

Participating Laboratories

Seven independent Veterinary Reference Laboratories (VRLs) participated in the 2021 proficiency evaluation of macELISA. Participating laboratories included three separate IDEXX laboratories located in Memphis, Tennessee, Kornwestheim, Germany, and Markham, Ontario Canada. Other affiliated European laboratories that participated in this evaluation included Agrolabo (Scarmagno, Italy), Laboratories LETI Pharma (Barcelona, Spain), and Ceva Biovac (Beaucouzé, France). Stallergenes Greer Laboratories (Lenoir, NC) served as the prototype for evaluation of the macELISA; the 2021 evaluations included results reported by three separate and independent operators. Because the performance characteristics of macELISA in Stallergenes Greer’s VRL have been well documented for use over an extended period [1-6], all results observed in the other participating laboratories were compared directly with the results observed in Stallergenes Greer’s reference laboratory.

Serum Samples

Separate pollen and mite reactive serum pools or non-reactive sera pools were prepared from cat and dog serum samples that previously had been evaluated using the macELISA for detection of allergen specific IgE. The reactivity of each sera pool ranged from nonreactive to reactive for multiple pollen or mite allergens. These sera pools and admixtures of the pools were used to construct a specific group of samples that exhibited varying reactivity to the allergens included in the evaluation panel. Twenty-four samples were included in the blinded evaluation conducted by each laboratory. Identical replicates of the high, low, and negative controls routinely used in the assay were also included as unknown samples. Also included in the array of samples was a five tube three-fold serial dilution of a highly pollen reactive pool, diluted into non-reactive sera, which served to document the dose response evident within the assay. All samples were stored at -20°C for the interim between testing.

Calibrators

Mite reactive calibrator solutions of predetermined reactivity in the macELISA were prepared as three-fold serial dilutions of a sera pool highly reactive to Dermatophagoides farinae, Acarus siro, and Tyrophagus putrescentiae. Replicates of each were evaluated in each assay run and served as a standard response curve for normalizing results observed with the various samples. All results were expressed as ELISA Absorbance Units (EAU) which are background-corrected observed responses expressed as milli absorbance.

Buffers

The buffers used throughout have been previously described,1-7 and included: a) well coating buffer: 0.05 M sodium carbonate bicarbonate buffer, pH 9.6; b) wash buffer: phosphate buffered saline (PBS), pH 7.4, containing 0.05% Tween 20, and 0.05% sodium azide; c) reagent diluent buffer: PBS, pH 7.4, containing 1% fish gelatin, 0.05% Tween 20 and 0.05% sodium azide. The buffer used for dilution of serum samples was identical to the reagent diluent buffer, but it has been supplemented (2.5 mG/mL) with a cross-reactive carbohydrate inhibitor derived from the carbohydrate components present in bromelain (BROM-CCD)7. BROM-CCD was prepared in house and remains a proprietary product of Stallergenes Greer (Lenoir, NC, USA).

Allergen Panel

The allergen panel was a 24 allergen composite derived from the array of allergens that are included in the specific panels routinely evaluated in the various laboratories; the composite allergen panel consisted of 4 grasses, 6 weeds, 6 trees, 5 mites, and 3 fungi. The protocol for coating and storage of wells has been previously described [1-7]. Immulon 4HBH flat bottom 12 well strip assemblies (Thermo Electron Corporation, Waltham, MA) were used throughout and served as the solid phase for all assays. The individual extracts were diluted in bicarbonate buffer (pH 9.6) and 100 µL was added to each assigned well. Following overnight incubation at 4-8°C, the wells were washed with PBS, blocked with 1% monoethanolamine (pH 7.5) then air dried and stored at 4-8°C in Ziploc bags until used.

Sample Evaluations – macELISA

The operational characteristics and procedures for the macELISAs have been previously described [1-6]. Following incubation of allergen coated wells with an appropriately diluted serum sample, allergen-specific IgE is detected using a secondary antibody mixture of biotinylated monoclonal anti-IgE antibodies, streptavidin alkaline phosphatase as the enzyme conjugate, and p-nitrophenylphosphate (pNPP) as substrate reagent. Specific IgE reactivity to the allergens is then estimated by determining the absorbance of each well measured at 405 nM using an automated plate reader. All results are expressed as ELISA Absorbance Units (EAU), which are background-corrected observed responses expressed as milli absorbance [8-13].

To evaluate the stability of stored wells, the reactivity of wells coated in April 2019 and in April 2021 was assessed by Stallergenes Greer technicians. The storage stability of the anti-IgE-biotin reagent was assessed by comparing the reactivity of a preparation of reagent that was prepared in January 2017 with that of one that was prepared in April 2020.

Statistics

A coefficient of variation was calculated as the ratio of standard deviation and means of the responses observed for the calibrator solutions within different runs in multiple laboratories. Pearson’s correlation statistic was used for inter-laboratory comparison among individual allergens. Statistical analyses were conducted using EXCEL (2016; Microsoft; Redmond, WA, USA).

Results

The assay variance (% CV) observed with the calibrator solutions in the different laboratories are presented in Table 1 and are representative of the assay reproducibility in the various laboratories. The average intra-assay % CV among positive calibrators (#1-5) was 5.3% (range=0.8%-12.6%); differences among laboratories or between assays and within assay runs were not detected. No substantial difference in results among various operators was revealed. The average intra-operator variance documented for Stallergenes Greer technicians was calculated to be 4.6% (range=0.8%-8.7%) while the average inter-operator variance was 5.7% (range=1.4%-7.8%). The average inter-assay variance (% CV) observed in Stallergenes Greer’s laboratory with the positive calibrators from multiple runs over a one year period has been documented at 8.9% (range 7.1% -9.7%), and the inter-laboratory % CV among reactive calibrators also remained relatively constant (average 12.1%; range=11.2%-13.4%). The results of the current evaluation (Table 1) are consistent with these unpublished findings; the inter-assay variance among positive calibrators for all laboratories included in this evaluation was calculated to be 10.1% (range=4.4%-12.8%). Similar to previously published studies [1-7], the intra-assay variability was higher with the calibrators containing lesser amounts of allergen specific IgE, and a similar increased intra-assay variability was evident with the background ODs (average 8.6%; range=2.0%-18.1%). A negative response is classified as anything with an EAU below 150 [1]. Any analysis of results below this threshold, especially when looking at %CV and relative differences should be done cautiously.

Table 1: Calculated variance of macELISA calibrator solutions observed with different laboratory runs by multiple operators during the 2021 Proficiency evaluation.

                                                           Calibrator % CV BG % CV

Variance

N

#1 #2 #3 #4

#5

Inter-Laboratory

352

4.4 10.0 12.8 12.2 10.8

19.8

Inter-Assay (Stallergenes Greer)

160

1.4 6.2 7.8 6.7 6.6

7.7

Intra-Assay
Stallergenes Greer #1

32

1.3 6.1 5.9 4.5 3.7

3.8

Stallergenes Greer #2

32

1.2 3.4 6.8 4.5 6.5

2.0

Stallergenes Greer #3

32

1.3 6.7 7.9 4.8 6.1

9.9

Stallergenes Greer #4

32

0.8 4.1 4.2 5.0 3.9

4.9

Stallergenes Greer #5

32

1.1 4.7 4.6 8.7 7.0

7.9

IDEXX Memphis

32

3.3 6.9 12.2 7.0 10.9

14.6

IDEXX Canada

32

1.5 3.0 5.2 4.2 3.5

9.4

IDEXX Germany

32

2.0 6.6 11.1 7.5 4.0

9.9

Agrolabo

32

1.0 3.2 5.7 6.9 12.6

18.1

Biovac

32

2.6 7.2 6.6 6.3 6.8

6.0

LETI

32

2.2 4.5 8.9 6.7 7.3

7.6

* Calibrator #1 was prepared as a dilution of a sera pool which is highly reactive to mite allergens; Calibrators #2 – #5 are prepared as a serial 3-fold dilution of calibrator #1.
† Background responses observed with diluent in place of serum sample.

To evaluate the strength of association with the magnitude of EAU results observed for each allergen among the different laboratories a Pearson’s correlation coefficient was determined (Microsoft Excel 2016) for each laboratory pair. Because the macELISA is designed to yield comparable responses in dog and cat samples, comparison of results among affiliate laboratories included both cat and dog samples as a single population of sera samples [5-7]. These results (Table 2) demonstrate that very high inter-laboratory correlation (r>0.90; p<0.001) is evident between the results observed in Stallergenes Greer laboratory and those observed in six affiliate laboratories for all pollen, mite, and fungi allergens. The overall correlation of results observed in the various laboratories is summarized in Table 3; a very strong correlation (r>0.90, p<0.001) was demonstrated between and among the results of the participating laboratories.

Table 2: Inter-laboratory correlation of macELISA results observed with individual allergens in Stallergenes Greer Laboratory and the results observed in the individual affiliate laboratories.

Allergens

Inter-Laboratory Coefficient of Correlation Stallergenes Greer vs
IDEXX Memphis IDEXX Germany IDEXX Canada Ceva Biovac Agrolabo

LETI

Mites
Acaris siro

0.996

0.995

0.981 0.988 0.995

0.972

Dematophagoides farinae

0.992

0.993 0.998 0.984 0.994

0.972

Dematophagoides pteronyssinus

0.990

0.982 0.971 0.980 0.976

0.882

Lepidoglyphus destructor

0.971

0.967 0.893 0.953 0.974

0.838

Tyrophagus putrescentiae

0.993

0.986 0.975 0.992 0.991

0.956

Grasses
June Grass (Poa pratensis)

0.995

0.990 0.997 0.988 0.990

0.937

Meadow fescue (Festuca pratensis

0.989

0.987 0.983 0.983 0.987

0.908

Orchard Grass (Dactylis glomerata)

0.984

0.982 0.993 0.984 0.984

0.904

Perennial Rye (Lolium perenne)

0.985

0.984 0.988 0.983 0.986

0.899

Trees
Birch (Betula pendula)

0.977

0.978 0.965 0.908 0.964

0.900

Cypress (Cupressus sempervirens)

0.981

0.972 0.904 0.948 0.898

0.926

Hazelnut (Corylus avellana)

0.978

0.970 0.983 0.977 0.955

0.915

Olive (Olea europaea)

0.980

0.972 0.991 0.964 0.965

0.889

Populus mix (P.nigra, P. tremula, P. alba)

0.976

0.970 0.988 0.975 0.964

0.894

Willow Black (Slix discolor)

0.971

0.962 0.963 0.976 0.968

0.927

Weeds
English Plantain (Plantago lanceolata)

0.988

0.974 0.979 0.985 0.977

0.905

Lambs Quarter (Chenopodium album)

0.981

0.961 0.944 0.933 0.934

0.916

Mugwort (Artemisia vulgaris)

0.977

0.967 0.980 0.971 0.953

0.915

Pellitory (Parietaria officinalis)

0.985

0.974 0.986 0.981 0.977

0.914

Ragweed (Ambrosia trifida, A. artemisifolia)

0.999

0.992 0.996 0.997 0.989

0.994

Sheep Sorrel (Rumex acetosella)

0.990

0.982 0.986 0.988 0.980

0.931

Fungi
Alternaria alternata

0.953

0.991 0.977 0.977 0.945

0.931

Aspergillus fumigatis

0.993

0.995 0.994 0.958 0.998

0.950

Cladosporium herbarum

0.995

0.992 0.843 0.914 0.994

0.944

Overall

0.991

0.986 0.977 0.987 0.983

0.956

*Pearson Correlation Coefficient (r); Good Correlation (r > 0.8, p<0.001)

Table 3: Inter-laboratory correlation of macELISA results observed among individual affiliate laboratories.

Interlaboratory Coefficient of Correlation
Laboratory Stallergenes Greer IDEXX Memphis IDEXX Germany IDEXX Canada Ceva Biovac Agrolabo

LETI

Stallergenes Greer

1

0.991 0.986 0.977 0.987 0.983

0.956

IDEXX Memphis

0.991

1 0.990 0.980 0.989 0.986

0.967

IDEXX Germany

0.986

0.990 1 0.967 0.981 0.994

0.956

IDEXX Canada

0.977

0.980 0.967 1 0.978 0.962

0.955

Biovac

0.987

0.989 0.981 0.978 1 0.974

0.969

Agrolabo

0.983

0.986 0.994 0.962 0.974 1

0.948

LETI

0.956

0.967 0.956 0.955 0.969 0.948

1

*Pearson Correlation Coefficient (r); Good Correlation (r > 0.8, p<0.001)

For an evaluation of the dose response in this ELISA, a five tube three-fold serial dilution of a reactive dog sera pool was prepared using a negative cat sera pool as diluent. Each of the dilutions was then evaluated by all of the participating laboratories as unknown independent samples. Similar responses were yielded by all of the laboratories and the results observed within the various laboratories are encompassed by the acceptable variance limits [1-3] (±20%) established for macELISA. Further, the magnitude of responses observed in each laboratory was reduced in direct proportion to dilution. Consequently, the dose responses for the individual allergens are presented as aggregate responses. The results presented in Figure 1 confirm the sera pool was highly reactive to mites as well as grass, weed, and tree pollen allergens, but it was not reactive to fungi. To be expected, the magnitude of responses observed in each laboratory was reduced in direct proportion to dilution. Results from the final tube in the dilution scheme yielded results that were indistinguishable from negative responses, indicating a dilution extinction of detectable response.

fig 1(1)

fig 1(2)

fig 1(3)

Figure 1: Dose response evident in macELISA with a pollen reactive serum pool.

The final objective for the current evaluation was to document the stability of the anti-IgE biotin reagent and the allergen coated wells. For these evaluations two separate lots of each assay component were reciprocally assessed. The two lots of allergen coated wells were manufactured in April 2019 and April 2021 and stored in zip closure plastic bags at 4-8°C until used. The separate anti-IgE reagent lots were manufactured in January 2017 and April 2021 and were store at -10°C in alkaline phosphatase stabilizing buffer containing 50% glycerin. All evaluations were completed in July 2021.

The results present in Table 4 demonstrate that similar responses are yielded with calibrators when evaluated with either lot of anti-IgE biotin. The average intra assay variance (% CV) observed with the two reagent lots were evaluated by two separate technicians and calculated to be 5.5% (range=0.9%-11.9%). The average inter-assay variance for the two reagent lots was calculated to be 7.1% (range=1.1%-12.0%); whereas the average inter-lot/inter-operator variance was 12.1% (range=2.2%-17.9%). To be expected, the greatest variance was noted for calibrator solutions that yielded signals of lesser magnitude.

Table 4: Correlation of responses observed with calibrator solutions when evaluated with separate lots of anti-IgE biotin that were stored for 3 or 55 months.

Anti-IgE Biotin Calibrator % CV*
Variance Lot # Storage(Months) N #1 #2 #3 #4 #5

BG % CV

Inter-Lot/ Operator

1 & 2

3 & 55 160 2.2 9.8 15.7 17.9 15.0

9.5

Inter-Assay

1

55 96 1.5 7.6 6.3 7.0 7.8

7.0

2

3 96 1.1 5.7 10.6 12.0 11.2

10.3

Intra-Assay
Operator #1

1

55 64 1.6 9.0 4.9 4.0 3.1

4.0

2

3 64 0.9 3.2 6.7 5.5 7.4

3.8

Operator #2

1

55 32 1.2 3.4 6.8 4.5 6.5

6.8

2

3 32 1.2 6.3 10.1 11.9 11.5

11.4

* Calibrator #1 was prepared adilution of a sera pool which is highly reactive to mite allergens; Calibrators #2 – #5 are prepared as a serial 3-fold dilution of calibrator #1. Background responses observed with diluent in place of serum sample.
† Anti-IgE biotin was stored at -10 °C in alkaline phosphatase stabilizing buffer containing 50% glycerin

The final endeavor of the present study was to document the storage stability of the individual allergen coated wells along with the anti-IgE biotin conjugate stability. For these evaluations a single dilution of each of the sera included in the proficiency panel were evaluated separately by two technicians on both lots of wells using each of the anti-IgE biotin lots. Because the magnitude of signals evident with the individual allergens between the two technicians was indistinguishable all results were treated as a single population for each allergen. The results present in Table 5 demonstrate a very high correlation (Pearson’s) of results for each of the allergen coated wells and for each lot of anti-IgE biotin (r>0.900, p<0.001).

Table 5: Correlation of results observed with proficiency sera samples when evaluated with two separate lots of anti-IgE biotin stored for 3 or 55 months using allergen coated wells that were stored for 3 and 24 months.

                                                                           Coefficient of Correlation

Allergens  Wells*
Apr 2019     vs      Apr 2021

  Biotin+
Jan 2017    vs     Apr 2020

Mites

Biotin
Jan 2017
Biotin
Apr 2020
Wells

Apr 2019

Wells
Apr 2021

Ascaris siro

0.993

0.992 0.995

0.994

Dermatophagoides farinae

0.999

0.999 0.996

0.993

Dermatophagoides pteronyssinus

0.987

0.985 0.995

0.988

Lepidoglyphus destructor

0.959

0.975 0.987

0.976

Tyrophagus putrescentiae

0.988

0.987 0.996

0.991

Grasses
June Grass (Poa pratensis)

0.995

0.997 0.965

0.946

Meadow fescue (Festuca pratensis

0.998

0.998 0.956

0.937

Orchard Grass (Dactylis glomerata)

0.990

0.996 0.952

0.926

Perennial Rye (Lolium perenne)

0.993

0.997 0.956

0.929

Trees
Birch (Betula pendula)

0.997

0.971 0.903

0.960

Cypress (Cupressus sempervirens)

0.874

0.918 0.956

0.962

Hazelnut (Corylus avellana)

0.998

0.998 0.944

0.947

Olive (Olea europaea)

0.999

0.995 0.935

0.950

Populus mix (P.nigra, P. tremula, P. alba)

0.995

0.992 0.942

0.949

Willow Black (Slix discolor)

0.983

0.973 0.931

0.953

Weeds
English Plantain (Plantago lanceolata)

0.995

0.985 0.957

0.982

Lambs Quarter (Chenopodium album)

0.996

0.992 0.952

0.962

Mugwort (Artemisia vulgaris)

0.980

0.985 0.954

0.950

Pellitory (Parietaria officinalis)

0.997

0.996 0.940

0.953

Ragweed (Ambrosia trifida, A. artemisifolia)

0.999

0.990 0.997

0.992

Sheep Sorrel (Rumex acetosella)

0.999

0.991 0.942

0.963

Fungi
Alternaria alternata

0.989

0.993 0.986

0.969

Aspergillus fumigatis

0.997

0.998 0.996

0.993

Cladosporium herbarum

0.932

0.923 0.974

0.966

Overall

0.972

0.975 0.974

0.975

*Allergen coated wells were air dried then stored at 4-8 °C in plastic bags
† Anti-IgE biotin was stored at -10 °C in alkaline phosphatase stabilizing buffer containing 50% glycerin

Discussion

Consistent with previous proficiency evaluations of laboratories that routinely run the monoclonal antibody cocktail based enzyme linked immunoassay (macELISA) manufactured by Stallergenes Greer [1-6], the results of the present study demonstrated that the intra-assay variance observed with the positive calibrators remains relatively low and indistinguishable among the various laboratories. Likewise, the inter-assay variance within each laboratory remained relatively constant and the results from all laboratories was demonstrably similar and the CV of the positive responses was relatively constant across the entire range of reactivity tested. The results demonstrated that the variability between and among the affiliate laboratories and technicians are indistinguishable from the results evident within and between runs completed in the laboratory of Stallergenes Greer. Thus, all laboratories and technicians included in the study were equally proficient in providing consistent results for all allergens tested and the results were well within the acceptable variance limits (±20%) established for this assay and reflects the robustness of the assay [1].

During the 2020 proficiency evaluations, we documented the stability of allergen specific IgE in serum samples stored frozen for at least one year. In the present study we have documented the stability of allergen coated wells that have been stored for at least 24 months. In addition, we have shown that our anti-IgE reagent maintain functional utility for at least 55 months when stored at -10°C in an alkaline phosphatase stabilized buffer containing 50% glycerin.

There was no compelling evidence that the level of allergen specific IgE correlates with severity of clinical disease [14-17]. However, an evaluation that purports to measure allergen specific IgE should have a reduction in signal that is directly proportional to the dilution factor of the test ligand [18]. Similar responses were yielded by all of the laboratories for the samples that comprised the dose response and the results observed within the various laboratories are encompassed by the acceptable variance limits (±20%) established for macELISA [1-3]. Further, the magnitude of responses observed in each laboratory was reduced in direct proportion to dilution. Consequently, the dose responses for the individual allergens are presented as aggregate responses (Figure 1). The responses of greatest magnitude were evident with the grass pollen allergens, and these responses were reduced in direct proportion to dilution; the magnitude of responses ranged from near maximum to those that were indistinguishable from background responses. The reaction profiles for grass allergens also appear to be parallel and quite similar in magnitude of response. Whether or not these like responses result because of a similar level of co-sensitization or allergen epitope similarity combined with cross-reaction remains to be determined. Although the responses evident to differing tree and weed allergens are more variable in magnitude of response, the observed response in each laboratory was reduced in direct proportion to dilution. The positive response profiles evident with these allergens also appear to be parallel and, it becomes evident that the detectability of allergen specific IgE within this assay spans at least a 150-fold dilution range. Substantial responses to A siro, D farinae, and T putrescentiae were noted in the original sample and these responses decreased in direct proportion to dilution. Reactivity to fungal allergens were lacking in the original sample. We have demonstrated a continued reliability and reproducibility of our macELISA with the open publication of our proficiency testing procedures and results [1-6]. We encourage other groups to determine and document similar findings; however, we emphasize the importance of identifying results below the cutoff of 150 EAU merely as non-reactive and consequently negative responses. The reproducibility of the assay for these responses should be defined only as negative and their numerical values become meaningless; comparison of EAU values are meaningful for reactive samples only (EAU>150). Because the magnitude of specific responses is dependent on the concentration of allergen-specific IgE that can span a wide range, a better means of comparison of repeat results for individual samples in an assay of this sort should be to evaluate the correlation (perhaps Pearson statistic) of results that might exist.

The lack of a regulatory mandated quality assurance program for serum allergen specific IgE testing in companion animals, that independently monitors performance of all laboratories and assay formats, prompts Stallergenes Greer to focus on its continued evaluation of laboratories that routinely use the company’s assays. Information presented herein documents the continued commitment of Stallergenes Greer and its affiliate laboratories to providing a stream of information relating these results to the veterinary community.

Funding

Funding for this study was provided by Stallergenes Greer.

References

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  2. Lee KW, Blankenship KD, McCurry ZM, Kern G, et al. (2012) Reproducibility of a Monoclonal Antibody Cocktail Based ELISA for Detection of Allergen Specific IgE in Dogs: Proficiency Monitoring of macELISA in Six US and European Laboratories. Vet Immunol Immunopathol 148: 267-275.
  3. Lee, K.W, Blankenship, K, McKinney, B, Kern, G, et al. (2015) Proficiency monitoring of monoclonal antibody cocktail–based enzyme-linked immunosorbent assay for detection of allergen-specific immunoglobulin E in dogs. Journal of Veterinary Diagnostic Investigation 27: 461-469. [crossref]
  4. Lee K, Blankenship K, McKinney B, Kern G, et al. (2017) Continued Proficiency Monitoring of Monoclonal Antibody Cocktail-Based Enzyme-Linked Immunosorbent Assay for Detection of Allergen Specific Immunoglobulin E in Dogs – 2016. Integr J Vet Biosci 1: 1-10.
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  12. Kaulfürst-Soboll H, Mertens M, Brehler R, von Schaewen A, et al. (2011) Reduction of cross-reactive carbohydrate determinants in plant foodstuff: elucidation of clinical relevance and implications for allergy diagnosis. PLoS One 6: 17800.
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  15. DeBoer DJ, Hillier A (2001) The ACVD task force on canine atopic dermatitis (XVI): laboratory evaluation of dogs with atopic dermatitis with serum-based “allergy” tests. Vet Immunol Immunopathol 81: 277-87. [crossref]
  16. Gorman NT, Halliwell, REW (1989) Atopic Diseases. In: Halliwell REW, Gorman NT. ed. Veterinary Clinical Immunology pp 232-52. WB Saunders, Philadelphia.
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fig 2

Reaching a Meaningful Agreement among Diverse Parties: The Potential Contribution of Mind Genomics to an Iterated, Optimal Policy

DOI: 10.31038/PSYJ.2021343

Abstract

Mind Genomics was used to assess the response of ordinary people to different prospective strategies involved with the nuclear deal with Iran, in 2016. Each respondent read a unique set of 25 small vignettes comprising systematically varied messages about the nuclear deal, rating each on likelihood for an agreement, and expected emotional response from Iran. From the set of 20 elements only seven elements performed strongly, but not among the total panel, only among emergent mind-sets. These were MS1 (Focus on military aspects, specifically prevention, n = 29 respondents), MS2 (Focus on economic development, n=45), and MS 3 (Focus on effective negotiations and diplomacy, n=11). Most of the emotional reactions were negative. The paper suggests that Mind Genomics be used as an iterative, low cost, rapid fashion, to identify strong negotiating points, base upon the mind of the average citizen. The iterations each lasting 3-4 hours, with several iterations possible in a day at low cost, and with deep learning may radically change the process of negotiation. Mind Genomics identifies what specific messages ‘work’. The process can evolve to a joint effort by both parties to the disagreement, and by so doing craft an agreement attractive to both sides, an agreement emerging from the positive responses of the citizens of both sides

Introduction

The world of US policy the domain of the three branches of the government, and in practice the domain of a host of consultants and others helping to formulate the policy. Often the policy seems well thought out, other times the policy seems to be either poorly thought out, or more of concern, the influence of various parties which dictate aspects of policy for their own interest.

The topic of this paper is the introduction of a tool, Mind Genomics, to help formulate policy by understanding the ‘mind’ of the average citizen, in a way that could tap into the ‘wisdom of the crowd’, and become an iterative, affordable, rapid tool to help policy formulation.

We illustrate the approach by a study run five years ago on responses to policy about Iran. The objective of the study was to demonstrate the potential of what one could learn in a matter of two days, a time that would be shortened to period of 2-4 hours as of this writing (Fall, 2021). The topic of what to do with the fractious government of Iran continues to rear its head. At the original time of the experiment, the last months of the Obama administration, the issue was raised as to what could be done to deal effectively with Iran. Donald Trump was in the midst of pre-election efforts. The research was done to identify key issues and what people wanted as support for the Republican party.

Formulation of Public Policy with the Aid of Polls

Public policy is often announced by a spokesperson for the committee putting forward that policy. It is obvious from the reports both before, and during the birth of the policy, that the policy was ‘crafted’ by a group, and that often the group is bipartisan. There is the phrase ‘horse-trading’ to discuss the back-and-forth negotiations.

At the same time, in the world of politics, whether for candidates or for political issues there are two worlds intertwined. One world is the world of experts, such as individuals from so-called think tanks, who come up with the recommendations. In the United States these individuals are disparaging called ‘Beltway Bandits’, because are housed near Washington. The experts are highly paid to work with the lawmakers and policy makers, to give advice (Alden & Aran, 2016; [1]. Occasionally, scientists enter the process as well because the issue is technical [2].

At the same time there are the pollsters, who measure public opinion, attitude. The emphasis here is on accurate measurement. Occasionally these pollsters might be asked to consult on policy, but their expertise is accurate measurement. The measurement may occur with well conducted local and national polls, focus groups, individual depth interviews, perhaps coupled with their own observations of what is happening at the time they are doing the research [3].

There are two languages in policy, the language of artisanship in the creation, and the language of statistics and measurement in people’s response to the creatin. The language of policy creation is the language of the artisan shop, where the policy is ‘crafted,’ ‘hammered out’, etc., through the interactions and efforts of the individuals involved. The policy is ‘created’ by those tasked with the job. We can contrast this policy of ‘artisanship’ with the language used in measuring responses to the policy, the language of statistics, polls, degree of confidence, measurement of trends, and assignment of reasons for specific patterns of people’s response to the policy. Furthermore, he two languages do not overlaps. There is not much published in terms of scientifically guided iterations in the development of the artisan-crafted policy. The two worlds are different, creation and measurement.

In contrast to the above is the world of product design, especially the world of software design, but engineering in general. The product may be created by an artisan, but that product is special, one time. The true effort is to create products which work, products that have been created by iterations, with the creation coming first, then the testing, then the revision, and the testing again [4]. The key word is ‘testing as part of the iteration,’ something that is not heard publicly in the world of government policy

A search through the literature reveals a moderate number of papers on policy, but almost none on measurement during the course of policy development in the way that one might iterate in the creation of software. We might we be in different worlds. Policy again and again seems to be crafted as a one-tine reaction, rather than being quickly evolved from iterations and testing propositions in the policy. It is that opportunity, creation and optimization through iteration, which constitutes the contribution of this paper.

Beyond Polls to Experimentation

The notion of experimentation in political science seems at first strange, simply because one thinks of the political order as an emergent, resulting from the confluences of forces and the ‘Zeitgeist,’ the spirit of the times. Philosophers have debated the nature of the political orders, the classes of political orders, and of course both the assumed ‘original political order of man’ (if there ever was one), and the most appropriate political order for a society. The important thing to note is that political order is so critical that it begs for study, whether for itself or knowledge of which allows one to achieve one’s goals.

At the same time, during the past decades there has emerge a notion of experimentation, and the idea of an experimental political science, perhaps of the same type as experimental psychology. The difference is where the material is published, and the nature of the published material. Experimental psychology began to emerge in Germany almost two centuries with the publication of Ebbinghaus’ book ‘On Memory’. The book was filled with the results of experiments, with data that could be studied, reanalyzed, challenged, and ultimately replicated or not.

We can contrast the early beginnings of experimental psychology with the beginnings of experimental political science, whose material appears in book after book, as points of view, substantiated with one or two experiments, or better rethinking of data [5,6]. There are no standard experiments in political science, experiments which constitute the basis of the science. Rather, there is talk, philosophical point of view, the need and from time-to-time re-presenting data, cast in this new light of experimentation. In other words, experimental political science is very much alive, but as hope for the future, not as a daily, simple, scalable system for producing data and knowledge. We are just not ready although the interest is certainly real, as shown by the intellectual vibrancy of the topic, a ‘must’ for breaking through into new territory [7-9].

The Mind Genomics Approach

Mind Genomics is an emerging science with roots in experimental psychology, marketing research and public polling. The fundamental nature of Mind Genomics is of a science of experimentation which discovers the mind of people with respect to a specific micro-topic. The key word is micro-topic, a focus on easy-to-understand ideas. The objective is to quantify decision making from the bottom up, and identify coherent groups, ‘mind-genomes’, based upon different, recurring patterns describing how individuals make judgments about the world of the everyday [10,11].

The part of Mind Genomics emerging from experimental psychology is the focus on the measurement of ideas, the inner psychophysics as it was called by modern day psychophysics pioneer, S.S. Stevens of Harvard University. Psychophysics itself is the search for lawful relations between physical stimuli and subjective responses, so-called outer psychophysics. It is the aspects of psychophysics to which most scientists familiar with psychology and referring to when they refer to psychophysics. Inner psychophysics, Stevens’ dream, was to apply metrics to ideas, to measure ideas.

The part of Mind Genomics emerging from consumer is the use of mixtures of test stimuli which simulate real world stimuli have cognitive meaning. One of the tools of consumer research, coincidentally developed by experimental psychologists Luce and Tukey is ‘conjoint measurement,’ the evaluation of mixtures of stimuli, and the estimation of the contribution of each element in the mixture to the overall response. In the world of commerce, mixtures are importance. They are the substance of which products and services are composed. We don’t buy single ideas, but rather combinations of features and benefits embedded in a product or a service.

The Seven Steps

Mind Genomics follows a templated process comprising seven steps. The steps begin with the creation of raw material, and finish with the identification of strong performing elements, among defined groups of respondents, including new-to-the-world groups of respondents who can be shown to think alike on this topic. The output of the Mind Genomics study may find use in driving a better program of communication of one’s product, or part of an academic effort to create the ‘wiki of the mud for a set of related issues’

Step 1: Define the Problem, Create the ‘Raw Material’, Defined as a Set of ‘Questions’, and a Specified Number of Answers to Each Question

The Mind Genomics effort is an experiment, rather than a questionnaire, although Mind Genomics has often been defined in public terms as a survey’.

The essence of Mind Genomics is to measure responses to defined stimuli, viz., combinations of messages, these combinations called vignettes. The vignettes are combinations of statements about the topic, in our case policy towards Iran. As a consequence, the Mind Genomics process prescribes the raw material, namely the topic (Iran), a set of ‘questions’ or ‘categories’ which in sequence describe or tell a story, and for each question or category, an equal number of ‘answers.’

The approach for finding the raw material may range from sheer expertise and ‘off the cuff’ to serious research into what is in published. With the growing interest in Mind Genomics as a fast, iterative process, the movement is towards simple, superficial ideas, some based upon what has been seen or read in public sources, the others based upon one’s own ideas, or the ideas of a creative group, thinking about the topic.

Table 1 shows the list of elements. The structure of the table, four questions, five answers per question, is based on the one of the designs of the Mind Genomics system. The elements were created by author Bitran based upon his on strategic analysis work with his program, Enterprizer(r). It is important to keep in mind that Mind Genomics is a tool which puts the elements to a hard test, as we will see below. The iterative nature of Mind Genomics will allow strong elements to emerge. At the same time, however, the Mind Genomics system is not ‘creative’. And so, a good knowledge of the topic is helpful but not a requirement.

Table 1: The five questions (categories) and four answers (elements) for each question.

Question Non-Aggression Pact
A1  Non-aggression pact signed by ALL countries … those affiliated with Iran and as well those left out. Examples of affiliated – Syria, Lebanon, Palestine. Examples of those left out – Egypt, Israel, Saudi Arabia, Arab Emirates
A2 Non-aggression pact signed by ALL countries NOT AFFILIATED with Iran and Egypt, Israel, Saudi Arabia, Arab Emirates
A3  Bilateral non-aggression pact between all pairs of Arab countries involved
A4 Bilateral non-aggression pact between all pairs of Arab countries involved, and with Israel as well
B – Middle East Security Agreement
B1 Innovative US Policy … advancing economic prosperity & security (for Egypt, Israel, Jordan, Saudi, Emirates)
B2  Create strategic alliances among the group (Egypt, Israel, Jordan, Saudi, Emirates)
B3 Cyber Protection Policy to protect the signing group from cyber disruptions of critical national ‘infrastructure’
B4 Regular meetings to understand current situations and threats, with feedback to improve policy
C – Middle East Free Trade Region (Egypt, Israel, Saudi, Emirates, with Iran option)
C1 Middle East Free Trade Area can include Iran if it signs new agreement
C2 No BDS (Boycott, Divestment, Sanctions) among Egypt, Israel, Saudi, Emirates
C3 Economic development initiatives… job creation through small / medium companies
C4  International innovation zones in each country…attract corporations & startups
D – US Foreign Assistance to Promote American Values
D1 US Foreign assistance only when receiving governments commit to promote no racism & anti-Semitism in trade and education systems
D2 You get foreign aid from the US – forbid BDS against Israel (Boycott, Divestment, Sanctions)
D3 All conditions must be part of every US foreign and defense program
D4  American Values …. Projects/policies have to contain them
E – Renegotiate Iran Deal
According to a recent survey by United Against Nuclear Iran, a large majority of American registered voters view Iran as the greatest state threat facing the United States.
E1 Close consultations by US with Egypt, Israel, Jordan, Saudi, Arab Emirates, who will also publicly sign the new agreement
E2 Deal with Iran…Strict, REAL, proactive enforcement by IAEA (International Atomic Energy Agency). No Iranian ‘self-inspection’
E4 Deal with Iran…. Forbid Iran to transfer ballistic missiles and related technology
E4 Deal with Iran …Exclude Iranian Revolutionary Guard Corps (IRGC), so they have no official standing

Step 2: Create Short Vignettes Using Experimental Design

The world of science works by identifying a phenomenon of interest, defining aspects of the phenomenon to be studies, and when possible, isolating those aspects of interest, and measuring them. The aim is to determine the nature of the variable of interest. Doing so means reducing the haze around the variable, the random variation which hides that nature of the variable. The variability itself is unwanted and eliminated through research. The two strategies are to isolate the variable, eliminating extraneous forces which lead to variation, or measure the variable many times, under different situations, and average out the unwanted variation.

When we deal with issues of foreign policy and break out the issues into elements such as those shown in Table 1, the typical research strategy would be to polish each element so that each element is as clear as possible, and as simple to understand as possible. That corresponds to the first effort, measuring the variable which has been made as simple as possible, so other factors do not affect the results. The second is to test that single idea with hundreds of people, one idea at a time with each of the hundreds of people. Averaging the results from the large group should provide a stable measure of the response to the variable.

The one-at-a-time method dictates that the researcher presents the respondent with each of the elements, one element at a time as the phrase says. The respondent is instructed to maintain the same criterion, and with that one criterion rate the element. It does matter whether the element is positive, negative, deals with peace, deals with conflict; the respondent is to use the same rating scale all the time.

An ongoing problem in the on-at-time research is the unnaturalness of single elements. There is no context. The rating is easier when all of the test stimuli, the elements, are of the same type, such as military alliances, or economic alliances, educational strategies, and so forth. The respondent reads the elements, all of the same time, and has no problem evacuating the elements themselves. They are commensurate with each other. The problem arises when the elements are different. The differences may be vast, such as economic policy versus military policy. Although the researcher can instruct the respondent to use the same criterion, it is not clear that the respondent can actually do so.

A better approach, one which removes some of the artificiality of the one-at-a-time method, works by creating combinations of ideas. This is the approach used by Mind Genomics. Rather than forcing the respondent to maintain the same criterion with palpably different types of statements, Mind Genomics puts together the ideas or statements into small easy to read combinations, such as that shown in Figure 1. There is no effort to polish the combination, or to create connectives so that the combination is even more natural looking, appearing like the paragraphs that the respondent is comfortable evaluating. Although the critic might aver that the combination is not polished, that there are no connectives, that some of the laws of grammar are violated, the reality is that the combination forces the respondent to adopt one criterion and keep it b3cuase it is impossible in a Mind Genomics experiment to continue to shift judgment criteria to match what ends up seeming to be an ever-changing set of random combinations of ideas. The easiest way is to maintain one’s judgment criteria in the face of ever-changing combinations.

fig 1

Figure 1: Example of a four-element vignette. Each respondent evaluates 25 unique vignettes. The vignettes for each respondent differ from each other.

The combinations themselves may appear to the respondent to be utterly random. Nothing can be further from the truth. The combinations are created according to an experimental design (Gofman & Moskowitz, 2010). The experimental design comprises specific combinations, allowing the variables to interact, but making sure that the 20 elements in this particular case are presented iso that they are statistically independent of each other. That statistical independence is accomplished by the specific combinations. The design comprises 25 combinations or vignettes. Each vignette has a specified number of elements, at most one element or answer from any question.

The vignette structure is:

Two elements in the vignette – 2 of 25 vignettes

Three elements in the vignette – 4 of 25 vignettes

Four elements in the vignette – 11 of 25 vignettes

Five elements in the vignette – 8 of 25 vignettes

Although some critics might aver that the vignette has to be complete, with one element from each of the five categories, the reality is that respondent have no problem dealing with the sparser vignettes. The problem is the attitude of the researcher who wants completeness.

The basic design of 20 element embedded in 25 vignettes is a very efficient design. The breakthrough is design came around 1998, when the notion emerged of a permutable design. That is, one could create the basic mathematical structure of the design, specifying the combinations, and so forth. Once this was done, i was simple and straightforward to create a basic design, and then permute it, changing the elements, but maintaining the design structure. That meant renumbering the elements but keeping the elements in the same category. Thus, A1 would become A2, A5 would become A4, and so forth. The renumber would be done for all elements. This strategy, described in detail by Gofman and Moskowitz (2010), maintained the structural integrity of the experimental design, but recrafted the design slightly to cover many more of the possible combinations.

Figure 1 shows an example of a four-element vignette. The physical layout is simple, one phrase atop the other. There is no indication of categories or questions, simply a combination of the elements. No effort is made to connect the combinations.

Step 3 -Execute the Study (viz., Experiment) Online

The actual study was executed through an on-line panel provider, specializing in recruiting respondents and providing them for these studies. The company, Luc.id Inc., in Louisiana, USA, is an aggregator of respondents from various panels. Working with a panel provider such as Lucid. makes the process easy. Over the past two decades it has become increasingly difficult to recruit one’s own panelists, especially for interview or experiments lasting 10+ minutes. The refusal rate has skyrocketed. As a consequence, the panel providers can deliver a group of respondents, generally filling easy specifications, for a reasonable price.

The respondents were invited to participate. The respondents were shown the following orientation. Note that a link was given for further reading about the JCPOA.

box

By way of background Wikipedia as this this writing (Fall 2020) presents a background to the JCPOA, the Joint Comprehensive Plane of Action, which was signed in 2015.

Under the JCPOA, Iran agreed to eliminate its stockpile of medium-enriched uranium, cut its stockpile of low-enriched uranium by 98%, and reduce by about two-thirds the number of its gas centrifuges for 13 years. For the next 15 years, Iran will only enrich uranium up to 3.67%. Iran also agreed not to build any new heavy-water facilities for the same period of time. Uranium-enrichment activities will be limited to a single facility using first-generation centrifuges for 10 years. Other facilities will be converted to avoid proliferation risks. To monitor and verify Iran’s compliance with the agreement, the International Atomic Energy Agency (IAEA) will have regular access to all Iranian nuclear facilities. The agreement provides that in return for verifiably abiding by its commitments, Iran will receive relief from the U.S., European Union, and United Nations Security Council nuclear-related sanctions.

https://en.wikipedia.org/wiki/Joint_Comprehensive_Plan_of_Action

The study was complete by 85 respondents, recruited by Luc.id. The base size of 85 suffices for a simple but often deep focus on the topic. The reason for the need for fewer than the hundreds of respondents in conventional survey work is that the research is searching for patterns, not for a precise measure of one point.

Step 4: Prepare the Data for Analysis by Creating New Binary Variables

The Mind Genomics exercise produces a great deal of data, since each of 85 respondents evaluated 25 different vignettes on two types of attributes, a degree of belief in the meaningful agreement (1=Definitely No … 9 = Definitely yes) and a selection of the emotion that would be felt by Iran, if Iran were a person.

Our goal is to link the 20 elements to the ratings and the emotions. We do that in the next section. In this first section we transform the 9-point rating to a no/yes scale. Managers find it easier to work with binary scale, rather than to talk in percentages. Following the convention of previous efforts with Mind Genomics and the 9-point scale, we recode ratings of 1-6 to 0 (low probability), and ratings of 7-9 to 100 (high probability). The recoding could be made more stringent or less stringent. There is no ‘right answer,’ just appeal to previous processes. We do the same type of recoding for the emotions. We recode emotions as positive) negative). (Positive: Happy, Relieved, Victorious; Negative: Defeated, Fearful)

Thus, each vignette ends up with three numbers. One for the binary recode for probability of meaningful agreement, one for a positive emotion, and the complement for a negative emotion. The numbers are either 0 or 100. When it comes to the positive versus negative emotion, one of the two variables will take on the value 100, and the other by definition will take on the value 0

Finally, vanishingly small random number is added to every newly created binary scale. This random number does not affect the results but does avoids a problematic statistical issue emerging from OLS (ordinary least0squares) regression occurring when the respondent selects all ratings for question 1 (meaningful agreement) either 1-6 or 7-9 (all 0’s or all 100’s across the 25 vignettes) or select all emotions as positive or all emotions as negative.

Step 5: Compute Means for to Better Understand the Patterns of Responses

By Step 5 we have already put the data into a form that makes it easy to compare average ratings (the focus of this step), and to link the elements to response (focus of Step 6).

We can explore the quality of the data by computing averages, considering both the number of elements in a vignette as a stratifying variable, and considering the order of testing as a stratifying variable. Even without knowing which elements are present in a vignette, we can ask whether there are any differences in the average ratings assigned to vignettes of 2,3,4 or 5 elements respectively, in terms of the binary transform of likelihood of agreement (TOP 3), and for the average Positive and average Negative emotions.

To answer the foregoing questions means simply to identify each vignette in two ways, first by the number of elements (2, 3, 4 or 5, respectively), and second by the position in the respondent’s sequence (first third, second third, final third).

Table 2 that there is no difference by position in terms of how it covaries with either likelihood to reach agreement (Q1) of emotion selected.

Table 2: Average values for TOP3 (likelihood of an agreement), and emotions selected (positive, negative) versus order of testing, and the number of elements in a vignette.

Q1 Top 3

Positive Emotion

Negative Emotion

Order in the sequence of 25
Vignettes 1-8

35

48

52

Vignettes 9-16

30

47

53

Vignettes 17-25

32

48

52

Number of elements
2

38

55

45

3

33

53

47

4

31

48

52

5

32

42

58

Table 2 also shows no effect of number of elements in terms of affecting the likelihood to reach agreement. There is, however, a quite strong and inverse covariation between the number of elements in the vignette and the selection of a positive emotion. Shorter vignettes are perceived as more likely to generate a positive emotional response by Iran, perhaps because the terms are defined, and the permission is direct. That is, shorter vignettes may leave less ‘wiggle room’, ‘and less ‘fine print’ in the agreement.

The final topic of our surface is analysis is to get a sense of how the respondents feel about what they are reading. Question 1 allows us a sense of whether respondents feel optimistic about the process, viz., that it will happen, or feel pessimistic. Question 2 give us a sense of their emotions. Let us average the ratings from their reactions to their own 25 vignettes, independent of what is in the vignettes. (Although, we know that each element appears equally often in the 25 vignettes; it’s just the combinations which vary).

Figure 2 shows a scatterplot of the average score for ‘reach agreement’ (% rating 7-9) vs. the average percent of selections of a positive emotion. Figure 2 shows a concentration of respondents on the left, with low average value of TOP3. We conclude from this that the individual respondents, on average, feel that the agreement will not be reached. There is no sense, however of a preponderance of emotions. Respondents simply do not seem to be able to figure out what the feelings of the Iranians will be a finding which should not surprise. Response can feel strongly about the outcome but not feel strongly about the expected feelings emerging from that outcome.

fig 2

Figure 2: Scatterplot showing the average ratings for reach agreement (abscissa, TOP3) versus the percent of times that a positive emotion will be experienced by the Iranians.

Step 6 –Relate the Elements to the Ratings

As of today’s state-of-the-art, the pinnacle of the analysis is the ability to relate the presence / absence of the 20 elements to the response, whether the response be the TOP3 (strong likelihood of that there will be an agreement), or the selection of a positive emotion, and finally the selection of a negative emotion. Mathematically, the selection of positive versus the selection of negative emotions are complements of each other. We will be dealing with both, because in our presentation of data will look only at strong performing elements driving positive emotions, and strong performing emotions driving negative emotions, and in turn NOT presenting data from elements which do not strongly engage of or the other.

The experimental design allows us to create both group models and individual-level models relating the presence/absence of the 20 elements to the response. The original design was set up to allow a simple regression equation to describe the data: Response = k0 + k1(A1) + k2(A2) … k20(E4). Recall that each respondent evaluated a unique set of 25 vignettes, comprising a permuted variation of the original design, a variation known to ‘work’, viz., to mathematically identically to the original design.

The first analysis created models relating the presence/absence of the elements to the actual rating of Question 1 on the 9-point scale. Although we will be looking at a transformed variable (TOP3 instead of the 9-point rating), it is instructive to see the degree to which our 85 respondents generate data which is consistent. We measure consistency by estimating the equation, and computing the goodness of fit, the multiple R, the multiple correlation. The multiple R goes from 0.00 (no fit of the variables to the ratings; totally inconsistent results) to +1.00 (perfect fit of the variables to the ratings, totally consistent results which trace the ratings precisely to the presence/absence of the elements).

Figure 3 shows the distribution of the 85 ratings. We can feel confident about the data. Even though most respondents feel that they are ‘guessing’, that they cannot figure out the ‘correct answer,’ our estimation of consistency suggests that the results are reasonably consistent.

fif 3

Figure 3: Consistency of the results for the 85 respondents, shown by the Multiple R statistic estimated from the individual-level multiple linear regressions.

Step 7: Divide the Respondents by the Pattern of the Coefficients to Create Mind-sets

Our last analysis divides the respondents by the pattern of their coefficients. For each respondent we create a model or equation whose dependent variable is TOP3, previously defined as taking on one of two values. The values depend upon the original rating of Q1, the probability of reaching an agreement. Recall that ratings of Q1 1-6 were coded 0, ratings of 7-9 were coded 100.

The database generated from the individual-level regressions comprises 85 rows, one row corresponding to each respondent. Each row comprises 21 columns, one column for the additive constant, and 20 columns for the 20 coefficients. The objective of clustering is to divide this group of 85 ‘objects,’ viz respondents into a limited number of non-overlapping groups, the clusters or mind-sets, based upon a mathematical criterion. The criterion does not require the researcher to know the ‘meaning’ of the measures, viz., in this case the coefficients, but simply to have each object quantified on each measure. Thus, we have 85 objects (people) on 20 measures (coefficients). We do not consider the additive constant in the process.

The clustering program is a heuristic. There are many different clustering programs. The program used here is k-means (Likas et. al., 2003), with the objective of putting the 85 people into either two groups (analytic pass 1) or three groups (analytic pass 2). The criteria are that the profiles of the 20 averages (one per coefficient A1-E4) should be ‘far away from each other’, and the distance between the objects or people in a cluster should be as small as possible. The criterion for distance is (1-Pearson Correlation Coefficient, R). The Pearson R shows the strength of a linear relation between two variables, taking on the value +1 (viz., Distance = 0) when they are perfectly linearly related, and taking on the value -1 (viz., distance = 2) when they are perfectly inversely related Our criteria for choosing the ‘best’ number of clusters combines a desire for parsimony (fewer clusters are better than more clusters), and interpretability (the clusters must tell a coherent story, and the stories of the clusters must differ from one another).

The two-cluster solution, although parsimonious, seemed too jumbled. There was no clear story. The three-cluster solution seemed a bit better. A four-cluster solution was virtually no different in types of groups than the three-cluster solutions. That is, two of the clusters in the four-cluster solution seemed quite similar. The decision was to work with a three-cluster solution.

In the language of Mind Genomics, the cluster becomes a mind-set, a way of responding to a limited set of related stimuli. The min-sets are constructed from the patterns of the coefficients form the 85 respondents who participated in this study. Over the years, the mind-sets which emerge from these focused, quite small studies, continue to repeat. The repetition comes about because when we abstract the type of individual based upon the pattern of responses, we end up with just a few really quite different groups. The psychologists called the ‘archetypes’, but the archetypes emerging from Mind Genomics are based on small, single-focus studies. Yet, again and again, these mind-sets continue to appear in many different ways. The great anthropologist, Joseph [12], would call this the ‘hero with a thousand faces.’

Step 8 – The Total Panel and the Mind-sets

The Mind Genomics effort naturally brings with it many numbers, for this study 21 numbers for each group, or 84 numbers for the combination of total panel and the three mind-sets. The objective of these studies is to find patterns, and not to overwhelm ourselves with numbers which may end up disguising the patterns in the dense undergrowth of numbers. To counteract the death by wall of numbers were show only positive coefficients of 8or higher. These strong performer in a Mind Genomics study. We may be losing some information by this stringent cutoff, but a coefficient of +8 or higher is strongly significant from the regression modeling, with a t statistic approaching 2.0.

Table 3 shows the total panel and the three mind-sets, created for the results from Question 1, on the likelihood of an agreement. The cluster uses the coefficient emerging when TOP3 is the dependent variable. The table shows base size first, then the additive constant, and then the strong performing elements for each mind-set.

Table 3: Performance of the strong performing elements for total panel and three emergent mind-sets. Only the seven elements with coefficients of +8 or higher are shown.

table 3

The additive constants are 32-38 meaning that without additional information, but just knowing that there are negotiations, about one in three responses to the vignettes are 7-9. We know this because the additive constant tells us the likelihood of a rating of 7-9 in the absence of elements, and is a purely theoretical, computed value. Nonetheless, the additive constant gives us a good sense of basic response. It is remarkable that all three mind-sets agree so well. This is unusual. The agreement means we are dealing with specifics.

When we look at the column for total panel, we find NO strong performing elements that disappointing finding does not mean that we failed in this attempt, although it might mean failure. Our success in the study comes after we deconstruct the total panel into the three groups, based upon patterns of coefficients, not upon magnitude of coefficients. That is, our three mind-sets would have emerged if all of the coefficients were equally reduced by 20 points. In such a case three mind-sets would emerge from the patterns, but NO elements would emerge as being strong.

Before we go into the three mind-sets, which is now quite simple, it’s worth remarking that we began with 20 elements, the best guesses from people involved. Yet, only seven of the 20 elements emerged as strong, no elements emerged as strong for total, and surprisingly, each strong performing element appeared strong only in one of the three mind-sets.

The min-sets are easy to describe. One simply looks at the strongest element.

Mind-Set 1 = Focus on military aspects (prevention) – 29 of the 85 respondents

Mind-Set 2 Focus on economic development – 45 of the 85 respondents

Mind-Set 3 – Focus on effective negotiations and diplomacy – 11 of the 85 respondents.

We move now to the elements which drive strong positive and strong negative responses. The coefficients in Table 4 emerge from six regressions. The six regression comprised three regressions for the selection of a net positive emotion, and three regressions for the selection of a net negative, in both cases two regressions for each mind-set, respectively. The regression model was run without the additive constant, because of the previously conventions in Mind Genomics practice, that emotions and other selections emerging from the nominal scales are estimated without coefficients.

Table 4: Strong positive and negative emotions selected by the respondents from the three mind-sets as they think about the feeling emerging from Iran, as driven by the element. Only coefficients of +16 or higher are shown.

table 4(1)

table 4(2)

This time we look only the elements which drive a percent selection of 16% or more, for either a positive or a negative emotion. Table 4 shows us that only one mind-set, MS1 (focus on military aspects, prevention) feel that there will a strong positive response. All three mind-sets feel that there will be a strong negative emotion from Iran.

Discussion and Implications

When this study was executed in 2016, Mind Genomics was just beginnings its broader application to international relations, having begun in 2012 with studies of the Israeli Palestinian conflict. The realization at that time, confirmed by many subsequent studies in a variety of areas, is the relative paucity of solid information about the mind of the citizen in the world of social issues, the mind of the customer in the world of commerce, the mind of the patient in medicine, the mind of the client in legal and business issues, and so forth. There were dozens of polls, dozens of learned volumes on key issues, the ongoing broadcasting, and increasing ‘natter’ of the media with ‘talking head’ proclaiming the same new, spun one or another way.

A cursory content analysis of the literature, of the media, and so forth brings out facts, histories, opinions, and the voice of the citizen. The voice of the citizen, however, appears to be limited to simple factoids, statements, voting on issues. Furthermore, there seemed to be a desire to compare changes, and by that comparison to get a sense of where things were going. In other words, the focus was on the macro, with little content, and the depth was assumed to emerge by observing the path of the macro trends over time, perhaps with an effort to see how the trend covaries with exogenous factors, like world order world economics, and so forth. And perhaps even the world’s ‘Zeitgeist’ although Zeitgeist might be more the bias of the analyst than the reality of the items. There are examples of iterated efforts, such as China’s policy [13], but these iterations are large-scale, in the manner of iterating products, rather than ideas.

Enter Mind Genomics, here presented as the first experiment on international relations, at a time when Mind Genomics was conceived of as a one-off process, requiring a lot of thinking, a great deal of expertise for choosing the ‘right material’, and the careful efforts which accompany a scientific project. There were 85 respondents, rather than the customary hundreds of respondents, but that is not a problem. the problem here is the fact that the Mind Genomics study at that time was considered as a final effort, a one time ‘deep dive’ into the mind of the citizen. And the results are what they were, pointing to different mind-sets, but with remarkably few elements performing strongly, either in terms of driving agreement or driving emotions.

The methods of Mind Genomics have been proven again and again, in the legal, [14] medical [15] and commercial realms [16]. In those realms, the efforts of Mind Genomics have evolved from one-off, large-scale studies with 36 elements down to the current size of 16 elements (four questions and four answers to each question). The notion of the ‘final experiment’ has given way to Mind Genomics as a fast, iterative, learning=based process. Within that world-view, this study would be updated by a series of short studies, each requiring about 60 minutes to set up on publicly available program (www.BimiLeap.com), and then executed with 50-100 respondents automatically with 60-90 minutes, and the entire data set totally analyzed 10 minutes, and returned to the researcher. One might imagine the use of the iteration as a way both to arrive at good ideas, acceptable to both sides, as well as a consensus-building method, wherein both sides cooperate, and thus build good will.

In the evolution of political science, and the evolution of knowledge of people, these early studies by Mind Genomics of political issues show the potential of a systematic exploration of a topic. When that exploration becomes inexpensive, quick, easy to execute on the internet, and most importantly, ITERATIVE, we have the potential a new political science, one based upon data, extending across many countries, many people, over time, and many topics [17-19]. What was one study in 2016 could well generate a wiki of the mind for the topic of dealing with Iran, that ‘wiki’ filled with data, topic-related, and searchable for specific results and for general patterns [20-22].

Acknowledgments

The author would like to acknowledge the help of four associates who helped to design the study.

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fig 1

Talking Across Divisions Inside a Community, and Across Lines of Hatred: The Contribution of Mind Genomics

DOI: 10.31038/MGSPE.2022212

Abstract

We present the results of two Mind Genomics cartographies, each focusing on the discovery of common points of view in areas of political disagreement (discussions about Israel among New York City Jews), and areas of open hostility (discussions about what is needed to stop hostilities and begin a peaceful future enjoyed by Palestinians and Israelis). The cartographies searched for specific messages which drive respondents to feel that these messages ‘will work.’. We suggest that an iterative, inexpensive, rapid set of such cartographies can quickly reveal common mind-sets in mutually argumentative and even openly hostile populations. The promise of such iteration is the discovery of topics of mutual interest and agreement in a manner which is practical, which increases insight and wisdom, and which can produce reference databases about the mind of the antagonist, becoming a guide for productive negotiations. We suggest that the effort to find the ‘right messages’ through extensively reasoned efforts followed by an effort to validate these messages be replaced by a mechanistic, iterative, rapid, inexpensive system requiring just a few hours from start-to-finish for each iteration.

Introduction

The world of people is no stranger to difficult issues. Whether the issues are people vs. the environment (viz., global warming), people vs. economic realities (we all cannot really live equally well), or people vs. people (long standing political disagreements, quick starting personal disagreements), there are always conflicts. And there are no prospects for the conflicts to end, or even to be resolved simply. Efforts as grand as the League of Nations and the United Nations, or as intimate as couples counseling continue to reveal the almost absolute impossibility of imposing harmony in an environment when there are different goals, different viewpoints, different levels of power and influence.

The foregoing is a truism. Anyone reading newspapers, sitting in a political debate, or sitting in a home with adolescent children and their parents know about the need to find ways to have meaningful conversations. The real issue is how to do it. Conversations themselves will not solve problems, but without the conversations the problems will never be solved, except through force. And force will not keep the problem solved when the balance of power shifts, when the anger builds. Conversations will help the parties involved come to an agreement, accepting each other. This paper focuses on two difficult problems, one involving the New York Community of identified Jewish people, and the other involving Palestinians and Israelis. The objective of both studies was to assess whether one apply a method hitherto used by marketers (Mind Genomics) to issues of public discourse, and specifically, divisions about Israel. The first was from the point of view of Jews in the United States, where there are many opinions about Israel, not all positive, not all negative [1-5]. The second was from the point of view of self-described Israelis and Palestinians [6-9]. The two projects were run during the two-year period 2012-2014 to determine what Mind Genomics might contribute.

Moving from Opinion to Experiment

It is obvious to anyone who observes the behavior of people, whether dealing in the worlds of goods or services that people differ from each other. Differences can end up being a simply a nagging reality which gets in the way of efficient activities, whether social, economic, and so forth. Indeed, there is an old French proverb, translated into English as ‘Of taste one does not dispute.’ The smart professional knows these differences exist, the experienced professional knows about the nature of these differences, and the effective professional knows how to work with these differences to achieve objectives. In their minds people live in different worlds; one size does not fit all. People need to hear different things. The smart marketer recognizes these different worlds, often establishing them by one or another research effort such as focus groups, in-depth interviews, surveys, and now more recently observing the behavior of a person over time in terms of what the person searches for or how the person shops on the Internet. The smart marketer then digests this information and feeds back a (presumably) motivating offer to the individual using messages which seem to be in line with what the person has done, said, or even looked at.

How can this knowledge-based approach be used in situations where there is natural disagreement, conflict? Is there a way to deeply understand the mind of people in conflict, whether the conflict is open and mutually aggressive, like war, or simple civil disagreement? In other words, if the knowledge-based approach can be used to sell soap, can it be used to sell or at least to message ‘peace’.

The Mind Genomics Worldview

In the 1960’s mathematical psychologists R. Duncan Luce and Patrick Suppes introduced what then was an esoteric paper, presented in the first issue of the Journal of Mathematical Psychology, and as the first paper of that issue. The title of the paper was daunting: Simultaneous conjoint measurement: A new type of fundamental measurement [10]. The focus of psychologists in the 1960’s was to establish the science of measurement, doing so in what was called the ‘axiomatic measurement’. The elegance was at first mathematical. Over the years, the importance of the thinking behind this new method, conjoint measurement, would overshadow the mathematical elegance. This then-esoteric approach would be a way to deep, often profound knowledge about how people think, knowledge that could be applied in a practical way to problems of everyday life. Conflict is one of those problems.

The basic idea behind conjoint measurement is that one could ‘measure’ ideas by putting them in combinations, getting responses to the combinations, and somehow deconstructing the response to the contribution of the separate ideas. The mathematics of the approach, the various postulates, lemmas, and so forth, are no longer of interest to most people, although remain of great import to mathematical psychologists. What is important is the notion that by measuring responses to combinations which simulate ‘reality’, one can deduce the part-worth contribution of each component of the combination.

The immediate importance of this discovery comes from the realization that the typical approach in science including social science, is to isolate the factors, control everything, and measure the response to those factors. Thus, in a study of conflict, for example, or in a study of tomato sauce in contrast, one might look at a set of single factors in a questionnaire and ask how important the factor is to drive negotiations for conflict or drive acceptance for tomato. The process breaks down for tomato sauce because tomato sauce is meaningless unless the mixture is created. Asking a person ‘how important is sweetness’ in tomato sauce is meaningless because the taste profile and smell and appearance profiles must be correctly balanced. So, when it comes to products, importance is not a meaningful topic. It is the mixture.

Moving now to conflict, it is hard to understand how to rate ‘openness to negotiation’ vs. rating ‘Having evidence about one’s point of view’, in terms of importance. It can be done. Most questions about ‘importance’ and aspects of the topic rely on this one-at-a-time effort. The effort certainly does not work for products, although it may work for more complete descriptions of products. The effort may or may not work for the topic of ‘discussions’, although showing that the one-at-a-time approach does not work for topics of ‘discussions’ and ‘arguments’ is harder to prove because we are dealing with simple ideas which have meaning.as.

Evolving from Compound Mixtures to Systematic Variation – The Contribution of Mind Genomics

Mind Genomics emerged in the early 1980’s, with work done under contract for a number of companies, one of which deserves both acknowledgment and thanks. This was the Colgate Palmolive Company of Canada, and its visionary general manager at the time, the late Mr. Court Shepard. As the general manager, it was Mr. Shepard’s simple objective to increase the company’s sales, rather than to simply do his job well and protect his job in any way he could. Mr. Shepard confessed at a meeting that he did not know what to say about Colgate Dental Cream to increase sales, a statement which led to the discussion of how a ‘different’, and possibly more complex but powerful method might help. The method involved mixing messages together in a systematized way using the statistical discipline of experimental design, presenting the combinations, obtaining ratings to the combinations, deconstructing the ratings to the contribution of the different messages, and then discovering which messages ‘worked’. To his credit, Mr. Shepard said ‘yes’, and within a week the study was run, analyzed, and the results implemented. Sales increased. The lesson from that early experiment, fall, 1980, was that systematics work. The respondent, the person evaluating the test combinations need not be an expert. In fact, what happened was that the respondent became disinterested in the task, and answered almost ‘automatically’, without thinking.

The approach ended up descending deeply into the mind of the respondent, even for such a mundane product as toothpaste or dental cream. What becomes important in this regard is that the results could not be faked. There could emerge a ‘stance,’ driven by one’s conscious beliefs. The mixtures of messages prescribed by experimental design, whether of dental cream or of social issues and feelings, were simply too hard to disentangle at an intellectual level. When the messages comprised three or four different ideas, seemingly thrown together, even the person who wants to ‘fake’ the study cannot figure out what to do to bias the results. One could answer randomly, but that is quickly revealed by a statistical analysis of how well the ratings co-vary with the presence/absence of the elements. In the end, the respondent relaxes, and in a somewhat bored way, reads the vignettes, and ‘guesses’.

To summarize the first part of the Mind Genomics effort emerged from the creation of mixtures of messages (elements) using experimental design, the evaluation of these mixtures by respondents, and then the deconstruction of the responses to the contributory impacts of the separate elements. There is a second part of this, one which is just as important. This second part is the discovery of mind-sets, of groups of people who respond in similar ways to sets of elements. These groups, mind-sets, are not necessarily similar in who they are, or what they buy. They are similar in the pattern of their responses to the elements but may be radically different otherwise. Yet, knowing these mind-sets allows the marketer to tailor the messages to a mind-set. That knowledge would prove invaluable for marketers, because it was simple to change the message in a knowing way to appeal to the mind-set. The discovery seemed to be like having an experienced salesperson involved in every messaging effort, a person who would know ‘what works.’ Only there was no person, just a simple algorithm to create these mind-sets, and then to uncover these mind-sets in new populations, groups who may never even have been encountered before.

Applications of Mind Genomics

The foregoing presented the theory of Mind Genomics. The two experiments presented here show the approach of Mind Genomics to issues of prospective conversations about Israel first, and then the Palestinians and Israel. The objective of the two experiments, both done around 2012, ten years ago, was to identify the common topics of conversation which could heal potential fractures in the relationship of people. The Mind Genomics process follows a set design and analysis approaches, created to produce ‘actionable’ data sets in days, and thus be amenable to continual improvement, at low cost, and in a speedy, efficient, knowledge-building way.

The background and processes of Mind Genomics have been written about for more than 15 years, and can be found in a variety of papers, some dealing with the general method and applications (e.g., [11]) others dealing in more depth with specific applications, such as the law [12], charity donations [13], environmental considerations [14], digital marketing [15], and so forth. Some of the seminal experiences in the formation of the emerging science of Mind Genomics appeared almost 15 years ago in a book Selling Blue Elephants: How to Make Great Products that People Want Before They Even Know They Want Them [16].

The Mind Genomics process follows these seven steps:

Step 1 – Define the Topic, Create a Set of Questions Which Elaborate the Topic, and for Each Question Create a Set of Answers

The Mind Genomics ‘template’ provides a structured system to focus the researcher’s effort. For these two projects presented in this paper, the experimental design comprises a topic, six questions elaborating the topic, and in turn six answers to each question. It is important to keep in mind that the Mind Genomics effort lends itself naturally to fast feedback and iteration. Thus, the elements need not be worked and reworked until ‘perfect.’ Rather, it suffices to have a reasonable set of elements. It is very straightforward to run the study, considering it as a first iteration. The results, when returned, can always be improved, and the study re-run in a few hours using new elements to replace the elements which did not perform well.

Step 2: Create Vignettes, Combinations of Elements

The vignettes are put together according to an underlying plan, the so-called experimental design [17]. The design for these studies prescribed precisely 48 combinations, vignettes, 36 of these vignettes comprising four elements, 12 of these vignettes comprising 3 elements. Each element appears exactly five times in 48 combinations and absent from the remaining 43 combinations.

An important feature of Mind Genomics is the ability to cover as much of the design space as possible. The design space is another way of describing the many possible combinations that could emerge from creating 48 vignettes, and it is in this precise point that Mind Genomics differs from conventional research. Conventional research would create 48 vignettes, and then have many respondents test the same 48 vignettes, with the objective of reducing the variability of measurement. That is, conventional research implicitly limits the focus of the effort, creating what is thought to be correct, and spending the time, money, and effort on validating the guess. There is little learning to be gained as one goes along the research path. The hope is that the research can ‘intuit’ what to do next when the effort fails, recognizing that the research steps are not iterative, but rather evaluative. Iteration thinking is not built in, but rather becomes an unwanted necessary step when the research fails to confirm the ingoing intuitions manifested in the test stimuli, here the 48 vignettes combining the 36 elements.

In contrast to the above, Mind Genomics takes as its cue the approach represented by the MRI, the magnetic resonance imaging, used in medicine. The MRI takes many pictures of the underlying tissue, each picture from a different angle. Afterwards, through a computer program, the MRI combines these pictures to get a better idea of the underlying tissue, one in three dimensions. No single ‘picture’ is right. Each picture is ‘noisy’, and not useful by itself, but it is the pattern emerging after combining the pictures which is realistic.

Step 3: Define the Rating Scale

The rating scale is the way that the respondent can communicate with the research and give her or his opinion. In these two studies, the rating scales were 9-point scales (Likert or category scales), anchored at each end.

The 9-point scale is simple, easy to use. The ratings for the scale, however, the nine points, are hard to understand for the manager, despite being easy and widely accepted by researchers. Common practice for the past decades is to transform the scale to a binary scale, a yes/no scale. Managers can easily understand the scale. Ratings of 1-6 were transformed to 0; ratings of 7-9 were transformed to 100. This transform converted the scale to a format that managers can more easily understand. The transformation is accompanied by the addition of a vanishingly small random number (~ 10-4). This small number prevents the analysis program (OLS, ordinary least-squares regression) from ‘crashing’ when it tried to deal with a set of data all of which have either value 0 (all vignettes had been rated 1-6), or values of 100 (all vignettes had been rated 7-9).

Step 4: Invite the Respondents to Participate

The respondents are invited by professional groups, called online panel providers. It is always tempting to save money and provide panelists from one’s ‘network’, but the reduced cost turns of out to be one of the most expensive ‘savings.’ With 304 respondents participating for the New York study, and with 158 respondents for the Israel Palestine study (about half Israelis, half Palestinians), the judicious approach is to hire a professional organization to provide the panelists. The organization does so at a reasonable fee, which allowed each study to be completed in less than 24-48 hours, without effort by the researcher.

Step 5: Orient the Respondents in the Task

It is best to provide as little information as possible about what is really expected, and instead simple introduce what the study is about, and some of the necessary information, such as the length of the interview (very important), the fact that the all the vignettes are different, and that there are either one or two rating scales. Often respondents who participate, evaluating 48 vignettes, feel sure that they have ‘seen this vignette before.’ They could not have, but it matters little, and it is important to assure them that they are seeing stimuli that have been meaningfully crafted.

Step 6: Create Equations (Models) Relating the Presence/Absence of the 36 Elements to the Binary Ratings (0/100)

The equation is written as: Dependent Variable (Top 3) = k0 + k1(A1) + k2(A2) … k36(F6). The foregoing equation deconstructs the response to the vignettes, so that we begin with an additive constant, and then estimate the part-worth contribution of each element to the dependent variable. The additive constant is the estimated value of the dependent variable (0 or 100), in the absence of any of the 36 elements.

The additive constant is a purely estimated parameter. It has no real existence, but it can be used to estimate the proclivity of the respondent to rate a vignette as 7-9 in the absence of elements. Of course, by design, all of the vignettes comprised 3-4 elements, so the additive constant cannot really exist. Nonetheless, as we will see, the additive constant gives us a sense of the degree to which a respondent is ‘ready’ to say something, even without evidence.

When we see high additive constants, we can be sure that the respondents feel strongly and positively towards the topic. In contrast when we see low additive constants, we can feel strongly that the respondent is not predisposed to rate the vignettes high but rather waits for the momentum imparted by just the right elements to carry matters forward.

The 36 coefficients each reflect the marginal, or part-worth contribution of the individual element to the value of TOP3. When the coefficient is 0, we conclude that the element has no ability to drive the response. When the coefficient is positive, we conclude that adding the element to a vignette increases the percent of respondents rating that vignette 7-9. For example, a coefficient of +5 for an element means that when the element appears in the vignette, an addition 5% of the responses will be 7-9. In contrast, when the coefficient turns out to be -5, we conclude that when the element appears in the vignette, 5% fewer of the responses will be 7-9. We don’t know whether the 5% fewer will migrate to very strong negatives (viz., 1-3) or migrate to mere indifferences (viz., ratings of 4-6).

From the point of view of statistics, the coefficients usually end up with standard errors of approximately 4-5, meaning that we should pay strong attention to elements with coefficients of 8 or greater. We should pay attention to all positive coefficients, but the elements with high positive coefficients, 8 or greater are really important.

The Mind Genomics method ends up producing many numbers. For example, just looking at the total panel coefficient can be overwhelming. There are 37 numbers to consider when searching for a pattern, the additive constant and be coefficient for each element A good practice, one adopted here, is to present only those coefficients that are noticeably positive (2 or higher) and ignore those coefficients which are 1 or lower. Furthermore, when an element has no coefficients for any group which are positive, it is not instructive to present that element. The element ends up taking up room, and not teaching anything. In the data tables presented later in this paper many elements do not appear because they fail to produce impactful statements.

Step 7: Create Individual Level Models and Use the Coefficients as Inputs to Clustering

Clustering will identify new-to-the-world groups (mind-sets) based on the patterns of responses to the messages. We are taught to think of people in terms of who they ARE, what they DO, and what they say they THINK/BELIEVE. Marketers call this segmentation.

The standard ways of dividing people, so-called geo-demographics, can generate a large vector of information about a person, based upon gender, age, income, education, marital status, and so forth. In the 1960’s, William Wells, a market researcher working in advertising introduced the notion of psychographic segmentation [18], a way to divide people by the pattern of what they believed when the topics were lifestyle, beliefs, etc., so-called macro-topics. Today’s technologies allow people to be divided by more micro-patterns, such as the way they search on the Internet for specific ‘things.’

In the spirit of dividing people, Mind Genomics looks for groups as well, but this time groups based upon the pattern of responses to a limited, focused issue. These are called mind-sets. A mind-set comprises individuals who think alike in a limited topic, such as the patterns of discussions that they prefer (viz. mind-sets emerging from Study 1 on Jewish discussions or mind-sets emerging from Study 2 on positive outcomes in the conflict between Israelis and Palestinians). The mind-sets are obtained from the pattern of coefficients of the respondents who participated. Recall that each respondent evaluated a unique set of vignettes, but that the mathematical structure of the 48 combinations evaluated by each respondent was the same. The 48 combinations sufficed for a valid experimental design that one creates the set of coefficients for each respondent separately. It is the set of 36 coefficients for each respondent in the study which becomes the basis on which individuals are separated into mind-sets. Individuals with ‘similar’ patterns of 36 coefficients are put into a cluster or mind-set by a mathematical algorithm (k-means; [19]). The outcome is a small set of clusters, which comprise individuals within a cluster having similar patterns of coefficients, and with the patterns of averages of the 36 coefficients different from cluster to cluster. One might envision this as a set of globes, far away from each other (the clusters or mind-sets), but a group of points (respondents) swirling around inside the globe and being close to each other. The number of such mind-sets is left to the researcher. Two criteria have been used to select the number of clusters, parsimony and interpretability, respectively. Parsimony refers to the number of clusters or mind-sets. Fewer is better. Interpretability refers to the fact that the pattern of coefficients, the strong performing elements are similar, and tell a ‘coherent story.’ Not a perfect story, of course, but something which seems to make sense.

As the number of clusters increases, parsimony decreases, but interpretability increases. The act of clustering respondents calls into play a balancing act between creating sets of respondents whose data can be easily understand, and creating at the same time a large number of such groups, so that at the end of the process one is not sure whether the clusters or mind-sets are ‘real’ They may tell interesting stories, but there may be simply too many clusters on which to make generalizations.

We now move to the two studies, first the study of a cohesive group, the Jewish population of New York, and then study of two historically opposed populations, Palestinians and Israelis. Both studies are about discussion, about finding common ground, the first with New York City Jews to bring an ethnic group together, the second with Palestinians and Israelis to reduce tension, and begin to bring the groups together.

Study 1: Search for Common Ground for Discussions about Israel among NYC Self-defined Jews

This study was run under to aegis of Dr. Jonathan Cummings of the Jewish Community Relations Council of New York to determine the features of a venue for productive conversations. We show the elements, the mind-sets, and then where relevant information about the mind-sets (for study 2). Table 1 presents the elements.

Table 1: Elements for the Mind Genomics study regarding common ground for discussions about Israel among NY self-defined Jews.

Question A: What kind of activity is it?
A1 A highly structured single meeting… where people feel free to disagree with each other
A2 People sharing ideas/feelings during a highly structured single meeting
A3 People sharing ideas/feelings during a single meeting with no clear structure
A4 Several highly structured meetings…where people feel free to disagree with each other
A5 People sharing ideas/feelings during several highly structured meetings
A6 People sharing ideas/feelings during several meetings with no clear structure
Question B: Who provides the content?
B1 Group members give presentations… then open the discussion to everyone
B2 A facilitator presents a topic… then opens it up for discussion
B3 A prestigious speaker is invited to the meeting… then every gets a chance to present their views or ask questions
B4 No preparation… whatever is the hot topic of the day
B5 Studying important historical texts… then open discussion
B6 Current events about Israel… then open to Q&A
Question C: What is talked about?
C1 Discuss the peace process between Israelis and Palestinians
C2 Talk about the American Jewish community… their views, their concerns, what’s near and dear to their heart
C3 Talk about the Israel you love!
C4 Discuss how you can stop American Jews from fighting about Israel
C5 Discuss how Israel is part of my Jewish identity or heritage
C6 Discuss Israeli arts and culture as a way to understand Israel better
Question D: Who should be in this conversation?
D1 With people who have a different perspective
D2 With people who want to get to know you personally…to really understand how you think
D3 With people who are very knowledgeable about Israel’s history and current affairs
D4 With people who already have a strong standpoint about Israeli
D5 With individuals who rarely consider Israel in their day-to-day lives
D6 With individuals who are concerned about the divisions in the Jewish community about Israel
Question E: What are the outcomes?
E1 After the meeting, you decide who’s right and who’s wrong
E2 Hear other people’s views and learn how they think about a particular issue
E3 Get to meet and mingle with interesting people
E4 Understand the range of feelings and thoughts on a particular topic
E5 You continue to meet and work together on Israel activities
E6 Nothing changes, but you enjoy it nevertheless
Question F: Where is the venue?
F1 In someone’s living room
F2 In a classroom
F3 At a synagogue
F4 In a conference room at someone’s office
F5 In a restaurant
F6 Over dinner in your home

The orientation was simple, focusing primarily on the process, and providing few specifics about the topic. It is the topic which will be ‘particularized through the elements.

Today you will be taking a survey regarding conversations about Israel in New York’s Jewish Community. Sometimes, talking about Israel can be difficult. Sometimes, we may not want to talk about Israel at all. We are interested in finding out what might make those conversations more satisfying and would like to know your opinion regarding different kinds of conversations with others in the local Jewish community, outside of your inner circle of contacts and friends. It will take you between 10-15 minutes to complete the survey. During this survey, we will show you several scenarios describing different conversations in various discussion settings. Although they may seem similar, please note that each screen combination is UNIQUE.

You will be asked the same question for each test screen: How satisfying would a conversation about Israel be with members of the Jewish community with whom you do not generally converse based on the above: 1 = not at all satisfying…, 9 = very satisfying

Figure 1 shows a sample vignette that the respondent would see, except for the boxed information on the left. These are the ‘questions’, which the respondent never sees. The role of the question is to provide a stimulus for the six different answers.

fig 1

Figure 1: Example of a 4-element vignette shown to the respondent. The respondent does not see the boxed information on the left.

The study was run with 304 respondents. Table 2 shows the strong performing elements. Table 2 suggests that:

Table 2: Result from models for the conversations about Israel among NYC Jews (Study 1).

table 2

  1. The basic level of expected satisfaction from the conversation (additive constant) is moderate for total, for Mind-Set 1 and Mind-Set 2, but quite low for Mind-Set 3
  2. No element drives a feeling of strong satisfaction when we look at the total panel of 304 self-identified Jews in the New York region. The 304 respondents would be considered a homogeneous group, discussing a topic of concern among Jews.
  3. The data suggests dramatically different mind-sets. What appear to be irrelevant elements at the level of the total panel end up being strong performers for the mind-sets?

Study 2: Discussion among Palestinians and Israelis Regarding What Will It Take to End the Conflict (Question 1) and Create Lasting Peace (Question 2)

The objective of Study 2 was to develop a system which could deal with conflicts in a way consonant with the vision of Mind Genomics, namely treat the issue as the conflict of different mind-sets. The second study was run, under the aegis of Professor Peter Coleman and his associates at Teacher’s College, in Columbia University, and under the aegis of Professor Martin Braun of Queens College, City University of New York. The study was run 2011-2012, a decade ago, using the same experimental design as had been used for Study 1 on Discussions about Israel.

The elements appear in Table 3. The elements were created by the team led by Naira Musallam at Teacher’s College. They were designed to be short, easy to read ideas. The elements were created through a process involving depth interviews, ethnography, brainstorming, competitive analysis. Finally, the elements were developed with a psychodynamic and psychoanalytic orientation, dealing with different aspects of needs, wants, and perceptions.

Table 3: Elements for the Mind Genomics study regarding cessation of hostilities and lasting peace.

Question A: What are individual benefits?
A1 Lasting peace will allow me to fulfill my personal dreams and aspirations
A2 Lasting peace will help improve my physical and mental health
A3 Lasting peace will ensure a better future for my children and grandchildren
A4 Lasting peace will allow me to live a much more fulfilling life
A5 Lasting peace will improve my personal economic situation
A6 Imagine what our life would be like if the conflict and occupation had ended 10 years ago
Question B: What positive events are happening or could happen?
B1 Israelis and Palestinians are increasingly working together to address the pending water crisis in the region
B2 The safety and security of our children are completely dependent on the safety and security of their children, and vice-versa
B3 Lasting peace and justice in Israel-Palestine will only happen when Israelis and Palestinians are working together
B4 There are currently many areas of economic, technological, cultural and educational cooperation between Israelis and Palestinians
B5 Israelis and Palestinians both have much to gain from negotiating an end to the conflict and a lasting peace
B6 A solution to the conflict and compromise over Jerusalem and the refugees is possible
Question C: What are the benefits of lasting peace
C1 Lasting peace will bring great economic prosperity to the region
C2 Lasting peace will enhance everyone’s health and well being
C3 Lasting peace here will stand as a beacon of hope for all societies suffering from violent conflict
C4 Lasting peace will lead to vast improvements in the education of our children
C5 Lasting Peace will bring more stability and security to the region
C6 Once a peace agreement is reached, the UN, US, Arab League, NGO’s and the International Community will work together to help maintain a lasting peace
Question D: What are the benefits of ceasing violence?
D1 Freedom from violence and oppression are individual human rights
D2 Committing acts of violence and oppression always have unintended consequences that eventually come back to haunt you
D3 I don’t believe everything I am told by our leaders about the history of the conflict and the occupation
D4 I am eager for a more safe, just, and peaceful life
D5 I believe that Palestinians and Israelis can coexist without oppressing and killing one another
D6 I have a great deal to gain personally from ending the occupation and building a lasting peace
Question E: How can we build a community to incorporate both groups, and what will be the benefits?
E1 Parents would be increasingly able to raise their children in a safe, secure home and community
E2 Communities would be increasingly working to increase fairness, safety, security, and non-violence
E3 Our communities would do more to limit hate speech against members of other groups
E4 The Internet and social media provide ideal places for young Palestinians and Israelis to communicate and share their experiences and interests
E5 Ongoing community exchanges between Israeli and Palestinian youth help our situations
E6 The schools would improve the accuracy and reduce the bias with which history is taught to our children
Question F: What is happening on an international scale
F1 The UN/US/EU and Regional Arab nations are working together to establish less unjust processes for allocation of scarce resources such as land and water
F2 Increasing signs of cooperation are emerging between the Arab League, the UN, US, and EU
F3 More and more people everywhere are developing a stronger sense that they are all members of one global community
F4 Thee UNB/US/EU and Regional Arab nations are increasingly working together to fight crime and corruption in our region.
F5 GPS mapping is showing a significant increase in joint Jewish/Arabic development projects in the region
F6 The increasing number of projects by businesses that encourage entrepreneurship by our youth will substantially improve our economic future.

It is important to note that there is no fixed process for developing ideas. in the end, it is always a matter of creative thinking, of merging the richness of language to describe and the need to portray what should be described.

The respondents read the test vignettes, but this time rated the vignette on two rating scales. The first was the likelihood that this described the situation where the mutual hostilities would stop. The second scale was whether this described a situation which would move to lasting peace. One can look at these two sales as intellectual and emotional, as evaluating what will happen, and what could happen.

Half the respondents were Palestinians, recruited by friends, and half the respondents were Israelis, also recruited by friends. There was no pre-screening about attitude. Rather, the respondents simply were introduced to the topic with an explanation of the scale.

The study was set up so that the 158 different experimental designs were divided, so that the first set of unique designs was allocated to the Palestinians (with study totally in Arabic), the second set of unique designs was allocated to the Israelis (with study totally in Hebrew), and then the process repeated. The data for the Palestinians and for the Israelis were treated as one large group, both for clustering into mind-sets, and for reportage of results. This is possible because to the computer we are dealing with 158 respondents, all evaluate vignettes from the same large design.

Once again, the focus of the study is the identification of groups of like-minded individuals existing in groups which are in conflict.

Figure 2 shows the orientation pages in Hebrew and Arabic. Figure 3 shows examples of what the respondents saw in terms of vignettes. Since there were two rating questions, the vignette remained on the screen, the rating question changed. When the respondent completed the second rating, the vignette changed to the next prescribed by the underlying experimental design.

fig 2(1)

fig 2(2)

Figure 2: The orientation screen in both Hebrew and Arabic.

fig 3(1)

fig 3(2)

Figure 3: Example of a screen showing a vignette and the rating scale, in Hebrew and Arabic.

After the vignettes were completed, the respondents completed a short, self-profiling questionnaire, with some results shown in Table 5.

Table 5: Self-profile of the respondents in the two key mind-sets who are enthusiasts: Mind-set 3 (End conflict enthusiasts) and Mind-Set 2 (Peace enthusiasts).

End Conflict & Peace Enthusiasts (Combined) %

Age
18-29

47

30-38

22

39-44

16

45-52

13

53-64

2

Political Affiliation
Rightist

16

Centrist

38

Leftist

16

No Answer

31

How many years have you been living in Israel/Palestine
11-15 years

6

16-20 years

6

21-25 years

16

More than 25 years

69

I do not live in….

3

Were you or any members of your family harmed by the Palestinian-Israeli conflict
Yes, I was personally harmed

9

Yes, someone from my family was harmed

25

Yes, someone I know (not family) was harmed

19

No

47

Table 4 shows the significantly positive elements and the strong performing elements. The respondents were clustered simultaneously on ratings for Question 1 (cessation of hostilities) and Question 2 (lasting peace). This joint clustering was done by combining the two sets of coefficients to create a vector of 72 numbers, to which the k-means clustering was applied.

Table 4: Result from models for ending the conflict (Q1) and establishing long-lasting peace (Q2), from Israelis and Palestinians. Each mind-set comprises both Israelis and Palestinians.

table 4

The results suggest four interpretable mind-sets. Across both questions Mind-Set 2 appears to respond to elements which are positioned as ‘end the hostilities’ and Mind-Set 1 appears to respond to elements which are positioned as peace.

It is striking and somewhat disconcerting that in Table 4 that most of the cells are blank, having generated coefficients of +7 or lower. To help the patterns emerge, we show only those cells with strong performance, viz., coefficients of +8 or higher dramatically, we look only for strong performing elements.

The four mind-sets each comprise a mix of Palestinians and Israelis. This is important, because it gives hope that there can be found like-minded individuals in hostile populations, with perhaps some of the mind-sets capable of negotiation.

The total panel contains no strong performing elements at all. Nor do Mind-Sets 3 and 4, comprising 67 of the 158 respondents. There are, however, strong responses in the mind-sets, viz., suggesting that there are areas of agreement. All that we have to is find them.

The messages which drive interest for ending the conflict are:

  1. Freedom from violence and oppression are individual human rights
  2. Ongoing community exchanges between Israeli and Palestinian youth help our situation
  3. More and more people everywhere are developing a stronger sense that they are all members of one global community

The messages which drive work for peace (Mind-Set 1) are:

  1. Lasting peace and justice in Israel-Palestine will only happen by Israelis and Palestinians working together
  2. There are currently many areas of economic, technological, cultural and educational cooperation between Israelis and Palestinians
  3. A solution to the conflict and compromise over Jerusalem and the refugees is possible

The traditional approach to understanding people is to create a surface understand of their minds, and in turn probe deeply into who they are. Table 5 shows a breakdown of self-profiling classification of mind-sets 2 (End Conflict enthusiasts) and mind-set 3 (Peace enthusiasts). The information is enlightening, but the important information is missing, viz., the reason for the strong performing messages. We know about the enthusiasts, but would never have predicted which elements in Table 4 would have performed well

Discussion and Conclusions

At the start of the efforts underlying these two studies a decade ago, the vision for Mind Genomics was to identify the ‘optimum messaging.’ The size of the study, 36 elements (six questions, each with six answers) provided a large array of possible ideas to include in the study. The rapid turn-around time, less than a day, was not considered a particularly strong ‘positive’, but the possibility of testing many messages was a positive. The notion was that Mind Genomics provided a testing platform for many well-thought-out ideas, rather than one or two ideas. The worldview that accuracy, even with long cycle times, was critical. It was better to expend a great effort, to get deep thinking, and then to do the study.

The outcomes of the studies, reported here, were “interesting” but failed to find a receptive audience. Part of the failure was lack of visibility of the results. Another part was lack of knowledge about what Mind Genomics was, and what Mind Genomics could deliver. The target audiences, those in policy, those in academia, were stuck on the traditional methods, the slow, often tedious, eventually self-correcting, one-at-a-time thinking.

Over the decade, however, Mind Genomics has evolved to an iterative system, one providing virtually instantaneous results, at very low prices, with the objective of creating an ongoing database, the wiki of the mind. Coupled with this is the recognition that the traditional methods of science, the tortuous one-at-a-time hypothetical-deductive system, the creation of hypotheses and careful testing, does not work well in a world of language and feelings, where there are many ways to express winning ideas, and many more ways to express losing ideas. Furthermore, speed, once a negative because ‘if it is so fast it can’t be particularly good!’ has been supplanted by a culture of speed.

There is something, so obvious that it may be boggling. A continuing finding of Mind Genomics is that virtually no one really ‘knows what will work.’ These studies, run today, often show a lot of blank cells, not so much for products and services which are tangible, but rather for social issues which have been the food and drink of policy makes for generations. A better system was needed. The plethora of empty ‘data’ cells in Tables 2 and 4 are witness to the fact that the ‘best guess’ elements from experts do not drive the response. People in the business of ‘knowing’ may not know. This is not a criticism. The same plethora of empty cells for results occurs for marketing services and products, as well as social issues, legal statements in litigation or patients in the hands of medical professionals looking for guidance in the way which is most appropriate to their mind-sets.

Some of the answer to ‘fewer empty cells’ comes from the use of Mind Genomics, perhaps in a more abbreviated, simper form, not with 36 elements (6×6; 48 combinations) but with fewer than half that number, 16 elements (4×4; 24 combinations). There are three aspects to the opportunity all embodied in a publicly available tool, BimiLeap (www.BimiLeap.com).

Up-front Thinking

It may be daunting to have to think of 36 elements, but to think of 16 elements should be a far simpler task.

Speed, Collapsing the Process to Minutes and Hours

The second is to produce a system with collapsed timelines, a system which is templated, so that the Mind Genomics Project’ can be set in up in 15 minutes, launched, and the fully analyzed reports, ready for presentation,, emerge within 15 minutes, or at most minutes.

Change from Confirming to Iterating

Analysis paralysis, one of the banes of progress, perhaps the cause of the results here, emerges from the dutiful action of ‘measuring nine times, cutting once’. It might be better to think quickly, iterate quickly, update, and iterate again. Each iteration, in turn, to be done from front to back in the space of 60-90 minutes, at low cost, with ongoing updating, keeping and expanding the good, throwing away the ‘bad’, the ‘poor’, the irrelevant.

The prospect of going from no knowledge at 9am to nine iterations by 9pm or earlier, is simply ‘game changing.’ One can just imagine the number of elements which emerge over time as potentially strong messages, as the researcher iterates to better and better messages, simply by the mechanical effort of testing, evaluating, discarding, expanding, and retesting. Furthermore, the proof is immediate, manifested in the number of ‘filled cells,’ the magnitude of the positive coefficients, and the practical results from messaging.

One last part of the vision from 2012 deserves mention, a vision which is now becoming almost a trivial application of the above. As noted above segmentation and the use of mind-sets has been the domain of the world of marketers. But would about databases of mind-sets for conflicts around the world? What if each conflict could be studies with an iteration of 20 studies, as noted above, so that one arrives as a database of elements which reveal what can be agreed upon? It is quite likely that the results will require mind-sets. What if the process of iterating could be continued, the strong performing elements validated, and then a ‘PVI’, personal viewpoint identifier incorporated into the database [20]. The PVI would allow people in the conflict on both sides to be assigned to one of the mind-sets involved in the conflict. From there, negotiations could begin between antagonists on the two sides who happen to share the same mind-set, a mind-set which holds a point of view allowing for peace. One can imagine a library of 100 books, the Library of Today’s Conflicts, one book for each conflict, created in weeks, at low cost, from 10-20 iterations, and with its own PVI!

Acknowledgments

The authors wish to acknowledge the support and encouragement of these individuals a decade ago who made the studies possible, both through financial support, and through direct participation.

Peter Coleman, Columbia University, Teacher’s College, New York, USA

Jonathan Cummings, Jewish Community Relations Council of New York, New York, USA

Naira Mussallem, Columbia University, Teacher’s College New York, USA,

Janna Kaminsky, Moskowitz Jacobs, Inc. White Plains, USA

John Lightstone, Lightstone Capital (Deceased), White Plains, USA

Taly Marian, Teacher College, Columbia University, New York, USA

Nora el Zokm, Teacher’s College, Columbia University, New York, USA

Steven Onufrey, The Onufrey Group (Deceased), Philadelphia, USA

Note: The current (free) program for Mind Genomics is located at www.BimiLeap.com. The only fees are processing fees on a per respondent basis.

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