Monthly Archives: December 2021

fig 3

In Search of Beautiful Bodies: A Meta-analysis of Five Mind Genomics Cartographies – Equipment, Gyms, and Fitness Clubs

DOI: 10.31038/AWHC.2021453

Abstract

We present a meta-analysis of five Mind Genomics cartographies, done over a 20 year period, all dealing with exercise; purchasing exercise equipment (Buy It!, 2002), joining a branded, well know exercise spa franchised around the US (Curves, 2010), what to say to entice a person to join an exercise club or a gym (2012, student projects at Queens College), and, at the tail-end of a Covid-stricken 2019, how to lure customers back to using exercise equipment either at home and/or the same equipment in a gym (2020). We present the strong performing messages for each cartography, show the power of mind-set segmentation, the power of doing simple background research (student work in 2012), and introduce new foci as well, emotions linked with elements and engagement with messages revealed by response times. These five case histories, the paper shows how Mind Genomics was used by different people in the same ‘general space,’ over a 20-year period, and how Mind Genomics evolved to incorporate new measures alongside its basic measure.

Introduction

We live in a society focused on beauty, whether beauty of the face or of the body, occasionally of the spirit and even of the mind. Whereas among the ancients and their successors in the medieval and modern worlds the search for physical beauty was both artistic and philosophical, today it manifests itself in the world of cosmetics and the world of fitness. One can barely drive through a town, a city, even a rural area without seeing stores devoted to making people more beautiful.

Our focus in this paper is on the world of exercise, a world perhaps not as glamorous as the world of facial beauty and the world of fashion, but a world important, nonetheless. With increasing prosperity and with increasingly caloric intake, coupled with lessened demand on physical activity for work, there is the natural result of increased weight, of lessened body tone. Add that to the oft-feared factor of aging, and one has created a perfect storm for people to focus on what can turn back the clock of time.

The topic of gyms and fitness clubs has enjoyed a moderate amount of published research, and undoubtedly a great deal more one-off business studies deposited after use in the corporate files, presumably hidden away forever, or until the issue has been forgotten along with the research effort. The topics involved in gyms range from a focus on the trajectory of human development [1] to the emotions and motives for joining gyms [2], to health, both physical and psychological [3,4]. At the same time, there is the business aspect of clubs, the need to convince people that certain clubs are worth paying for [5-7].

During the past two decades, as Mind Genomics evolved into the science it is today, a variety of research efforts generated some interesting data on exercise, fitness, and related topics. We look at the salient results from five studies, one run 20 years ago, three run about 10 years ago, and one run a year ago. One study was run to understand how people wanted to shop for exercise equipment. The remaining four studies were run to understand what messages makes people want to join health spas and exercise gyms.

A Short Introduction to Mind Genomics

In 1964, mathematical psychologists R. Duncan Luce and John Tukey had been involved in creating a strong, new, axiom-based foundation for mathematical psychology, and particularly for powerful measurement without using numbers. The approach they developed was called conjoint measurement, the measurement of quantities by the measurement of combinations of such quantities. The approach sounds perfectly ordinary today; measurement mixtures of ideas and from the measurement of the mixtures deduce the measure of the components. The mathematics would appear in a daunting first paper in a new journal, the Journal of Mathematical Psychology, volume 1, number 1, first paper. IN other words, the premier new journal, and the lead article [8].

Conjoint measurement would have remained a stunning intellectual contribution, albeit an esoteric one, except for the efforts of Wharton business school professors Paul Green, Abba Krieger, and Yoram Wind, who would take it, make it practical, and apply it to various problems [9-11]. The literature using conjoint measurement would grow, until the approach would be used for products, for public policy, and so forth [12,13]. One needs only Google(r) the academic literature to get a sense of its applications.

Despite its popularity, most published papers, and indeed most likely research reports buried in corporate offices are one-off studies, executed to solve a particular problem. Conjoint measurement required knowledge of the variables, a painful creation of the combinations, a painful execution, and an analysis, not to mention an equal painful explanation of the method. In other words, the system was expensive, slow, and clunky, reserved for the most important (better read better-funded) project [14].

Mind Genomics emerged out of conjoint measurement, propelled by three key goals:

  1. Create a system which, like Conjoint Measurement, would be able to measure the strength of ideas by measuring combinations of ideas, so-called vignettes. There was recognition that responses to vignettes could not be easily ‘faked’ as well as the fact that compound messages were more typical in the everyday world than single messages comprising one idea.
  2. Make sure that each respondent evaluated a unique set of combinations of the same set of elements. This notion of different sets of the same elements emerged from the world of medicine, and the MRI, which takes pictures of the same tissue from different angles, and then recombines them in the analysis phase to come up with a single, 3-dimensional picture [15].
  3. Create a system which could generate information that would be databased, with the data comparable within a study, and across studies [16].

The studies reported here were run in the same way, following these steps:

    1. Raw Materials: Create a topic, create a set of questions which ‘tell a story’, and for each question provide a set of ‘answers’ which give different facts. The number of questions can vary but the number of answers for each question is always equal. The Mind Genomics method allows for a variety of such options, such as four questions with nine answers, six questions with six answers, four questions with four answers, etc. The most common study as of this writing (2021) is the design comprising four questions, each with four answers (16 elements).
    2. Test Combinations: Create a fixed set of combinations, specified as an experimental design The experimental design prescribes the precise set of combinations, doing so by specifying which elements are put together. The experimental design is set up so that the variables are statistically independent, allowing methods such as OLS (ordinary least-squares) regression to reveal how each element or message contributes to the rating assigned to the vignette, viz., to the combination. Respondents do not rate the components; they rate the vignettes, the combinations, which is more natural to them [17].
    3. Permute the Combination: There are a fixed set of combinations, but the combinations are permuted [15]. For example, one design comprised four questions, nine answers per question, 60 combinations, and many different variations of the underlying design with 60 combinations. This approach lets the ‘experiment’ cover much of the range. Thus, Mind Genomic trades off precision of measuring one small region of the possible combinations of messaging, and instead opts to measure a great deal of the region, albeit with less precision.
    4. Transform the Ratings in a Way Which Permits Managers to Understand the Results More Easily: In these five studies, four used a 1-9 scale anchored at each end; one used a 5-point scale. Managers who work with the data derived from scale often ask ‘what does a 6 mean’ or a ’4’ mean, etc. To make the data easier for managers to use, consumer researchers and political pollsters have learned transform a scale with many points to a binary scale, no/yes. Following this practice, the researcher transformed the ratings on the 9-point scale to a binary scale (1-6 transformed to 0, ratings of 7-9 transformed to 100). In the case of the 5-point scale, the conversion was 1-3 transformed to 0, 4-5 transformed to 100. In each case, a vanishingly small random number was added to every data point, whether transformed to 0 or to 100, respectively. The random number ensured that no dependent variable would ever be all 0’s or all 100’s for any single individual. This slight variation ensured that the OLS regression always worked for each individual respondent
    5. Create Equations Relating the Presence/Absence of the Elements to the Newly Created Binary Variables: The experimental design makes it possible to create the equation even with the data of one respondent. Whether the equation is created for a group of respondents, or even for a single individual, the equation is expressed in the same way:
    6. For those experiment designs using the 4×9 structure (four questions, nine answers for each question): Binary Variable (TOP3) = k0 + k1(A1) + k2(A2) … k36(D9)

      For those experimental; designs using the 6×6 structure (six questions, six answers for each question):

      Binary Variable (TOP3) = k0 + k1(A1) + k2(A2)… k36 (F6)

      For those experimental design using the 4×4 structure (four questions, four answers for each question): Binary Variable (Top2) = k0 + k1(A1) + k2(A2) … k16(D4)

    7. Uncover Mind-sets: We often divide people by factors that we can easily measure. The easiest of course are WHO a person is, and in today’s digital world, what a person DOES. One can also divide people by the patterns of their answers to sets of questions, the pattern of answers to these questions assigning a person to a group based on attitude. These groups are large, and not particularly actionable. That, knows what a person buys do not tell us what messages move the respondent to buy, and what messages are turnoffs. We don’t typically think like that – viz., having details information about how the world of people’s minds divide for a topic. Usually, the topic is too small, too irrelevant for a deep, detailed investigation.
    8. Mind Genomics create different groups of people, not based on who they are, but rather on the pattern of their reactions to limited types of information. That is, the division of people is not based on the way the person thinks about large (and important) problems, buts divides people on the pattern of responses to any topic, in ways which make sense. The method is called clustering [18]. Clustering is based upon mathematical criterion. However, the choice of the number of clusters to use is based upon two non-mathematical criteria. The first is parsimony – fewer clusters are better than more clusters. The second is interpretability – the clusters must tell a coherent story. Parsimony and interpretability are opposed; more clusters mean easier to tell a story, but only the truly relevant elements need be included in the cluster.

    9. Relate the Elements to the Transformed Rating Scale to Show the Impact of Each Element: The OLS (ordinary least-squares) regression analysis uses the data defined by the researcher Once members of the different groups have been identified (viz., respondents belonging to Total, to Males vs Females; to mind-sets 1 vs 2 vs 3), etc. The subgroups are defined either by how the respondent describes himself or herself (done in the context of the study, through self-profiling classification), or the mind-sets are created through clustering and the data from all respondents in a specific mind-set or cluster are combined to create one dataset, and the OLS regression run using all data from that dataset.

    Cartography 1 – Buying Exercise Equipment

    Study # 1 was done in 2002, just about 20 years ago. The study was part of a large group of studies which focused on the nature of messaging which represent one’s idea shopping experience [13]. Figure 1 shows the wall of studies. All studies were identical except for the name of the product, and certain features and stores. The respondent selected the study and was led to the introduction for that study shown in Figure 2.

    fig 1

    Figure 1: The wall of studies for Buy It! the respondent selected the study.

    fig 2

    Figure 2: Respondent instructions for the Buy It! Study. The introduction comes from the study dealing with exercise equipment.

    The different studies in the Buy It! project comprised four questions or silos, each with nine answers or elements. We will use the term element instead of answer. The 4×9 design (four questions, nine answers) generate 36 elements in total, combind according to an underlying experimental design into 60 vignettes. Each element appear an equal numbr of times across the 60 vignettes. Furthermore, the vignettes comprised 2-4 elements, so by design many of the vignettes were ‘incomplete,’ viz.,lacking an answer from one of the four questions. As noted above, each respondent evaluated a unique set of combinations, permutations of the original design.

    Table 1 shows only those elements which exhibit at least one strong performing element. The element had to have an estimated coefficient of +8 or higher when the dependent variable was defined as a binary scale (1-6 → 0; 7=9 → 100). Table 1 thus shows the highlights. We show the elements first in terms of total panel, then in terms of three mind-sets to emerge, and then in terms of gender.

    Table 1: Strong performing element for the 2002 Buy It! study on exercise equipment. (Table courtesy of It! Ventures).

    table 1

    1. The additive constant is a measure of the closeness of the vignette to one’s ideal shopping experience, in the absence of elements. The additive constant is purely theoretical, an estimated parameter. It does tell us, however, how positive the respondent is to the shopping experience. The additive constants are all low, between 26 and 34. It will be the elements which will make a difference.
    2. In most Mind Genomics studies we end up with a few elements which do well. The total panel shows two elements, C2 (Let’s you get your shopping done quickly), and B1 (The price is JUST RIGHT … ALL OF THE TIME). They score 9 and 8, weaker than we will see when we turn to the three mind-sets which emerged from clustering the respondents based upon the similarities among the set of 36 coefficients.
    3. It will be the mind-sets which show the big differences, differences which suggest three patterns:
    4. a. Mind-Set 1 responds to the stores

      b. Mind-Set 2 convenience

      c. Mind-Set 3 wants price and choice.

    5. It is mind-sets, not genders, which show the strong responses to the elements, a pattern which shows the power of Mind Genomics to uncover these basic groups in what would seem to be a population which is indifferent to the messages because the first data column. There is no indifference, but rather strong albeit different preference patterns.

    Cartography 2 – What Messages Drive Women to Say that They Will Join Curves

    Study # 2 was run in December 6-7, 2010, at the behest of Queens College, in collaboration with author HRM, and the mathematics department of Queens College. The study was part of the ‘vetting processes that Queens College used to create a mathematics course, Math 110, offered 2011-2013. Two of the owners of a local gymnasium were interested in signing up with Curves. They approached Queens College and funded the study, which was otherwise done on a pro bono basis with permission to publish the results of the study in two years.

    The ingoing brief for the study was the following:

    To prosper in the present economy Curves Owners must always be on the look-out for new ways to accommodate and engage their members. Curves owners need faster access to useful consumer insights in developing marketing messaging and programs, products and services. The Vision – Increase lasting memberships at Curves. The marketing and sales strategy to emerge from Mind Genomics was set forth at the set-up meeting:

    Attract prospects to come into your club by using optimum message appearing to the general marketplace through: Web coupons, Mailing Value Coupon packs, Web site landing page, E-mails, In person

    When the prospect comes in, lead the discussion with those Curves features that appeal most to each individual: Use a simple approach to tell you EXACTLY what to say to each individual

    Study # 2 was run on December 6-7, 2010, with a population of women of all ages across the US. The raw material for the study came from current (2010 basis) marketing and advertising messaging from Curves website as well as from websites of peer fitness clubs: Butterflylife, Contours express, Fitness club Forwomen, and Lady of America, respectively.

    Table 2 shows the strong performing elements for the study. There were 36 elements. Surprisingly, most of the elements fared quite poorly. That is, despite their use in the promotional literature, their actual performance was poor using the criterion of consumer reactions. This is often the finding of a Mind Genomics study, perhaps because the elements used have not been established ‘effective’, in a rigorous, unbiased manner. That is, most elements used in the study may well have been legacy elements, the origin and usefulness of lists lost if, in fact, they are really existed.

    Table 2: Strong performing elements for the ‘Curves’ study.

    table 2

    A key benefit of the Mind Genomics approach is the ability to assign new people to the appropriate mind-set. This is done with the PVI (Personal Viewpoint Identifier). The PVI uses statistical methods such as DFA (Discriminant Function Analysis), and Decision Trees to create a limited set of questions emerging from the elements or answers of the study. These are the elements which best differentiate the mind-sets from each other. Figure 3 shows an example of how the PVI appears in 2010, summarizing the process. The figure shows the objective, the respondent introduction (left column), and then one of the three questions and one of the three outputs (right column). The new respondent completes a short set of questions. The pattern of responses to the questions suffices to assign that respondent to one of the three mind-sets just uncovered. The process lasts about 30-45 seconds.

    fig 3

    Figure 3: The PVI (Personal Viewpoint Identifier), showing the introduction. one question (of three) from the PVI, and the feedback when the respondent is assigned to Mind-Set (Segment) 1. The figure shows the version of the PVI from 2010.

    Cartography 3 – Joining a Fitness Club

    Study #3 (as well as Study #4 on joining a gym) was done in 2012 at Queens College by a cadre of four students in the Math 110 course. The course was an experiment run for five semesters at Queens College of City University of New York. The idea was to teach the students a combination of critical/creative thinking with a dose of mathematics and mathematical thinking. The students were divided into groups of four individuals, instructed on the basics of Mind Genomics (at that time called Addressable Minds for business), and selected a topic. The two studies reported here, chosen by two separate groups of students, show the power of creative thinking, and the strong performance of the elements when the students were engaged in research, and challenged to do their best.

    Figure 4 shows the orientation page to the study and is similar to the orientation pages of previous studies. The student was interested both in what drives interest in joining a fit club (question #1), as well as the emotional reaction to after reaching each vignette (question #2). This presentation of data from Study # 4 focuses only on the data from Question #1 (joining) to demonstrate the richness of the results. Emotions will be shown in the next study on joining a gym (Cartography #4).

    fig 4

    Figure 4: The orientation page to the study on joining a fitness club.

    The actual design was a so-called 4×6 (four questions, six answers). Table 3 shows the strong performing elements by total panel, by gender, and by four emergent mind-sets. One mind-set, MS1, is very small, and should be discarded, but we leave it here for completeness. What emerges as remarkable in light of the previous two studies in the richness of the results, something that will be seen in the next study as well on joining a gym? The reason for the richness can be principally attributes to good up-front thinking by the four students who participated. The students took the project seriously, looked at the different messaging on the Internet, selected what seemed to be reasonable, and put that messaging into the study. The results, with 50 respondents, are no less than spectacular, with the number of very strong performing elements.

    Table 3: Performance of elements for joining a fitness club.

    table 3

    Mind-Set 1: Very modestly interested (additive constant 29), but attracted by the ‘shock’ value of services and prices

    Spa: full body massages, facials, waxing, sauna

    Dollar a day trial membership (3 months max))

    Mind-Set 2: Barely interested (additive constant 9) but attracted by some outstanding features

    Spa: full body massages, facials, waxing, sauna

    Child-care available with an indoor playground, recreational activities and professional supervision

    Ultra clean environment with towels for all members

    Olympic size pool with over ten swimming lanes.

    Mind-Set 3: Basically disinterested (additive constant -8) but exceptionally interested in cardio and fitness, as well as making it part of an easy daily schedule

    Achieve your ideal weight

    Free shuttle bus within a 15-mile radius of the gym

    Gymnastic classes that help improve flexibility

    Dollar a day trial membership (3 months max)

    Spinning classes offer an innovative alternative for cardio training.

    Mind-Set 4: Modestly interested (additive constant 25), and want machines for self-training

    Two floors of free weights and machines.

    The words of the four students are especially relevant here to summarize the results, and to show how new-to-the-approach students can learn to think more deeply about the topic.

    “Addressable Minds was able to help identify the immense importance the therapeutic effect can provide to its members in a fitness center. Mostly overlooked, due to cardio and weightlifting but equally important to fitness and health is the state of the mind and spirit. The high response rate for the “Spa” and “Organic Food Court” elements demonstrate members are seeking more than just a weight room. Eating the right food along with properly relaxing the mind and body allow members to perform better in the gym thus maximizing the results. Providing these added qualities are crucial to health inside and out but also allow members to get more out of it than a traditional fitness center. Furthermore “Child Care” allows the member to escape responsibilities for a time, to truly focus on strengthening the spirit and mind.”

    Cartography #4: Joining a Gym

    Study # 4 was done at the same time as Study # joining a health club, but by a different team of students in the same class, Math 110 in Queens College. The process was the same and the instructions were virtually the same except that the work ‘gym’ replaced the phrase ‘fitness club’.

    The data for this fourth cartography once again shows the power of doing one’s homework, of taking messages from competition. Table 4 shows low additive constant (-6) suggesting that it is the specifics of the gym which make a difference, not the basic interest in the gym. Table 4 also shows that the additive constant is higher for males (+24) and vanishing low for females (-16). For females, it will be the elements which must do the hard work to convince.

    Table 4: Performance of elements for joining a gym.

    table 4(1)

    table 4(2)

    The data becomes, more interesting when we look at the three mind-sets which emerge.

    Mind-Set 1 is basically uninterested in the gym but strongly differentiates among the messages, and actually loves most of the messages except for those dealing with children. The elements interesting Mind-Set 1 are:

    No enrollment fee

    Feeling some pain…come get a massage from our wonderful masseuses

    One on one time with private fitness trainer

    Take part in one of our 50 different classes (yoga, spinning, Zumba etc.)

    Not sure if you want to join…sign up for a week free membership

    Come workout with our brand new 200 + fitness equipment

    Diet plans to help and encourage your health and well- being.

    Mind-Set 2 likes the notion of joining a gym, although again it is what the gym offers (additive constant 20). The key elements interesting Mind-Set 2 are:

    Take part in one of our 50 different classes (yoga, spinning, Zumba etc.)

    Relax in the Sauna and hot tub after a tough workout.

    Mind-Set 3 has no predisposition to joining the gym (additive constant 8) but like a low price. Their response show that they are the opposite of Mind-Set 1, viz., interested in an activity with their children. The elements interesting Mind-Set 3 are:

    Low monthly cost just 30 dollars a month

    Full time student? …Show your school ID and only pay 25 dollars a month

    Fun summer camps to allow children to stay fit and meet friends

    Looking for competition…Weekly contests with prizes offered

    Free childcare while you work out

    Different types of sports available for all ages

    Mommy and me classes with a variety of times to suit working parents

    Keep your child active after school with enjoyable activities.

    Table 5 shows how the elements link with the choice of emotion. The analysis of the emotion responses was slightly different from the analysis of the ratings for joining. Recall that for the reactions about joining, the 9-point rating scale was converted to one binary variable, taking on the value ‘0 when the original rating was 1-6, and taking on the value ‘100’ when the original rating was 7-9.

    Table 5: Strong linkages (>=8) between elements and selected emotion for the cartography on selecting a gym.

    table 5(1)

    table 5(2)

    This type of transformation does not work for the emotion scale, known as a ‘nominal scale.’ The numbers are simply placeholders for different, not necessarily related emotions. The solution, simple and in the same spirit, was to create FIVE new binary variables, one binary variable for each of the five emotions. A selection of an emotion for a vignette would result in the value ‘100’ for the newly created binary variable corresponding to that emotion, and the value ‘0’ for the four new created binary variables corresponding to the emotions not selected. For example, when the respondent selected the emotion ‘5’ (Interested), the newly created binary variable ‘INTERESTED’ was assigned a value of ‘100’ and the remaining four binary variables (EXCITED, WEARY, CERTAIN, APPREHENSIVE) were all assigned a value of ‘0’. The vanishingly small random number (<10-5) was added to each newly assigned value, whether ‘0’ or ‘100’, respectively.

    The regression analysis relating the presence/absence of the elements to the selection of the emotion was run separately five times, once for each of the five newly created vignettes. The equation was the now familiar regression equation, but the equation was absent the additive constant. The rationale is that the additive constant would be the same for the five newly created binary variables and provides no additional information.

    The two emotions selected most often are confident and curious. Only the strong linkages are show, 8 or higher. The emotion confident links with elements giving the respondent control and choice:

    No hidden fees

    Don’t worry about not finding a spot with our free underground parking garage

    Come workout and feel better about yourself

    Take a dip in the clean and refreshing Olympic sized swimming pool

    Do a lap(s) on the indoor and outdoor running tracks

    Don’t wanna go to the gym alone… 4 free guest passes a month

    Take part in one of our 50 different classes (yoga, spinning, Zumba etc.)

    Different types of sports available for all ages

    Take a class with friends that are offered all day

    Top of the line staff to help you with any questions.

    The emotion curious links with diversion (movie), children, easy to access, and a personal trainer

    Spin away while watching a movie in our luxurious fitness theater

    Free childcare while you workout

    Keep your child active after school with enjoyable activities

    Easily accessible from public transportation

    One on one time with private fitness trainer.

    The new learning here is that by linking emotion with the elements, one begins to get a deeper sense of why the elements seem to do well. The respondent may not be able to articulate the reason for choice, but the nature of the linked emotion may provide that insight.

    Cartography 5: Gym-Two-Ways (2020)

    Study #5 was done in late 2020, during the waning period, after the height of the lockdown due to Covid-19. The objective was to see what type of basic messages would attract prospective customers, who had just been through the lockdown, and might be interested in return to a gymnasium, or having a home trainer work with them using the same equipment in their home.

    By 2020 Mind Genomics had transitioned to the much easier to use 4×4 design, comprising 16 elements (four answers each to four questions) The design generated 24 vignettes, which were permuted by the standard permutation approach, so that across the 106 respondents many of the possible vignettes were estimated. The rating scale was also reduced from 9 points to 5 points. The total time for the Mind Genomics exercise went from about 15 minutes to 3 minutes

    Table 6 shows a much-reduced set of strong performing elements. There are still themes emerging, but what is important is the reduced set of strong performers, and the much lower coefficients. The reason for this may be the emergence of a society whose ability to concentrate on messages and to become excited has diminished and continues to diminish. It may well be that over the period of a decade the prospective audience has been saturated, the so-called paradox of choice [19]. That paradox may reveal itself in what might be called a customer-based ennui, and a growing indifferent to messaging.

    Table 6: Performance of elements for GYM-TWO-WAYS.

    table 6

    Our final analysis concerns response time. The Mind Genomics program recorded the interval between the presentation of the vignette and the respondent’s rating. The interval is called the response-time, and presumably co-varies with internal psychological processes, including reading and decision-making [20,21]. We can look at the estimated response time of each element, with the estimation coming from the OLS (ordinary least-squares regression). Once again there is NO additive constant.

    Table 7 shows the longest and the shortest response times. Most response times are between 0.5 and up to, but not including one second. Only a few elements are processed very quickly or processed more slowly than the half-second range between 0.5 and 1.0 seconds.

    Table 7: Estimated response time for elements. Only the ‘short’ and the ‘long’ response times are shown.

    table 7

    Elements that are quickly (estimated response time <= 0.4 seconds)

    No preparation…just be willing (males)

    Choose intensity that intrigues you (male)

    Share inspiration with GYM-TWO-WAYS community. (MS2 – Expertise)

    Support transition from at-home to gym experience. (MS2 – Expertise)

    Coaches understand YOUR fitness journey. (MS2 – Expertise)

    Elements processed slowly (estimated response time >= 1.0 seconds).

    Expert instructors.(MS1 – Experience)

    Lifelong results through education and access to science. (MS1 – Experience)

    Learn at home. (MS2 – Expertise)

    Learn at your own pace. ( MS2 – Expertise).

    Discussion and Conclusion

    During the past six decades, since the early and middle 1960’s, researchers have focused on obtain increasing amounts of information from customers. Sixty years ago, it was sufficient to measure general attitudes towards products, desires for certain features, and perhaps the ‘gap’ between what was being offered and what was desired by consumers. This so-called ‘gap-analysis’ was satisfactory but over time the world of consumer goods and services would evolve to cut-throat competition. New methods were needed to understand the competitive frame.

    The heyday of consumer research saw the development of new ways to understand the mind of the consumer. In terms of goods and services, Professors Paul Green and Yoram Wind at Wharton pioneered the methods of experimental design to study the trade-offs that consumers would make when considering a service or a product. The notion of trade-off was not new, but the zeitgeist of the 1970’s was moving towards the study of mixtures as being the natural stimuli.

    It is in the spirit of this movement towards studying mixtures that Mind Genomics was born. The objectives were no longer to do single, difficult-to-execute studies, but rather to create a system that would be able to produce knowledge on demand for verticals such as buying products (Buy It!, source of the study on exercise equipment), or solutions to practical problems at the time, at low cost, with cycle times per iteration of a day or less (Curves, GYM-TWO-WAYS), or teaching tools, forcing first-year, non-quantitatively oriented college students to research the competitive frame, and to run a study which both taught them how to structure their inquiry, and how mathematics could provide important information.

    The studies here represent a collection of different issues, done by different researchers, at different times. The numbers are comparable. The coefficient is the percent of respondents saying ‘yes’. Thus, there is ongoing learning, revealed by the meta-analysis, the learning transcending the specific elements, and in addition showing how nature of the up-front research may provide information of higher value.

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fig 1

The Prevalence of ASTRAZENECA COVID Vaccine Side Effects among Nigist Elleni Mohamed Memorial Specialized Hospital Health Workers: Cross Sectional Survey

DOI: 10.31038/IJAS.2021222

Abstract

Background: The best way to eradicate COVID 19 viral infection is mass vaccination. Many studies demonstrate vaccination is associated with some local and systemic side effects. This study aimed to provide evidence on ASTRAZENECA COVID vaccine side effects.

Method: Institutional based cross-sectional survey was conducted among 254 health workers at Nigist Elleni Mohamed Memorial Specialized Hospital (NEMMSH) from July 01/2021 to August 30/2021. Data were collected consecutively through self-administered online survey created on Google Forms of platform which had been randomly delivered via (Facebook or telegram pages). Demographic data of participants, side effect after first and second dose of vaccine were covered.

Result: The prevalence of at least one side effect after first dose was 91.3% and after second dose was 67%. Injection site pain (63.8% vs. 50.4%), headache (48.8% vs. 33.5%), fever (38.8% vs. 20.9%), muscle pain (38.8% vs. 21.7%), fatigue (26% vs. 28.7%, tenderness at the site (27.6% vs. 21.7%), and joint pain (27.6% vs. 20.9%) were the most commonly reported side effects after first and second dose vaccine respectively. Most of participants reported that their symptoms emerged after 6 h of vaccination and only less than 5% of participant’s symptoms lasted more than 72 h of post vaccination. The younger age (≤29 year) were more susceptible to at least one side effect (χ2=4.2; p=0.04) after first dose.

Conclusion: The prevalence of side effect after first and second dose vaccine was higher. Most of the symptoms were short lived and mild. This result might help to solve an emerging public health challenge (vaccine hesitancy) nurtured by misinformation related to vaccines safety.

Keywords

ASTRAZENECA COVID vaccine, Side effect, Wachemo University, Cross sectional study

Introduction

Corona viruses are single stranded RNA viruses that cause upper respiratory tract infection [1]. A clinical specimen from a patient having severe acute respiratory syndrome identified a novel coronal virus and named severe acute respiratory syndrome (SARS-CoV-2) [2].

The principal way for transmission of SARS-COVID 19 virus the exposure of the host to respiratory fluid containing the virus primarily Inhalation of air carrying virus, Deposition of virus onto exposed mucous membranes and touching surface exposed to respiratory fluid containing the virus [3].

Pathogenesis of COVID 19 begins when glycoprotein spike on the surface of the virus binds with ACE receptor of host cell [4]. After binding the viral particle get access to host cell through endocytosis [5]. The fused viral genome carries out a series enzymatic process transported by Golgi vesicles to the cell membrane and released into the extracellular space through exocytosis [6].

Multiple genomic sequence of the virus has made the development of effective vaccine to be limited [7]. 259 vaccine trials are proceeding from November 11, 2020 and the lack of effective vaccine has cost many lives. Several vaccines are developed from numerous trials, from those vaccine one of the vaccine made by ASTRAZENECA COVID vaccine [8].

COVID-19 Vaccine AstraZeneca is indicated for active immunisation to prevent COVID-19 caused by SARS-CoV-2, in individual’s ≥18 years old. The Vaccine AstraZeneca is a monovalent vaccine composed of a single recombinant, replication-deficient chimpanzee adenovirus (ChAdOx1) vector encoding the S glycoprotein of SARS-CoV-2. Following administration, the S glycoprotein of SARS-CoV-2 is expressed locally stimulating neutralising antibody and cellular immune responses [9].

COVID-19 Vaccine AstraZeneca has been assessed based on an short-term analysis of pooled data from four on-going randomised, blinded, controlled trials: a Phase I/II Study, COV001, in healthy adults 18 to 55 years of age in the UK; a Phase II/III Study, COV002, in adults ≥18 years of age (including the elderly) in the UK; a Phase III Study, COV003, in adults ≥18 years of age (including the elderly) in Brazil; and a Phase I/II study, COV005, in adults aged 18 to 65 years of age in South Africa [9].

The vaccination course consists of two separate doses of 0.5 ml each. The second dose should be administered between 4 and 12 weeks after the first dose. Individuals who have taken the first dose of COVID-19 Vaccine AstraZeneca should receive the second dose of the same vaccine to complete the vaccination course. The most frequently reported adverse reactions were injection site tenderness injection site pain, headache, fatigue, myalgia, malaise [10].

Vaccine Hesitancy (VH) refers to the “delay in acceptance or refusal of vaccines despite availability of vaccine services”; it is an emerging public health challenge nourished by misinformation related to vaccines effectiveness and safety [11]. This finding was supported in the context of COVID-19 vaccines, because a fear of side effects was the most prominent reason to decrease the readiness of healthcare workers and students in Poland to accept the vaccination [12]. Published data to support adverse reaction of ASTRAZENECA COVID-19 vaccine are lacking which is a driver of vaccine hesitancy. The knowledge about what happens post vaccination in the actual world among the general population is still modest, thus, by describing what to expect after 1st and 2nd dose of vaccination will help in lowering the apprehension about this type vaccines, increased the public confidence in the vaccines, safety, and accelerates the vaccination process against COVID-19.

The results of this study will be reassuring to those who are fearful of the ASTRAZENECA COVID-19 vaccine. So, the goal of this study to provide evidence on ASTRAZENECA COVID vaccine side effects after receiving 1st and 2nd dose of it.

Method

An institutional based cross sectional survey was conducted at Nigist Elleni Mohamed specialized hospital (NEMMSH), from July 01/2021 to August 30/2021 at Nigist Elleni Mohamed Memorial specialized hospital found in Hossana town, the capital of Hadya zone, Ethiopia (Figure 1).

fig 1

Figure 1: The duration of side effects of among NEMMSH health workers after first dose of ASTRAZENECA COVID vaccine from July 01/ 2021 to August 30/2021.

The required data were collected after obtaining ethical clearance from Wachemo University College of medicine and health science institutional review committee. Written informed consent form that included statements about voluntary participation and anonymity was sought from all the respondents prior to data collection. This was accomplished by sending a standardized general invitation letter with the survey link to accept or decline participation to those who took both dose of ASTRAZENECA COVID vaccine.

The participant who declined consent was not permitted to open the survey and participate in the study, and participants could withdraw from the survey at any time. The members who clicked on the link were directed to the Google forms and to avoid the missing data, the participants will be requested to fill all the questions of the survey or else could not proceed to the next section. No incentives or compensations have been given to participants.

The study employs a self-administered online survey created on Google Forms of platform which had been randomly delivered to NEMMSH health workers via (Facebook or telegram pages). Potential participants are directed to a page that included brief introduction to the aim and purpose of the study. Data were collected from all who took both dose of the vaccine and sent response during data collection period.

The survey will include two sections, the first section included demographic questions such as (gender, age, profession) second section reviewed the presence of participant’s chronic conditions and ASTRAZENECA COVID-19 vaccine side effects (pain at the vaccination site, tenderness, redness, fever, headache, fatigue, nausea, diarrhoea, muscle pain, back pain). For pilot testing, a questionnaire was passed randomly to 15 participants recently vaccinated and filled the questionnaire after taking the two doses and have been excluded from the study.

The Statistical Package for the Social Sciences (SPSS) version 20.0 was used to carry out descriptive statistics for the demographic variable’s similarly, chi square test analysis were performed to assess the correlation between the presence of vaccine side effects and demographic variables. The results were presented by using text, tables, charts and graph.

Results

Demographic Characteristics of Participants

A total of 261 responses were received from respondents. From the total number of responses 7 participants data was incomplete and totally 254 participants were included in the final analysis. 98 (38.6%) were females, 156 (61.4%) were males and the mean age of the respondents was 29.9 ± 5.8 years old with the median age of 28.5. About 13 (5.1%), 68 (26.8%), 124 (48.8%), 37 (14.6%) and 12 (4.7%) were Anaesthetists, Medical doctors, Nurse/Midwife, Pharmacy professional/Lab technicians and Public health experts, respectively. From the total participated health workers, 149 (59%) have ≤5 year of work experience and the rest of participants work experience was >5 years (Tables 1 and 2).

Table 1: Demographic characteristic of participants who took ASTRAZENECA covid vaccine from July 01/ 2021 to August 30/2021 in NEMMSH.

Variables

Category

Frequency (%)

Sex Female

98 (38.6%)

Male

156 (61.4%)

Age ≤29 year old

145 (57%)

>29 year old

109 (43%)

Year of experience ≤5 year

149 (59%)

 >5 year

105 (41%)

Profession Anaesthetist

13 (5.1%)

Medical doctors

68 (26.8%)

Nurse/ Midwife

124 (48.8%),

Pharmacy professionals/ Lab technician

37 (14.6%)

Public health officer

12 (4.7%)

Table 2: The prevalence of side effects among NEMMSH health workers after first dose of ASTRAZENECA COVID vaccine from July 01/ 2021 to August 30/2021.

Side effects

 Category
Yes

No

Injection site pain

162 (63.8%)

92 (36.2%)

Tenderness at the site

70 (27.6%)

184 (72.4%)

Fever

98 (38.6%)

156 (61.4%)

Muscle pain

98 (38.6%)

156 (61.4%)

Fatigue

66 (26%)

188 (74%)

Back pain

52 (20.5%)

202 (79.5%)

Joint pain

70 (27.6%)

184 (72.4%)

Diarrhoea

14 (5.5%)

240 (94.5%)

Headache

124 (48.8%)

130 (51.2%)

Nausea

12 (4.7%)

242 (95.3%)

Prevalence of Side Effects after First Dose Vaccine

From the total number of respondents (254), 91.3% (232) participants have reported at least one side effect after first dose of vaccine. Over all, injection site pain was the most prevalent side effect followed by headache (48.8%), fever (38.8%) and muscle pain (38.8%). The prevalence of at least one side effect is slightly greater on males (93.5% vs. 87.7%). At least one side effect among the younger age group (≤29 year old) is nearly greater than participants whose age was >29 year old (94.4%vs 87.7%, respectively).

Onset and Duration of Side Effects after First Dose of Vaccine

From the total number of respondents who experienced Side effect, 52.5% of them felt the side effect after 6 h of vaccination and followed by 26.7% (after 1 to 2 h), 18% (3 to 5 h), and 3% (immediately).

Prevalence of Side Effects after Second Dose Vaccine

A total of 69.7% of participants reported to have at least one side effect after second dose of ASTRAZENECA COVID vaccine. From the rest of side effects, again injection site pain was the most reported symptom with the magnitude of 50.4% and followed by headache 33.5%, fatigue 28.7%, and tenderness at the site 21.7%, fever 20.9% and joint pain 20.9%. There was no difference on the prevalence of at least one side effect between participants whose age is ≤29 year old and >29 year old (69.7% vs. 69.7%). Regarding sex, there was also no much difference on prevalence of at least one side effect between the two group’s male and female (68.5% vs. 71%, respectively) (Tables 3 and 4).

Table 3: The prevalence of side effects among NEMMSH health workers after second dose of ASTRAZENECA COVID vaccine from July 01/ 2021 to August 30/2021.

Side effects

Category
Yes

No

Injection site pain

128 (50.4%)

126 (40.6%)

Tenderness at the site

55 (21.7%)

199 (78.3%)

Fever

53 (20.9%)

201 (79.1%)

Muscle pain

55 (21.7%)

199 (78.3%)

Fatigue

73 (28.7%)

181 (71.3%)

Back pain

52 (20.5%)

202 (79.5%)

Joint pain

53 (20.9%)

201 (79.1%)

Diarrhoea

14 (5.5%)

240 (94.5%)

Headache

85 (33.5%)

169 (66.5%)

Nausea

22 (8.7%)

232 (91.3%)

Table 4: The correlation of participant’s age and side effect after first and second dose of ASTRAZENECA covid vaccine.

 

 Frequency (%)

Chi-square
Age ≤29 (year) (n= 145) Age >29 (year) (n= 109)

 P value

Side effect after 1st dose

137 (94.4%)

95 (87.7%)

0.04

Side effect after 2nd dose

101 (69.7%)

76 (69.7%)

0.999

Chi-squared test were used with a significance level of <0.05.

Onset and Duration of Side Effects after Second Dose of Vaccine

From the total participants who has experienced at least one side effect, most of emerged after 6 h (39%) of vaccination and followed by 35% (within 1 to 2 h), 14.7% (within 3 to 5 h) and 11.3% of them immediately. 54.3% of participants who experience at least one side effect didn’t take any treatment measure for the symptoms and about 16.1% of respondents just took bed rest. 29.5% of participants took antipain to relieve the symptoms.

The Correlation between Side Effects and Participant’s Age

After first dose of vaccine, the study finding reveals there is significant difference (p=0.04) between those who were under the age of 29 years and suffering from COVID-19 vaccine side effects and those over the age of 29. There was no significant difference between the two groups (Age ≤29 vs. >29) on side effect reported after second dose of vaccine (Table 5).

Table 5: The correlation of participant’s sex and side effect after first and second dose of ASTRAZENECA covid vaccine.

 

 Frequency (%)

Chi-square
Male (n= 156) Female (n= 98)

P value

Side effect after 1st dose

146 (93.5%)

86 (87.7%)

0.108

Side effect after 2nd dose

107 (68.5%)

70 (71%)

0.63

Chi-squared test were used with a significance level of <0.05.

The Correlation between Side Effects and Participant’s Sex

The study result demonstrates there were no significant differences in the number of female participants who reported side effects compared to males after both first and second dose of vaccine.

Discussion

Most of the studies assessed the adverse reaction of Pfizer, Moderna and BioNTech vaccines. There were no sufficient published studies done on side effect of ASTRAZENECA COVID vaccine. The first shipment of the AstraZeneca vaccines produced by Serum Institute of India (SII) arrived in Ethiopia on 6 March 2021.

Over all the finding of this study demonstrates the side effects of this vaccine appear to be mild. According to this study more than 90% of respondents have experienced side effect during the first shot. The prevalence of side effect during the second shot of vaccine was lower than the first dose (69.7%), none of this symptoms are serious in nature and requires hospitalization. This result is in line with the cross-sectional survey-based study among German healthcare workers, the frequency of experiencing at least one side effect were 88.1% [13]. Another study conducted in India, 65.9 % of respondents reported at least one post-vaccination symptom [14] cross sectional survey conducted on residents of Poland shows, Among those vaccinated with the first dose of the AstraZeneca vaccine, 96.5% reported at least one post-vaccination reaction. 17.1% of respondents reported all the side effects listed in the survey [15,16]. The variation in prevalence might be related with unequal sample size or difference in demographic distribution.

According to our study finding, injection site pain was the most prevalent side effect during both first and second dose of vaccine (63.8% vs. 50.4%) and followed by headache (48.8% vs. 33.5%), fever (38.8% vs. 20.9%), muscle pain (38.8% vs. 21.7%), fatigue (26% vs. 28.7%, tenderness at the site (27.6% vs. 21.7%), and joint pain (27.6% vs. 20.9%). Injection of drug at contracted muscle leads to pain at the site. Injection site pain was reported by many studies to be the most frequent side effect of post vaccination. Cross sectional survey conducted in Czech Republic health workers demonstrates 89.8% of participants reported to have injection site pain and followed by fatigue (62.2%), headache (45.6%), muscle pain (37.1%), and chills (33.9%) [15]. Another study conducted on Saud Arabian inhabitant also reported the short term side effect after first and second dose of COVID vaccine. According to this study the most common symptoms were injection site pain, headaches, flu-like symptoms, fever, and tiredness. [17].

According to our study, most of respondent’s side effects emerged after 6 h of vaccination during both first and second dose of COVID vaccine (52.5% vs. 39%, respectively). Nearly quarter of respondents after first dose and 35% of respondents after second dose reported the onset of symptom was after 1 to 2 h of post vaccination. Regarding the duration of symptoms, most of participants responded their symptoms disappeared with in the first 24 to 48 h of vaccination on both first and second dose of vaccine (44% vs. 34%, respectively) (Figure 2). Only 3% of respondent’s symptoms after first dose and 5% of respondent’s symptoms after second dose have lasted more than 72 h of post vaccination. This finding is in line with many of studies undergone to assess the side effect of COVID vaccine [13,14,16,17].

fig 2

Figure 2: The duration of side effects of among NEMMSH health workers after second dose of ASTRAZENECA COVID vaccine from July 01/ 2021 to August 30/2021.

In our study the younger age (≤29 year) were more susceptible to at least one side effect (χ 2=4.2; p=0.04) after first dose of ASTRAZENECA COVID vaccine. This result is in line with a study done to assess the side effect of COVID vaccine among German health workers [13] and another Cross sectional survey undergone among individuals in UAE [18]. However difference in terms of side effect between male and female were not statistically significant after both first and second dose vaccine.

Strength and Limitation of the Study

The finding of this study should be interpreted cautiously regarding the external validity since sex and profession of participants are not equally distributed. The data was collected online through Google form so that only respondents who are motivated will fill and submit the questions which might result for selection bias. Data were collected from health workers who have good understanding about the nature of items, so the outcome were expected to be reported correctly. The data were self-reported which strengthen its objectivity. To the best of our knowledge, this is the first study conducted to assess the side effect of ASTRAZENECA COVID vaccine among health workers resource limited setting.

Conclusion

The prevalence of side effect after first and second dose vaccine was higher. Most of the symptoms were short lived, mild and doesn’t require hospitalization. This result might help to solve an emerging public health challenge (vaccine hesitancy) nurtured by misinformation related to vaccines safety.

Ethics Approval and Consent to Participate

The required data were collected after obtaining ethical clearance from Wachemo University College of medicine and health science institutional review committee. In addition permission from both health institutions and written consent from each participant was obtained.

Acknowledgements

This work is dedicated to thousands of fatalities and their families who have fallen victim to COVID-19 in Ethiopia. The authors would also like thank respondents who gave their time to fill and submit the questioner.

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  10. Norweighan medicine agency, Reported suspected adverse reactions to coronavirus vaccine, 2021.
  11. Dror AA, Eisenbach N, Taiber S, Morozov NG, Mizrachi M, et al. (2020) Vaccine hesitancy: The next challenge in the fight against COVID-19. Eur J Epidemiol 35: 775-779.
  12. Szmyd B, Karuga FF, Bartoszek A, Staniecka K, Siwecka N, et al. (2021) Attitude and Behaviors towards SARS-CoV-2 Vaccination among Healthcare Workers: A Cross-Sectional Study from Poland. Vaccines 9: 218. [crossref]
  13. Klugar M, Riad A, Mekhemar M, Conrad J, Buchbender M, et al. (2021) Side Effects of mRNA-Based and Viral Vector-Based COVID-19 Vaccines among German Healthcare Workers. Biology (Basel) 10: 752. [crossref]
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fig 1

Encouraging Citizens to Register to Vote: A Mind Genomics Cartography of Messages to the New York Voter

DOI: 10.31038/PSYJ.2021344

Abstract

460 New York City based respondents participated in a Mind Genomics study to identify the messages which promote registering to vote. Each respondent evaluated 48 different vignettes, combinations of messages, created from a base of 36 messages. The vignettes for each respondent were unique, prescribed by an underlying permuted experimental design. The Mind Genomics design enables discoveries of mind-sets in the population (segmentation), and synergies among pairs of elements (scenario analysis). Data from the total panel revealed no strong performing elements driving intent to register to vote. Data emerging from three mind-sets revealed strong-performing elements for each mind-set. Scenario analysis, an analytic strategy which reveals synergies between elements. revealed the existence of far stronger messaging which could emerge by combining specific pairs of elements. The data and straightforward analytic process suggest that systematic exploration of issues in public policy can quickly create a repository of archival knowledge for the science of policy, as well as direct recommendations of actions to be taken. The speed of the approach furthermore allows the method to be even more powerful, as the iterations retain the strong performing elements, eliminate the weak performing elements, and replenish with new, hitherto untested messages.

Introduction

The case history we present grew out of a student competition to create more effective messaging regarding voting, specifically getting people to say that they intend to register to vote. Pollsters and other political professionals often have a sense of what is important to the voter, in terms of substantive topics, such as the economy, the looming issues with health care, and so forth. There is a plethora of possible messages from which to choose, with the problem being which specific topical message for which candidate. However, the important question on the table is, in the first place, how to get people to register to vote. For the more diffuse issue of ‘voting itself’, like the issue of ‘health maintenance itself,’ we deal with a more difficult problem. There is no pressing need, no issue to solve, no ‘pain points’ to address. Indeed, it is the exact opposite. There is an indifference to the democratic process, one that need not be explained nor studied, and whose origins are not relevant unless those origins can be marshalled to help identify an actionable solution. In other words, the general issue of ‘registering to vote’ is more difficult to understand [1]. There is no pressing fear on the part of the population. Rather, there is a creeping indifference, something which alarms a few people, but is irrelevant to many others until the consequences of such indifference destabilize the country or state or city, and the citizen’s pain begins [2]. The year-on-year decline in those who do not vote has been noted by a variety of sources [3,4]. The issues holding people back range from economics [5] to social alienation (Engler & Weisstanner, 2021), to inconvenience and forgetfulness in the wake of other commitments [6], all occurring in the advanced economies where there is freedom. The situation in the United States is interesting because at the same time that voting is deemed to an important civic duty, registering for voting entails passively registering to serve on a jury, an opportunity to do one’s duty, but not a popular one [7]. In other countries the change in voting over years emerges as a mixed set of patterns. There are a variety of countries where the voting is declining, and others where the voting is increasing. And then there are the dictatorship, where it is mandatory to vote, and of course to agree with the slate offered by the party. The increasing apathy of voters over the years has not gone unnoticed. In 2016, coauthor Markovitz, teaching a marketing class, used Mind Genomics to identify the messages that one could use, and the venues for those messages, both with the objective to increase voting. The idea way to find the different media used for each respondent, identify the strongest messages for the respondent (or group of respondents, called mind-sets), and then recommend the messages for each group, and the place to pick the messages. This dual strategy, optimize the message, and identify the right media, was done by the marketing class, and the results recommended [8].

The reanalysis presented looks more deeply at the nature of respondents, and the possible existence of synergies between elements.

  1. Stability of judgment across the array of evaluations: Are there respondents who change their minds during the course of the Mind Genomics evaluation? If so, how much do they change their mind? Are there those who increase their interest in voting with repeat evaluations, and if so, what messages appeal to them? And are there those whose interested decreases with repeat evaluation, and if so what messages appeal to them, but also what messages turn them off.
  2. Mind-Sets: Can we discover intrinsically different, structurally meaningful mind-sets of voters in the population of respondent? One of the foundations of Mind Genomics is its approach to uncover new-to-the-world mind-sets, different ways of making decisions about the same facts. Rather than differentiating voters on the basis of WHO they are, we focus on the way they weight information to make their decision, either YES – Register to vote, or NO – Do not register to vote, respectively.
  3. Interactions of messages: Can we identify synergisms between elements, so that with deep knowledge we can find those ‘nuggets’ of messages with the ability to break through the indifference?

Mind Genomics as a New Way to Accelerate Impossible-to-Game Measurement

Mind Genomics began in the world of experimental design, with the pioneering work of mathematical psychologists and statisticians R. Duncan Luce and John Tukey [9]. The objective was to create a new form of fundamental measurement. Their treatment is mathematical and filled with axioms. What is important to note is the word ‘conjoint’. The goal was to measure individual quantities by the behavior of mixtures of these quantities. In other words, to create variables, mix them, measure the reaction to the mixture, and then estimate the part-worth contribution of each element. Although conjoint measurement may seem a little too theoretical, the reality is that within a few years, consumer researchers at Wharton and other places (Green, Wind, etc.) would apply a version of Conjoint Measurement to features of services and products [10]. The engine of analysis would move from theoretical issues to practical applications in the world of marketing to focus on services and products. The early versions of conjoint measurement involved difficult-to-execute studies, where the respondent would compare two ‘bundles’ of ideas or offers and select one. The study required that the researcher know what to test ahead of time and know what to combine to get the best results, such knowledge coming from both experience with the topic. As a result, the early conjoint methods were cumbersome, requiring a significant knowledge of the topic with the study providing a little extra information.

There was a clear need to create a knowledge-development system, which could start at ‘ground zero’, with no knowledge, be easy to implement, be robust statistically, and be iterative. Thus was born the Mind Genomics approach, used here [11].

The foundations were simplified:

  1. Conceptualize the problem as a mix-and-match, rate, deconstruct, evaluate, discard, replace, move on. The steps were in part modeled after the classic books Plans and Structure of Behavior, by Miller, Galanter, and Pribram [12]. Their abbreviation for the process was TOTE, Test, Operate, Test, Exit
  2. The system should work with no starting knowledge and should NOT require much in the way of thinking by the researcher. All of the ‘hard’ work would be done in the template, the hard work being the up-front thinking of some ideas. The rest is mechanical [13,14].
  3. The process would become a discovery tool, open to inexpensive, rapid iteration, so that one would build up a great of knowledge at every iteration. The iterations should take no more than a few hours
  4. The data to be shown were collected by students, with little experience in the topic of voting or public polling, but who were able to create a powerful knowledge base in the matter of days.

Explicating the Mind Genomics Methods through a Case History

Step 1 – Create the Raw Materials

Mind Genomics works by presenting the respondent with specific combinations of messages, viz., so-called ‘elements.’ Step 1 creates these elements. The process begins by the selection of a topic (convincing people to register to vote). The process then proceeds by creating a set of questions which ‘tell a story’, and in turn a set of ‘answers’ or ‘elements’ for each question. In this study, we used a version of Mind Genomics set up for six questions, each question having six answers. The questions are not really questions, per se, but rather what one might call ‘topic sentences’ in writing and rhetoric. They move the account along. Ideally, they should fall into a logical order. Table 1 presents these six questions, and the six answers for each question.

In the Mind Genomics study, the questions are not shown to the respondents. As a result, the answers or elements must ‘stand on their own.’ During the evaluation, the respondent will find it easy to ‘graze’ through the different answers presented in the test combinations and make a judgment. The structure of the question, its clarity, is far less important than the structure of the answer, the element. Ideally, there should be no subordinate clauses, as few connectives as possible, and very little if-then thinking. In other words, simple declarative statements are best.

Table 1: The raw material for the Mind Genomics study, comprising six questions, and six answers (elements) to each question.

table 1(1)

table 1(2)

Step 2: Create Vignettes, the Stimuli to be Evaluated

One of the foundations of Mind Genomics is that the respondents should be required to evaluate vignettes, combinations of elements created according to an underlying experiment design [15]. The experimental design is a set of recipes, in this case 48 different recipes or vignettes for each respondent. Of these, 36 vignettes comprise four elements, with no question contributing more than one element. The remaining 12 vignettes comprise three vignettes, again with no question contribute more than one element. One of the differences between Mind Genomics and conventional research is the way that the underlying patterns are uncovered, viz., in terms of dealing with variability or ‘noise.’ The standard scientific approach is to suppress the noise by doing one element at a time so the respondent can focus on the element, or by testing the same vignette with many respondents, so that the variability can be averaged out. In both cases the research must perforce be limited to the 48 vignettes chosen, so it is good research practice to know a lot about the topic, so that the choice of the elements and the creation of the vignettes is ‘close to as good as it can be.’ The strategy seems adequate, unless of course one does not know much about the answer and does not even know where to start. In such a case, there is a reluctance to spend a lot of money on solid research. The Mind Genomics approach is quite different. The ingoing assumption is that the research should cover as wide a space of alternative combinations as possible, rather than be focused on a small, and presumably promising area. This strategy of covering a wide swath of the ‘design space,’ the world of possible combinations, is accomplished by a permutation strategy [15]. The basic mathematical structure of the experimental design is maintained, but the actual combinations differ. The happy consequence is that each respondent evaluates a different portion of the design space. That is, each respondent evaluates all elements, each element five times in different combinations, but it is the combinations which vary. Only at the end, when the ratings are deconstructed into the contribution of the individual elements do we get a consensus value for each element, the coefficient which is the key to the analysis, the ‘secret sauce’ in the parlance of business.

It is worth noting here that the systematic permutation and the potential for iteration means that the researcher really does not have to know, or even ‘guess’ what are the correct elements, and what are the combinations which will be most productive to reveal the answers to the problems. Rather, the underlying computer program for Mind Genomics will create the combinations for a respondent, present these combinations to the respondent, get the ratings, and store the data. The process is fast, the creation of the different sets of combinations is automatic, built into the system, allowing the entire process, from start to finish, from creating the elements to evaluating the analyzed results, to occur in a matter of hours, or a day at most.

Step 3 – Create the Additional Material for the Study

This material included the orientation page, comprising a short introduction to the topic, as well as a 9-point rating scale. As we see below, the orientation creates very little expectation on the part of the respondent about what the correct answer will be. It will be the task of the elements (Table 1), combined into vignettes (Step 2) which will drive the response. The orientation is simply a way to introduce the respondent to the task. The orientation for this study is simply the question ‘How likely are you to register to vote based on the information above?’. The respondent’s task was simple; read the vignette and rate the vignette. There was not deep information about the need for voting, etc. That information would be provided by the elements. The actual ‘look’ of the question appears below. Note that the vignette occupied the top of the screen, and the rating scale occupied a small section of the bottom of the screen:

box

In addition to the orientation and rating, the respondents were instructed to fill out a short questionnaire on who they were, and gave the researcher the permission to contact them, and to append additional third-party data of a non-confidential source. That additional information augmented the information obtained in the Mind Genomics experiments, allowing the researcher to understand the preferences and way of thinking of individuals based upon WHO they are, and WHAT they do. Such information is the typical type of information served up in studies. By itself the information informs but does not guide directly. Coupled with understand the important elements to drive a person to say she or he will register to vote, the information becomes far more valuable. One can then prescribe, rather than just describe.

Step 4 – Execute the Experiment

The respondents were from New York City participants who were members of a nation-wide panel company, Luc.id. Since around 2010 it has become increasingly obvious that it is virtually impossible to do online research, even with short interviews of more than 30 seconds without compensating the respondent. The days of massive responses to studies are finished, simply because people are both starved for time, and inundated with on-line surveys for every ‘trackable behavior’ of economic relevant. The refusal rate for interviews is skyrocketing. Thus, the use of online panel providers has dramatically increased, removing the onerous tasking of finding respondents for these short studies.

The study encompassed 460 respondents, with an interview lasting about 8-10 minutes. The compensated panelists generally do not ‘drop out’ of the study mid-way, as is the case for unpaid volunteers, where it is difficult to get panelists, and difficult to retain panelists to finish the task.

Table 2 gives a sense of the depth of information obtain about each respondent. Some of the questions were asked of the respondent at the time of the interview. Other questions were answered by third-party data purchased for the project.

Table 2: Example of some direct self-profiling classification questions and additional third-party data available and matched to the respondents by matching email addresses. A total of 145 additional data points were ‘matched’ to the study data of each of the 460 respondents.

table 2(1)

table 2(2)

Step 5: Create Models Which Relate the Presence/Absence of the Elements to the Rating

The respondent rated the vignettes on a 9-point scale. One might ordinarily wish to relate the presence/absence of the elements to the 9-point rating. The issue there is that we do not know, intuitively, what a 7 means, or what a 2 means, etc. We do know that the higher numbers mean that the respondent is more likely to register to vote, and that the lower numbers mean that the respondent is less likely to register to vote. That information is directional, but not sufficient.

In consumer and social research circles, there has been a movement to re-code scales such as the 1-9 or similar scales, to make the interpretation easier. We created six new binary scales, as follows:

box 2

The statistical analysis OLS (ordinary least squares) regression needs some minimum amount of variation in the dependent variable. Across the entire set of 460 respondents, it is very likely that the respondents will not generate the same rating (e.g., TOP3, all respondents rating the 48 respondents 7-9). If the respondents were to somehow do so, the statistical analysis would crash. On the other hand, for individual respondents, it is likely that a respondent might confine all ratings to 1-3, making BOT3 always 100. IN that case, the OLS regression would crash when creating a model or equation for that one respondent, bringing the entire processing to a halt.

To forestall the problem of a ‘crash; we add a vanishingly small number to each of the binary transformed variables that we just create ensuring that the actual transformed ratings vary a very little but do vary around the levels of 0 and 100, respectively. There is no meaningful effect on the regression coefficients emerging after performing this small prophylactic adjustment, but we prevent crashes. Indeed, without this adjustment, about 5% of the respondent models ‘crash’ because the respondent’s transformed numbers either all map to 100 or all map to 0.

The experimental design at the level of both the individual and at the level of the group allows us to create equations relating the presence absence of the elements to the transformed, binary ratings. We create six equations, each expressed as:

Binary Rating = k0 + k1(A1) + k2(A2) … k35(F5) + k36(F6)

Each equation is characterized by its own additive constant, and its own array of 36 coefficients. We interpret the additive constant as the expected percent of the respondents who will register to vote or not register to vote (according to the variable definition), albeit in the absence of elements. The additive constant is a purely estimated parameter but can be used as an index for predilection to register to vote. We expect increasing magnitudes of the additive constant as we go from TOP1 (Definitely intend to register to vote) to TOP3 (Intend to register to vote), and we expect a decreasing magnitude of the additive constant as we go from BOT3 (intend not to register to vote) to BOT1 (definitely not intend to register to vote). For the first analysis, we create six equations or models, based on the data from the total panel, and using each of the newly created binary variables as a dependent variable. With 36 elements, and six dependent variables, the OLS regression generates a massive amount of data (six additive constants, 216 coefficients, viz., 36 coefficients for each of the binary variables). That amount of information overwhelms the researcher, disguising patterns where they exist. To uncover the pattern, we blanked out all coefficients of 3 or lower, only to end with no strong performing elements. For the Total Panel only, we looked at elements with coefficients of +2 or higher. For all other analyses of coefficients, we look at elements with coefficients of +3 or higher. We begin first with the additive constant, the estimated propensity to register to vote, in the absence of elements. As we expected looking for individuals who feel strongly about voting generates a low additive constant of 10 (viz., for TOP1). We are likely to find only about 10% of the responses to be a ‘9’, in the absence of elements. When we make the criterion easier, accepting a 7, 8, or 9, (viz., TOP3) the additive constant jumps to 27.

Table 3 shows us that despite our efforts to find motivating elements, only six elements passed the relatively easy screen, viz., a coefficient of +2. The coefficient of +2 is very low in the world of Mind Genomics. Table 3 shows that the effort to find drivers of voting produced only three elements which show any promise, using the data from the total panel, and the promise they show is less than enthusiastic.

A4 You’ll be done registering in 5 minutes or less.

B2 You can get immediate answers for voter registration questions by calling, 1-800-FOR-VOTE.

D6 Voting allows you to be an advocate for your family and for your community: control your leadership and control your life.

When we move to the response ‘Not Register to Vote’ we see a similar pattern. The additive constants are similar in magnitude and go in the right direction. The strong statement about not voting, a rating of 1, captured by the variable BOT1, suggest that 10%, saying they would not definitely register to vote when the criteria are made less strict.

These are the three elements, presumed at the start of the experiment to drive positive voting, but instead drive the opposite, not registering to vote:

D3 Be an example for those who look up to you.

E5 You may have your things unpacked, but you haven’t moved in until you’ve registered.

F2 Government “of the people and by the people” requires your participation. The solution to your problems starts by registering.

Table 3: “Strong’ performing elements from the total panel, defined operationally as a coefficient of at least +2. Only those coefficients are shown. Missing elements failed to generate any coefficients of 2.0 or higher for any of the binary dependent variables.

table 3

Do People Change Their Stated Likelihood of Voting During the Interview?

Having now looked at the data from the total panel, and finding very little, we must pursue the reason why we fail to discover strong elements from the total panel. If we did not have the underlying structure, we would not know how weak the data are from the total panel. We would simply choose the strongest performing vignette and work with that vignette. Such an approach characterizes the research where the stimuli are put together, without structure. If we have one or two or even three or four elements varying, we might make a good guess, but we could not be sure. Mind Genomics take us in a different direction, to uncover the performance of the elements. It is those elements which constitute the building blocks of revised potentially better performing elements. Our first analysis looks at the (possible) change in the rating assigned by the respondents as the interview or experiment progresses. Recall that each respondent evaluated 48 unique vignettes, each vignette comprising 36 combinations of four elements (one from each of four questions), and 12 combinations or vignettes of three elements (one from each of three questions). By design, and by the systematic permutation of the vignettes, respondents saw different vignettes. We cannot measure change in the response to a specified vignette which most likely appeared just a few times, but we can measure the relation (if any) between the average rating assigned by the respondent and the order in the study (rating 1-9 for each vignette, order 1-48).

Our analysis uses OLS regression, done at the level of the individual respondent. For each respondent we know what was assigned to each vignette rated by the respondent, as well as the order of testing. We express the relation as: Rating (9-point scale) = k0 + k1(Order of Testing). The slope, k1, tells us the effect of repeating the interview. We are interested in the sign of the slope, k1, and then the magnitude of the slope. When k1 is positive we conclude that the respondent becomes more interested in registering to vote as the interview or experiment goes on. It may be linked to the respondent being more sensitive to messaging. When k1 is negative we conclude that the respondent becomes less interested in registering to vote as the interview or the experiment on. The respondent may be turned off. In turn, the magnitude of the slope, viz. the numerical value of k1, tells us how many rating points on a 9-point scale will be added to the rating or subtracted from the rating for each additional vignette evaluated. Figure 1 shows the estimated magnitude of change in the rating assigned by a respondent across the 48 vignettes. Most of the respondents show a small change in the rating from vignette #1 to vignette #48. Most the respondents are within +/- two points on the 9-point rating scale. Keep in mind that the regression analysis generating the data was did not look at the actual range, but simply the pattern of changes manifesting itself at the individual respondent level.

fig 1

Figure 1: The distribution of expected ranges to be expected as the respondent proceeds to evaluate 48 vignettes. Most of the range lies between an increase of 2 points to a decrease of 2 points from first vignette to last vignette.

Thus far we know the behavior of the respondent and can differentiate those respondents who are likely to increase versus decrease their ratings. We do not know anything about their criterion for making their judgments. We could ask the respondents to tell us their criteria, but it’s unlikely that they could tell us. The interview is so short, the vignettes judged so quickly, and the attention to the topic only modest while the interview is going on. Despite what might be wished for by novice researchers, most experienced researchers in these types of studies KNOW that their respondents are barely interested in the topic and are answering automatically to stimuli which much seem to them like a ‘blooming, buzzing confusion’. Those are the words of Harvard psychologist William James, when describing how a baby must perceive the world. Fortunately, Step 2 above tells us that despite the response of the respondent (or professional) asked to describe the test stimuli, there is a strongly laid structure underlying each respondent’s set of 48 vignettes. The structure prescribes exactly which elements belong in each vignette, doing so down to the level of a single respondent. We divide the respondents into three groups, defined qualitatively as those with positive range (one point or greater increase in the rating from vignette #1 to vignette #48), those with a flat range (between -1 and +1 point across 48 vignettes), and those with negative range (one point or greater decrease in the rating across 48 vignettes). The first become more interested in registering to vote, the second don’t really change their rating, and the get turned off.

Table 4 shows the strong performing elements for each group. Again, we select only those elements which have a breakthrough coefficient, now defined as +4, but which could easily be changed. The objective is to reduce the ‘wall of numbers’ to a limited set with the patterns coming through.

We see the following patterns emerging:

  1. There are breakthrough elements for Groups 1 (positive range) and Group 3 (negative range), but no strong elements for Group 2 (flat range)
  2. Despite the differences between the groups, and the differences in the patterns of the additive constants, there is no clear ‘story’ about what is driving Group1 (positive range) vs. Group 3 (negative range).

Table 4: Strong performing elements for three groups created on the basis of the range of the 9-point rating to be observed as the respondents proceeds to rate vignette 1 to vignette 48.

table 4(1)

fig 4(2)

We conclude that if there is a story, it is deeper than the observed patterns of responses. Looking at large morphological differences in the patterns of responses gives us a lot of data, a lot of comparisons, but sadly no insight.

Uncovering Underlying Mind-sets based on the Pattern of Coefficients

One of the hallmark features of Mind Genomics is its focus on the decision-making of the everyday, and the recognition that the variability often observed in the data may be result in part from the combination of underlying groups with different criteria. A good metaphor is white light without color. One who looks at white light would say that it is colorless, but the structure of white is that emerges from three primary colors, red, blue, and yellow, respectively. Continuing the metaphor, what if the lack of strong, interpretable patterns in the data come not so much from lack of patterns, nor from intractable variability, but rather from the class of different mind-sets, having different criteria. The failure to uncover strong patterns may be the result of mutual cancellation. Mind Genomics researchers have worked out simple ways to identify these mutually exclusive primary groups, without the benefit of ‘theory’ about how the topic actually works, but simply on the basis of ‘hands-off’, clustering. Recall that each respondent evaluated a unique set of 48 vignettes, embodying the 36 elements in different combinations, with the data from each respondent constituting a complete experimental design. That is, each respondent both evaluated different combinations, but the mathematics of each set of combinations allows us to create a model for that individual [15].

To create these primary groups, or ‘mind-sets’, we followed these steps, adapting the Mind Genomics process, but incorporating two dependent variables simultaneously, register to vote (TOP2), and not register to vote (BOT2).

  1. Create the mind-sets on the basis both of drivers of registering to vote, and drivers of NOT registering to vote. That is, we were interested in moving beyond one direction (drivers of registering to vote)
  2. For each of the 460 respondents, create a model for TOP2 relating the presence/absence of the 36 elements to the TOP2 value. Create another model for BOT2. We thus have 460 pairs of coefficients, each pair comprising 36 coefficients.
  3. When estimating the model for each respondent, do not use the additive constant. The rationale is that we will be combining the two sets of 36 coefficients to create a set of 72 coefficients for each respondent. All the information must be available solely in the coefficients. The technical appendix shows that estimating the coefficients without an additive constant produces the same pattern of coefficients as estimating the coefficients with an additive constant. The only difference is the magnitude of the coefficient. Figure 2 in the Technical Appendix shows the high co-variation between the two sets of coefficients, estimated for the same data, one without and one with the additive constant, respectively.
  4. Create the 460 rows of data, comprising 36 coefficients for TOP2, and 36 coefficients for BOT2. Each respondent now has 72 coefficients.
  5. Use principal components factor analysis to reduce the size of the matrix, by extracting all factors with eigenvalues of 1 or higher. This produced 19 factors.
  6. Rotate the factors by a simplifying method, Quartimax, to produce a set of 19 new factors, rather than 72. Each respondent becomes a set of 19 numbers, the factor scores in the structure, rathe than a set of 72 numbers. We van be sure that the 19 factors are independent of each other.
  7. Extract two and three clusters, or mind-sets, based on strictly numerical criteria [16]. The cluster method is the k means clustering, with the measure of distance between any two people defined by (1-Pearson Correlation between the two people on the 19 factors). In practical terms, any clustering method will do the job, since the clustering is simply a heuristic to divide the 460 respondents into similar-behaving groups
  8. The principal component factor analysis allows us to create models for two segments (mind-sets) corresponding to the two-cluster solution, and three segments (mind-sets) corresponding to the three-cluster solution. The three-cluster solution was clearer. One could extract ore clusters, or mind-sets, but we opted for parsimony.

Create the six equations, with additive constants, for each of the three mind-sets, using the respondents allocated to the mind-sets. Eliminate all elements which fail to exhibit a coefficient of +4 in any model. This step winnows out most of the elements. The elements which remain show strong performance, and also suggest an interpretation, something not seen the previous data because variables did not have ‘cognitive richness’.

Table 5 suggests that there are three subtly different groups

MS 1 – A sense of voting is easy, fun, like sports. Don’t want to be reminded of the ‘seriousness’ of voting

MS 2 – Make it easy, make it simple, learn. They are ready. Nothing really turns them off.

MS 3 – Hates lines, make it easy. That’s all. Avoid talking about social responsibility. It’s a turnoff

The additive constants suggest that Mind-Set 1 (voting as fun) is most likely to register, without messages

Mind-Set 2 is likely to register. Nothing really turns them off.

Mind-Set 3 can be swayed by the right or wrong messages

The three mind-sets differ both in the pattern of likelihood to register and in the topics which turn them off, if there are any. Only Mind-Set 3 really responds in a way that suggest they are turned off.

Table 5: Strong performing elements for three emergent mind-sets (coefficient > = 4).

table 5(1)

table 5(2)
 
fig 2

Figure 2: Scatterplot based on the data from the total panel, showing the strong co-variation of the 36 coefficients when estimated with an equation with an additive constant, vs. absent an additive constant.

Synergisms in Messages – Increasing the Likelihood of Mind Set 1 to Say They Will Register to Vote

As noted above, most conjoint measure studies with experimental design focus on a limited set of combinations, with the respondent testing all or only some of the combinations. None of the methods use permuted designs. It is the permuted design which allows the research to explore a great deal of the design space. One of the unexpected benefits is the ability to identify synergism and suppressions between pairs of elements. It to the study of interactions, and the search for synergism that we now turn.

Moskowitz and Gofman [11] introduced the notion of ‘scenario analyses for Mind Genomics. The guiding notion is that pairs of elements may synergize with each other, but the synergy could be washed out in a larger design. A better way to find out whether elements synergize is to select one of the questions (e.g., F), and separate all the data in the study into one of seven different strata, specifically all those vignettes where there is no F (by design), all those vignettes where F is held constant at F1, all those vignettes where F is held constant as F2, etc. Our starting data, therefore, is a set of several strata. We will end up running seven equations of the same type, one equation for each stratum. The equation will have only 30 independent variables (A1-E6), because for each stratus there is a single value of F, a single element. The set of elements from F are no longer independent variables. They simply exist in the vignette, or in the case of F0 deliberately left out of the vignettes. We can now select a target population, e.g., Mind Set 1, and run the regression seven times, once for each stratum. We will choose the most stringent dependent variable, TOP1 (definitely register to vote). The independent variables will be A1-E6, 30 out of the 36 variables. The additive constant is still the expected percent of response TOP1 (rating of 9, definitely register to vote), in the absence of the elements. The coefficients are the incremental percent of responses ‘will register to vote’ when the element appears in the vignette. Armed with that information let us now run the reduced model on each of the seven strata. Table 6 shows the coefficients. The columns correspond to the seven different strata. The rows correspond to the elements which show coefficients of at least +10 in one stratum. These are elements which are expected to synergize. To make navigating easier, and to uncover the strong performing combination, we present only those cells with positive coefficients of +4 or higher. The simplest way to discover combinations is to search for the shaded cells with the highest coefficient and add that high coefficient to the additive constant. The result will be the estimated score for that pair of elements as the key message. There are several very strong combination, combinations that we would not have guessed, first in the absence of mind-set segmentation, and second, in the absence of ability to uncover synergistic (or suppressive) combinations. A good example is the synergistic pair (F4, B6), and then ‘finished off’ with element D5. Table 6 suggests that the total score for TOP1 (definitely would register to vote) would be 11 for the additive constant, 15 for the synergistic pair (F4, B6, or 26 points. There is room for one more element, which we are free to choose, as long as the element makes intuitive sense and fits with F4 and B6. One example could be D5:

F4 = Big issues don’t slack during busy times. Neither should you. Go register today.

B6 = Everything you like and everything you don’t like in government came from elected officials. Your vote does matter.

D5 = Regret is the result of knowing you could have done more for your life. Register today, regret nothing tomorrow.

A possibly better strategy emerges when we look at F2 as an introductory phrase. The element itself does not bode well (additive constant of -1), but it synergizes with four of the six elements show in the stub (row) of Table 6.

F2 Government “of the people and by the people” requires your participation. The solution to your problems starts by registering.

B2 You can get immediate answers for voter registration questions by calling, 1-800-FOR-VOTE.

C4 New York City is first in a lot of things but ranks 46th in voting. Lead the movement. #NYCVotesTheMost

D2The best things in life come free. Registering will satisfy your lifestyle by improving physical and mental wellness.

E4 The best things in life come free. Registering will satisfy your lifestyle by improving physical and mental wellness.

Table 6: Strong pairwise- interactions between elements F1-F6, and the remaining elements. The data come from respondents in Mind-Set 1.

table 6

Discussion and Conclusions

The world of public policy requires that the citizens perform their duties. Some of these duties are mandatory, such as military service, education, and obeying the law. Some are rights, not necessarily duties, such as registering to vote. Ask any group of people about how they feel about registering to vote, and you are likely to get a range of answers, from affirmation of patriotism, to indifference, to the absolute dislike of registering to vote because it is at once disinteresting, a duty, and worst of all, it puts one on the list for jury duty, another public service not in great favor. The sentiments around registering to vote are often simply measured as ‘yes/no’, e.g., will you register to vote or not register to vote. In this Mind Genomics study (really experiment), we have gone into the topic as it were a product or service, being offered to the respondent. We have used the language often used to ‘convince,’ only to discover that across the entire panel respondents, there are really no strong messages. If voting were a service or a product, we would ‘go back to the drawing board’ and try again

The speed, simplicity, cost, and templated structure of Mind Genomics, especially with smaller versions of the study presented here, 16 rather than 36 elements, makes it now possible to iterate through, testing different messages of a ‘public service’ nature. Public service messages may be viewed as a necessary evil, to be checked off, even though they contain little of a sales nature, and are primarily exhortations to do one’s duty and to be good citizens. Or, as Mind Genomics suggest, public service messages may provide the necessary matrix of ideas to use as a way to understand and to motivate the citizen. The study run here itself constitutes a larger-than-usual study in terms of the ideas explored. The results suggest a lack of knowledge of ‘what really motivates people,’ or more correctly a lack of understanding of people who are the targets of communication for a topic which is at best unromantic, quotidian, ordinary, and perhaps even potential negative because it could lead to jury duty. How interesting, however, the study becomes when we peel back the layers, understand the minds of people through segmentation, and through understanding of synergies where two messages combine to do far more than one expected. This type of information, collected across different types of studies, in an iterative process, builds a bank of knowledge for messaging about the common weal, the common good. Having a process such as Mind Genomics embedded in our societal life and in our political process offers far greater benefits to society than we can imagine today. Just imagine messaging for the social good, and doing it expeditiously, inexpensively, effectively.

Technical Appendix Relation between Coefficients Estimated with vs. without the Additive Constant

Mind Genomics is founded on the use of experimental design and OLS (ordinary least-squares) regression. Experimental design creates the test stimuli (vignettes) by specifying the specific combinations. OLS regression deconstructs the response to the vignettes, to estimate the part-worth contribution of each element to the respondent. Traditional Mind Genomics has worked with OLS regressions estimated with an additive constant. The constant is a measure of the likelihood of the response in the absence of the stimulus, a purely theoretical parameter. In this study, comprising six questions, each with six answers or elements, the experimental design called for 48 vignettes. Each element appeared 5x in the 48 vignettes and was absent 43 times. We can estimate two equations for the Total Panel, or indeed two equations for any subgroup, both equations using the same data.

Equation 1: Equation with the additive constant

Binary Dependent Variable (e.g., TOP2) = k0 +k1(A1) + k2(A2) … k36(F6)

Equation 2…which looks exactly like equation 1, but has no additive constant

When we estimate the coefficients, and plot one set against the other in a scatterplot, Figure 2 tells us that the patterns are the same, although the coefficients are higher when there is no additive constant. Figure2 shows an almost perfect co-variation of coefficients estimated in the two ways (R=0.94), with different values, however for the same element.

Acknowledgments

The authors wish to acknowledge the contributions of those students at Pace University, New York, who designed, executed, and wrote up the study for presentation to the Office of the Mayor of New York City. The strategy and messaging were used prior to the elections to encourage New Yorkers to register to vote in the upcoming election. The students then presented the study to professional direct marketers, at a direct marketing conference. In their own words ‘this is a great, practical tool which taught us a lot as we used it and got to see what we could accomplish.’

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  11. Moskowitz HR, Gofman A (2007) Selling blue elephants: How to make great products that people want before they even know they want them. Pearson Education.
  12. Miller GA, Galanter EH, Pribram KH (2017) (Orig. 1960). Plans and the Structure of Behavior, Routledge.
  13. Moskowitz HR (2012) ‘Mind Genomics’: The experimental, inductive science of the ordinary, and its application to aspects of food and feeding. Physiology & Behavior 107: 606-613.
  14. Moskowitz HR, Gofman A, Beckley J, Ashman H (2006) Founding a new science: Mind Genomics. Journal of Sensory Studies 21: 266-307.
  15. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127-145.
  16. Xu R, Wunsch D (2008) Clustering (Vol. 10). John Wiley & Sons.
Featured Image2

Social Determinants Do Not Determine Me

DOI: 10.31038/AWHC.2021452

 

The apartment complex in which I lived growing up was called, “The Bellagio,” and its name was written in golden, cursive letters on the exterior of the building. As a child I always thought this name sounded so elegant, like a ballet dance step. But if you unlocked the front door, you would notice the dingy grey carpet, the cracked and yellowing blinds, and the faint stench of tobacco emanating from the apartment of the old man who lived in the unit below. It wasn’t elegant, but to my single mother and me, it was home.

My mother frequently tells me, “I didn’t want us to be another statistic.” What she meant was that as young, Hispanic women who lived below the poverty line, society expected our lives would amount to very little. These multidimensional identities – female, poor, Hispanic – had placed us at the front doorstep of intergenerational poverty, which we would have to defy serious odds to overcome. In medicine, we call these obstacles the “social determinants of health,” which we use to predict and explain health outcomes. But these issues do more than impact risk of disease: they extend their roots into class, career, and community. From the air quality of a neighborhood to the processed sugars in affordable food, they act as the cloudy weather that influences how readily the blossoms of life can bloom. My reflections on my childhood inform my understanding of how these social determinants both did and did not “determine” my life and provide a unique opportunity to serve and advocate for poor families, Hispanic families, and especially those families led by single parents.

Recent data demonstrates that families headed by single mothers are most vulnerable to poverty [1,2] and that their children face greater obstacles related to educational achievement and adjustment in school [3]. Indeed, for many years my mother and I relied on government assistance programs, including Aid to Families with Dependent Children (AFDC), Women, Infants and Children (WIC), and Medicaid, which funded the bare necessities required for child rearing. I remember spending afternoons in a grey government building playing with communal toys that had been well-loved by many children before me while my mother secured diapers and milk for another week.

Despite these barriers, I was fortunate to be among the 6.8% of Hispanic applicants that are accepted to medical school [4,5] a percentage that shrinks even further if you control for class, gender, and single-parent households. This felt strange to me, given that almost 18.5% of the American population is Hispanic or Latino, a number that continues to rise [6]. Together, these statistics suggest a severe underrepresentation of Hispanic medical school applicants and matriculants relative to the age-adjusted US population [5].

I felt the effects of my minority status almost immediately after starting medical school. During my first week, a group of peers were recounting their favorite travel stories. They took turns sharing tales of Icelandic landscapes and tropical paradises. In that moment, I realized I was one of very few to not have had those same kinds of experiences. My only travel history was my semester abroad, and I had taken out extra loans just to afford the plane ticket. It felt like no one else in my medical school cohort had a background like mine. The voice in my head told me that if you’re standing in a space where no one relates to you, that’s an unspoken affirmation that maybe you don’t belong there. This became a pattern, as I was reminded again and again that my peers and I had very different upbringings, leaving me searching for a personal connection to medicine.

Despite these peer interactions that colored my early medical school experience, I found that in clinical practice, many of my patients did share in my life experiences. It felt familiar interacting with patients who lived in poor areas reminiscent of my own neighborhood, or who were children of single parents. These patients remind me that I belong in medicine, and that my visibility and perspective are important. All patients can benefit from encountering physicians that look like them and relate to their background. These relationships can decrease subconscious bias [7], bridge gaps in health care delivery, and build a deeper bond of trust. Interactions with this patient population remind me that I represent the children of poor, Hispanic, single-parent households, and my personal connection to medicine is found in serving them.

One story from my clinical experiences that has remained with me is an encounter I had on the Mother-Baby Unit during my pediatric rotation. We were rounding on a one-day-old Hispanic baby girl whose mother was a single parent. After asking the mother about whether she needed financial assistance, the attending physician handed her a pamphlet on WIC, then wished her a genuine “good luck” before we hurried on to see the next family. As we left, I noticed that the mother had started to cry.

I couldn’t stop thinking about this mom and her child, and how closely this family dynamic mirrored the experience of my own mother. Alone and at the starting line of single parenthood, had someone once handed my mom a pamphlet on WIC? I couldn’t shake the need to go back to her room and take some time to initiate a heartfelt conversation. I rehearsed the different ways I could tell her that I understood her situation first-hand. I wanted her to know that single parenthood didn’t have to define what her and her daughter’s lives could be, and that there was every possibility that her daughter could accomplish anything she wanted, even end up in medical school someday.

As we finished rounding, I walked back to her room and stood outside the door. I started to doubt myself. I wondered if this conversation was inappropriate or unprofessional, or if I was somehow overstepping my boundaries as a medical student. I lingered outside her room for a few minutes, and when I finally walked in, she was asleep. I wish I could say that I came back later, spoke with her, and made a meaningful impact. But instead, I let the fear of repercussions get the best of me. Looking back, that experience taught me that if I want to make a difference in the lives of my patients, I must be brave and bold, as well as confident that these conversations and visibility are needed and necessary.

While I enjoy working with my peers to provide quality care, my sense of community is fulfilled by working with underserved patients. I am motivated to share my stories and explore the ways in which medical professionals can better advocate for and communicate with them. With these efforts, I strengthen my personal value system, bridge gaps in health equity, and pay homage to my upbringing. I am proud to be an example of how although “social determinants” may have an impact on life, they do not automatically determine worth, value, or achievement.

Abbreviations

AFDC: Aid to Families with Dependent Children

WIC: Women, Infants and Children

References

  1. McLanahan S, Percheski C (2008) Family structure and the reproduction of inequalities. Annu Rev Sociol 34: 257-276.
  2. Damaske S, Bratter JL, Frech A (2017) Single mother families and employment, race, and poverty in changing economic times. Social science research 62: 120-133. [crossref]
  3. Carlson MJ, Corcoran ME (2001) Family structure and children’s behavioral and cognitive outcomes. Journal of marriage and family 63: 779-792.
  4. https://www.aamc.org/data-reports/students-residents/interactive-data/2020-facts-applicants-and-matriculants-data Accessed July 19th, 2021.
  5. Lett LA, Murdock HM, Orji WU, Aysola J, Sebro R (2019) Trends in racial/ethnic representation among US medical students. JAMA network open 2: e1910490-e1910490. [crossref]
  6. United States Census Bureau: QuickFacts. 2019. https://www.census.gov/quickfacts/fact/table/US/RHI725219. Accessed June 16th, 2021.
  7. Bean MG, Stone J, Badger TA, Focella ES, Moskowitz GB (2013) Evidence of nonconscious stereotyping of Hispanic patients by nursing and medical students. Nursing research 62: 362-367. [crossref]
photo 1

Hematological Changes Associated with Amoxicillin, Paracetamol and Their Combinations on Rabbits

DOI: 10.31038/IJVB.2021542

Abstract

Extensive use or misuse of antibiotic and analgesic may lead to hematological changes. This study characterized the hematological changes associated with chronic gavage of Amoxicillin and Paracetamol in rabbits.

Amoxicillin, Paracetamol and their combination were dissolved in distilled water and given a rate of (0 mg/kg), (8 mg/kg), (24 mg/kg) and (4 mg/kg+12 mg/kg) to four groups of rabbits (control, amoxicillin, paracetamol and mixture group) respectively for 2 weeks period followed by 6 weeks relaxation period. Then rabbits were authenticated and sacrificed, blood samples were collected in EDTA-containing tubes and analyzed for complete blood counts using the standard blood analysis method.

Results showed significant increase in white blood cell (WBC) count only in paracetamol treatment. Furthermore, significant increases in hemoglobin (HGB), hematocrit (HCT) were observed in all treatments, whereas platelet (PLT) levels significantly increased in amoxicillin and paracetamol treatments and reduced in mixture treatment. In conclusion, the tested compounds significantly changed blood parameters suggesting potential hematotoxicity due to use of amoxicillin, paracetamol or their combination.

Keywords

Amoxicillin, Blood parameters hematotoxicity, Paracetamol

Introduction

Misuse of amoxicillin (an antibiotic) and paracetamol (an analgesic) may become one of the most difficult problems facing the health sector, which must have a quick and effective solution.

Antibiotic are specific chemicals that kill, slow or stop bacterial growth, they are commonly used by physicians to treat bacterial infections. Amoxicillin was first produced in UK in 1970 and used as antibacterial infections for gram positive bacteria [1]. It has a wide spread application for medical treatments [2]. It may cause liver injury [3,4], health risks due to its side effect to many organisms including fish [5,6].

Paracetamol/acetaminophen is one of the most widely used analgesics, clinical studies indicated many side effects [6]. So far, paracetamol or its metabolites may cause severe hepatic failure [7-9], acute live injury and cell death [10,11], inhibition of excessive amount of N-acetyl-p-benzoquinone imine formation [12], binding quinone reductase 2 in the kidney and liver [13] kidney damage [14] and inhibition of mitochondrial respiration [15].

Hematological changes associated with amoxicillin, paracetamol or their combinations among human beings are not fully understood, a gap of information is still missing. The authors designed this study to measure the hematological changes associated with use of amoxicillin, paracetamol and their mixture on rabbits. Rabbits were chosen as experimental animals because they are big enough, and have similar physiology to human beings [16].

Amoxicillin

Amoxicillin is a (2S,5R,6R)-6-[[(2R)-2-Amino-2-(4-hydroxyphenyl)acetyl]amino]-3,3-dimethyl-7oxo-4-thia-1-aza-bicyclo[3.2.0]heptane-2-carboxylic acid, semi-synthetic, acid stable drug belongs to a class of antibiotics called the Penicillins (B-lactam antibiotics).

Materials and Methods

Chemicals

Amoxicillin and Paracetamol (purity 99%) were obtained from Middle East Pharmaceutical and cosmetics laboratories Co .LTD. All other chemicals used in the experiment were purchased from standard commercial suppliers.

Experimental Animals

Adult male rabbits were purchased from locally certified farms. They were housed in a suitable room equipped with air conditioning according to US-EPA 2004 for a period of two weeks initially to acclimate to insure a stable experimental condition. The rabbits were properly maintained according to the principles and guidelines issued by the Ministry of Agriculture in Gaza And US-EPA2004 for animal care, rabbits were individually placed in appropriate steel cages at 22-26°C, 40-70% humidity and a clean environment with a light/12 hour cycle. A suitable diet of balanced feed and clean water has been provided for the duration of the total experiment.

Preparation of Amoxicillin and Paracetamol Solution

One gram (1000 mg) of Amoxicillin was dissolved in 100 ml of distilled water and1000 mg of Paracetamol was dissolved in 100 ml of distilled water under magnetic steering to ensure complete solubility of drugs . This was visualized by clean solution of water.

Experimental Design

Rabbits were randomly subdivided into four groups five rabbits each group, and monitored during 10 weeks, study period, (2 weeks of acclimatization +2 weeks of treatment +6 weeks without treatment). After acclimatization period, rabbits received the following treatments:

Group 1: Each rabbit received by oral administration amoxicillin at a rate of 8 mg/kg BW for 14 days; Group 2: Each rabbit received by oral administration paracetamol dose at a rate of 24 mg/kg BW for 14 days; Group 3: Each rabbit received by oral administration a mixture of Amoxicillin and paracetamol at a rate of 4 mg/kg BW+12 mg/kg BW for 14 days; and Group 4: control group, each rabbit received by oral administration 1 ml distilled water/rabbit for 14 day. Photo 1 shows the gavage process of the tested compounds.
photo 1

Photo 1: Oral administration of the tested compounds on rabbits

Collection of Blood Samples

At the end of the experimental period (10 weeks) rabbits were authenticated to for blood sample collections via cardiac puncture into sterile tubes containing EDTA to prevent blood clotting, then analyzed for CBC using standard method and previously described [17].

Statistical Analysis

Average and standard deviation were calculated. Analysis of Variances (ANOVA) was employed to detect significant differences among treatments at p-value 0.05. p-value ≤ 0.05 indicates significant differences among treatments whereas values > 0.05 are not significant.

Results

Effects on the Blood

Effects of the tested compounds on white blood cells (WBC) are shown in Figure 1.

fig 1

Figure 1: Chemical structure of amoxicillin and paracetamol.

It can be seen that concentration of WBC was increased in the treated rabbits above that of the control group. Statistical analysis detected significant differences only in paracetamol treatment.

Effects on blood lymph (LYM) are shown in Figure 2.

fig 2

Figure 2: Concentrations of WBC in rabbit treated with Amoxicillin, Paracetamol, and their mixture. Error bars represent standard deviation. Columns have the same letter are not significantly different at p ≤ 0.05.

Similarly, to the effects on WBC (Figure 2) increased levels of LYM were observed in rabbits treated with the tested compounds but statistical analysis did not detect significant differences among treatments.

Effects of the tested compounds on red blood cells are shown in Figure 4. Similarly, to the effects on lymph, increased level of red blood cells were observed in the treated rabbits but no significant differences were detected.

fig 4

Figure 4: Concentrations of RBC in rabbit treated with Amoxicillin, Paracetamol, and Their mixture. Error bars represent standard deviation.
Columns have the same letter are not significantly different at p ≤ 0.05.

Effects of the tested compounds on the blood hemoglbine (HGB) are shown in Figure 5. Increased levels of HGB were observed in the treated rabbits. Satstical analysis detected significant difference among all treatment. this suggests an occurrence different biochemical reactions between HGB and the tested compounds.
fig 5

Figure 5: Concentrations of HGB in rabbit treated with Amoxicillin, Paracetamol, and Their mixture. Error bars represent standard deviation.
Columns have the same letter are not significantly different at p ≤ 0.05.

Effects of the tested compounds on hematocreate (HCT) are shown in Figure 6. Similarly to the above effects, increased level of HCT were found in the treated rabbits but statistical differences were detected only in Amoxicillin and mixture treatments.
fig 6

Figure 6: Concentrations of HCT in rabbit treated with Amoxicillin, Paracetamol, and Their mixture. Error bars represent standard deviation.
Columns have the same letter are not significantly different at p ≤ 0.05.

Effects of the tested compounds on the platlets (PLT) are shown in Figure 7. Similarly to the above effects, increased level of PLT were found in the treated rabbits. Statistical analysis detected significan differences.
fig 7

Figure 7: Concentrations of PLT in rabbit treated with Amoxicillin, Paracetamol, and Their mixture .Error bars represent standard deviation.
Columns have the same letter are not significantly different at p ≤ 0.05.

The concentration of WBC and PLT in rabbits blood treated with Paracetamol were the highest among all treatments then Amoxicillin, whereas the concentration in rabbits treated with Mixture were lower than those of the control samples.

Discussion

Amoxicillin used as an antibiotic against bacteria [18] whereas paracetamol used as an analgesic for many diseases. There usage was associated with many complications as mentioned above. Furthermore, their chemical structure (Figure 1) shows the presence of highly water soluble groups such as (OH; C=O) which facilitate interaction and movement of the compounds in aqueous phase such as blood system. Additionally, the chemical structure includes phenyl ring which may enable covalent bonding with liver, kidney, and/or other tissue causing induced injury, in accordance with Lee et al. [19] who revealed similar phenomenon with other cases. Photo 1 show the oral gavage process of the tested compounds. The data in Figure 2, clearly demonstrates the effects of tested compounds on WBC. It can be seen that Amoxicillin and paracetamol increased WBC above that of the control, whereas the combination reduced the values. This suggests that treatments with Amoxicillin and paracetamol enhance the immune system to produce more WBC to defend the body from amoxicillin and paracetamol. Thus an increase of WBC cell would have occurred to enrich the body with the required level of WBC to insure health body. Our explanation agree with Díaz et al., [20] and Zarkesh et al., [16] who revealed the importance of WBC count on blood levels as long as the body exposed to bacterial infections and/or toxic chemicals [21,22].

On the other hand, the combination of the compounds did not increase the WBC. This suggests that the amoxicillin and paracetamol may antagonize each other in the combination accordingly no increase in WBC was observed (Figure 2). Furthermore, it can be suggested that application of the compounds in combination may provide a protection against possible injury. This suggestion is in agreement with [9] who revealed the activity of chiisanoside against liver injury induced by paracetamol in mice.

Nevertheless, the data in Figure 3, clearly shows increased levels of LYM but they remained insignificant with the control sample. This suggests that LYM does not involve in the immune system in the body. Similarly, no significant effects on RBC (Figure 4). This indicates that RBC is not involved in the immune system. On the other hands, HGB levels (Figure 5) are significantly increased in the treated rabbits. This suggests that HGB is involved in the defense systems throughout antibody antigen reactions. Our results are in accordance with El Menyiy et al. [23] and Biu et al. [24] who found that paracetamol significantly increased hemoglobin and platelet count as compared to the control group. An explanation of these results is that amoxicillin and paracetamol caused a dehydration process to the tested animal (data not shown) which may result in a hem concentration. Additionally, it can be suggested that paracetamol and/or amoxicillin can directly interact with blood system to further enhance the production of hemoglobin. Furthermore, it was reported that Paracetamol bond quinone reductase 2 in liver and kidney which modulated reactive oxygen species generation. This may further enhance the toxicity of paracetamol via quinone reductase 2 mediated superoxide production [13].
fig 3

Figure 3: Concentrations of LYM in rabbit treated with Amoxicillin, Paracetamol, and Their mixture. Error bars represent standard deviation.
Columns have the same letter are not significantly different at p ≤ 0.05.

So far, lack of hemoglobin due to paracetamol or amoxicillin exposure may enhance the body to produce more hemoglobin to compensate the losses consequently an increase in hemoglobin level may be observed. Furthermore, the tested compound may cause hematotoxicity by restoring almost normal counts of the hematological parameters through oxidative stress. Our explanation agrees with Oyedeji et al. [25] who report oxidative stress in rat experiments. Influence of the tested compounds on HCT (Figure 6) showed significant increase in the treatment of Amoxicillin and mixture. The explanation on these results is similar to that given above for HGB. On the other hands significant increases in PLT levels (Figure 7) were observed in all treatments. An explanation of these results is that the tested compounds directly interact with PLT counts resulting in either activation as in amoxicillin and paracetamol or aggregation phenomenon as in mixture. Thus PLT tends to increase or decrease (Figure 7). Our explanation is in accordance with Siauw et al. [26] who provided evidence of the direct involvement of platelets with bacterial toxins.

Mode of Interactions

It can be suggested that amoxicillin and/or paracetamol be oxidized by dehydrogenase enzymes in human or animal body producing oxygen reactive species (ORS) as shown in Figure 8. Then these ORS react with blood systems resulting in elevation of HGB, HCT, and PLT in case of amoxicillin and WBC and PLT in case of paracetamol.
fig 8

Figure 8: Possible mode of action of amoxicillin (A) and paracetamol (B) on blood systems after oxidation by dehydrogenase enzyme.

Moreover, the antagonistic effects of amoxicillin and paracetamol in the combination may result from the fact that both molecules have some similarity in the chemical structure such as phenyl ring, C=O, NH2, CH3, OH,. This similarity enhance hydrogen bonding, hydrophobic interactions and possible covalent bonding between both molecule resulting in a larger size molecule than parent ones (paracetamol, amoxicillin). This molecule can move freely in the human body and may not be able to be oxidized by dehydrogenases consequently no ORS were produced. Accordingly, WBC, HGB, LPT HCT contents remained in the acceptable range. This explanation is in accordance with El-Nahhal [27] who revealed hydrogen bonding and hydrophobic interactions between an organic molecules and acetylcholine esterase in human blood. Furthermore, previous reports [28,29] revealed the solubility of similar organic molecules to each other in aqueous solution. Similar observations were recently reported with other cases [30-34]. Additionally, our results are in accordance with Mwafy and Afana who revealed changes in hematological parameters, serum iron and vitamin B12 levels in hospitalized Palestinian adult patients treated with amoxicillin.

Conclusion

The rational of this work emerged from the fact that paracetamol and amoxicillin are widely used pharmaceuticals and their hematological effects are poorly investigated. Elevation of WBC, HGB, LPT HCT levels in treated rabbits were significantly increased indicating high potential of hematological changes. Amoxicillin has a tremendous effect on blood components more that paracetamol has. Combination of both molecules did not produce significant changes on blood parameters indicating a possible protection to blood components. An interesting outcome of the study is that combination of both molecules can be a safe administration for this case.

References

  1. Kaur SP, Rao R, Nanda S (2011) Amoxicillin: a broad spectrum antibiotic. Int J Pharm Pharm Sci 3: 30-37.
  2. Tong DC, Rothwell BR (2000) Antibiotic prophylaxis in dentistry: a review and practice recommendations. The Journal of the American Dental Association 131: 366-374. [crossref]
  3. Abenavoli L, Libri E, Bosco D, Gallo D, Luzza F (2012) Drug-induced liver Recenti Prog Med 103: 79-84. [crossref]
  4. Nicoletti P, Aithal GP, Bjornsson ES, Andrade RJ, Sawle A, et al. (2017) Association of Liver Injury From Specific Drugs, or Groups of Drugs, With Polymorphisms in HLA and Other Genes in a Genome-Wide Association Study. Gastroenterology 152: 1078-1089. [crossref]
  5. Elizalde-Velázquez A, Martínez-Rodríguez H, Galar-Martínez M, Dublán-García O, Islas-Flores H, et al. (2017) Effect of amoxicillin exposure on brain, gill, liver, and kidney of common carp (Cyprinus carpio): The role of amoxicilloic acid. Environ Toxicol 32: 1102-1120. [crossref]
  6. Jóźwiak-Bebenista M, Nowak J Z (2014) Paracetamol: mechanism of action, applications and safety concern. Acta poloniae pharmaceutica 71: 11-23. [crossref]
  7. Hinson JA, Roberts DW, James LP (2010) Mechanisms of acetaminopheninduced liver necrosis. Handb Exp Pharmacol 196: 369-405. [crossref]
  8. James LP, McCullough SS, Knight TR, Jaeschke H, Hinson JA (2003) Acetaminophen toxicity in mice lacking NADPH oxidase activity: role of peroxynitrite formation and mitochondrial oxidant stress Free. Radic Res 37: 1289-97. [crossref]
  9. Bian X, Wang S, Liu J, Zhao Y, Li H, et al. (2018) Hepatoprotective effect of chiisanoside against acetaminophen-induced acute liver injury in mice. Nat Prod Res 15: 1-4. [crossref]
  10. deLemos AS, Ghabril M, Rockey DC, Gu J, Barnhart HX, et al. (2016) Drug-Induced Liver Injury Network (DILIN) Amoxicillin-Clavulanate-Induced Liver Injury. Dig Dis Sci 61: 2406-2416. [crossref]
  11. Cao P, Sun J, Sullivan MA, Huang X, Wang H, et al. (2018) Angelica sinensis polysaccharide protects against acetaminophen-induced acute liver injury and cell death by suppressing oxidative stress and hepatic apoptosis in vivo and in vitro. Int J Biol Macromol 111: 1133-1139. [crossref]
  12. Bajt ML, Knight TR, Lemasters JJ, Jaeschke H (2004) Acetaminopheninduced oxidant stress and cell injury in cultured mouse hepatocytes: protection by N-acetyl cysteine. Toxicol Sci 80: 343-9. [crossref]
  13. Miettinen TP, Björklund M (2014) NQO2 is a reactive oxygen species generating off-target for acetaminophen. Mol Pharm 11: 4395-404. [crossref]
  14. Ghosh J, Das J, Manna P, Sil PC (2010) Acetaminophen induced renal injury via oxidative stress and TNF-alpha production: therapeutic potential of arjunolic acid. Toxicology 268: 8-18. [crossref]
  15. Satav JG, Bhattacharya RK (1997) Respiratory functions in kidney mitochondria following paracetamol administration to young-adult and old rats. Indian J Med Res 105: 131-5. [crossref]
  16. Zarkesh M, Sedaghat F, Heidarzadeh A, Tabrizi M, Bolooki-Moghadam K, et al. (2015) Diagnostic value of IL-6, CRP, WBC, and absolute neutrophil count to predict serious bacterial infection in febrile infants. Acta Med Iran 53: 408-11. [crossref]
  17. El-Nahhal Y, Al_shareef A (2018) Effective biomarkers for successful management of sepsis. Trends in Medicine 18: 1-8.
  18. Kim BJ, Kim JG (2013) Substitutions in penicillin-binding protein 1 in amoxicillin-resistant Helicobacter pylori strains isolated from Korean patients. Gut Liver 7: 655-660.
  19. Lee J, Ji SC, Kim B, Yi S, Shin KH, et al. (2017) Exploration of Biomarkers for Amoxicillin/Clavulanate-Induced Liver Injury: Multi-Omics Approaches. Clin Transl Sci 10: 163-171. [crossref]
  20. Díaz MG, García RP, Gamero DB, González-Tomé MI, Romero PC, et al. (2016) Lack of Accuracy of Biomarkers and Physical Examination to Detect Bacterial Infection in Febrile Infants. Pediatr Emerg Care 32: 664-668. [crossref]
  21. El-Nahhal Y (2017) Risk Factors among Greenhouse Farmers in Gaza Strip. Occupational Diseases and Environmental Medicine.
  22. El-Nahhal Y, Lubbad R (2018) Acute and single repeated dose effects of low concentrations of chlorpyrifos, diuron, and their combination on chicken. Environmental Science and Pollution Research.
  23. El Menyiy N, Al-Waili N, El Ghouizi1 A, Al-Waili W, Lyoussi B (2018) Evaluation of antiproteinuric and hepato-renal protective activities of propolis in paracetamol toxicity in rats. Nutrition Research and Practice 12: 535-540. [crossref]
  24. Biu AA, Yusufu SD, Rabo JS (2009) Studies on the effects of aqueous leaf extracts of Neem (Azadirachta indica A juss) on haematological parameters in chicken. Afr Sci 10: 189-92.
  25. Oyedeji KO, Bolarinwa A, Ojeniran SS (2013) Effect of paracetamol (acetaminophen) on haematological and reproductive parameters in male albino rats IOSR. J Pharm Biol Sci 4: 65-70.
  26. Siauw C, Kobsar A, Dornieden C, Beyrich C, Schinke B, et al (2006) Group B streptococcus isolates from septic patients and healthy carriers differentially activate platelet signaling cascades. Thromb Haemost 95: 836-849. [crossref]
  27. El-Nahhal Y (2018) Accidental Zinc Phosphide Poisoning among Population: A Case Report. Occupational Diseases and Environmental Medicine 6: 37-49.
  28. El-Nahhal Y, Safi J (2004) Adsorption behavior of phenanthrene on organoclays under different salinity levels. Journal of Colloid and Interface Science 269: 265-273.
  29. El-Nahhal Y, Safi, J (2004) Stability of an organo clay complex: effects of high concentrations of sodium chloride. Applied Clay Science 24: 129-136.
  30. El-Nahhal Y, Raaed Lubbad, Mohammad R Al-Agha (2020) Toxicity Evaluation of Chlorpyrifos and Diuron below Maximum Residue Limits in Rabbits Toxicology and Environmental Health Sciences.
  31. Matozzo V, Battistara M, Marisa I, Bertin V, Orsetti A (2016) Assessing the Effects of Amoxicillin on Antioxidant Enzyme Activities, Lipid Peroxidation and Protein Carbonyl Content in the Clam Ruditapes philippinarum and the Mussel Mytilus galloprovincialis Environ Contam Toxicol 97: 521-7. [crossref]
  32. Mwafy SN, Afana WM (2018) Hematological parameters, serum iron and vitamin B12 levels in hospitalized Palestinian adult patients infected with Helicobacter pylori: a case-control study. Hematol Transfus Cell Ther 40: 160-165. [crossref]
  33. Mihalaş E, Matricala L, Chelmuş A, Gheţu N, Petcu A, et al. (2016) The Role of Chronic Exposure to Amoxicillin/Clavulanic Acid on the Developmental Enamel Defects in Mice. Toxicol Pathol 44: 61-70. [crossref]
  34. Seal P, Sikdar J, Roy A, Haldar R (2017) Acetaminophen interacts with Human Hemoglobin: Optical, Physical and Molecular modeling studies. J Biomol Struct Dyn 35: 1307-1321. [crossref]
fig 2

Acupuncture Emergency Service in Brazilian Public Health System: Quantitative Analysis of Cases Attended in a Semester

DOI: 10.31038/PEP.2021247

Abstract

Background: Acupuncture is an effective technique for pain relief and is usually practiced in outpatient clinic setting. It can also be applied in emergency setting focusing on pain relief from non-life threatening diseases.

Objectives: This quantitative, retrospective and descriptive study aimed to demonstrate the dynamics of the Acupuncture Emergency Service at Hospital São Paulo (AES-HSP), linked to the Paulista School de Medicine of the Federal University of São Paulo (Escola Paulista de Medicina – EPM / UNIFESP), which provides free care for the population since 1998.

Methods: Data were collected from the care records of the second half of 2019, assessing gender, age group, complaint, technique (s) used, percentage of improvement reported by the patient and Visual Analogue Scale before (VASb) and after treatment (VASa).

Results: We identified 7647 visits, of which 78.3% (n=5986) were female; the mean age was 60.8 ± 14.3 years-old; the most common complaints were low back pain (26.4%), followed by shoulder pain (17.5%) and knee pain (14.8%); systemic acupuncture was used in a total of 7032 cases, only acupuncture microsystems were used in 615 cases, microsystems and systemic acupuncture were combined in 1815 cases; VASb average was 6.29 ± 2.17, while VASa average was 1.44 ± 1.42; in 21.4% of 6423 visits properly registered, patients reported 100% improvement and 72.2% reported more than 50% improvement.

Conclusion: Our service provides effective pain relief, allowing to receive a great demand from patients with fast execution in an emergency setting, reducing the use of pain killers and its side effects.

Keywords

Acupuncture analgesia, Traditional Chinese Medicine, Public health, Pain Control

Introduction

Musculoskeletal pain (MSP) is classified as acute or chronic, and is the most prevalent symptom in the world population. Its prevalence has increased in recent years due to higher prevalence of risk factors related to lifestyle habits, such as smoking, anxiety, physical inactivity, sleep disorders. Additional influences include low educational level, precarious family income and social isolation [1,2]. In addition, MSP represents an important cause of morbidity, with a large impact on quality of life and in the economic sphere, for example, absence from work, sometimes requiring long periods of recovery [3].

European data related that 15-20% of primary health care appointments are due to musculoskeletal problems [4].

In Brazil, a meta-analysis performed in 2012 estimated the prevalence of chronic MSP ranging from 14.1-85.5%. Considering only Brazilian studies were evaluated in the meta-analysis, the most affected sites were the dorsal spine and the lower limbs [5].

The impact of chronic pain on national economy also reaches a large proportion. For example, in 2007, Australia, a country with approximately 22.7 million inhabitants, had an estimated cost of $34.3 billion for expenses related to chronic pain, with an average of $10,847 per person with chronic pain [6].

The western medicine approach to MSP is mainly based on the use of common analgesics, opioids, anti-inflammatories and physical therapy. Allopathic drugs, however, are not exempt from adverse effects [7]. In addition, the presence of comorbidities, such as high blood pressure, diabetes, and chronic kidney disease, may restrict the use of such medications. Moreover, the inadequate follow-up of prescriptions and the practice of self-medication predispose to the overuse of anti-inflammatory drugs, which may cause serious complications, such as acute renal dysfunction, upper gastrointestinal bleeding due to peptic ulcer disease and occurrence of cardiovascular events [8-10]. The excessive use of opioids, in turn, might result in an increasing number of drug overdose, addiction and deaths [7].

Acupuncture has an energetic propaedeutic role, capable of detecting and treating an individual’s imbalances before they evolve into organic diseases. In addition to the preventive aspect, it is an effective and safe therapeutic tool for many diseases [11].

The mechanism of action of acupuncture involves stimulation of peripheral nociceptors at specific points, which reach the nervous system through neuronal pathways. Neuromodulation occurs at three levels: local, spinal and supraspinatus, resulting in the release of different substances, such as neurotransmitters, that modulate motor, sensory, autonomic, neuroendocrine and emotional responses [12]. Is important to achieve the Te Qi needling sensation, characterized as a set of sensations, such as pain, burning, tingling, pressure, weight, anesthesia and/or shock, directly related to clinical efficacy [13].

In the west, the growing demand for acupuncture treatment is due to its effectiveness in pain complaints, especially in individuals with limitations to traditional pharmacological treatment [14].

In Brazil, the practice of acupuncture was introduced for the first time in SUS in 1999, through Ordinance No. 1230/GM [15], and was reinforced by its inclusion in the National Policy of Integrative and Complementary Practices (PNPIC), published in Ministerial Ordinance No. 971 of May 2006 [15].

In 1992, the Chinese Medicine-Acupuncture Group of the Department of Orthopedics and Traumatology at Paulista School of Medicine of Federal University of São Paulo (EPM/UNIFESP) was created by Ysao Yamamura M.D., PhD. This physician established this group to foment academic undergraduate and graduate activities, including clinical research, of the institution.

Initially, the therapeutic proposals were exclusively provided on an outpatient basis, resulting in great demand by the population, with an average number of 90 patients daily. Due to increasing demand, it was necessary to establish a more dynamic service. The AES-HSP, characterized by providing public assistance predominantly focused on analgesia under free demand access, was opened in 1998.

The AES-HSP team is composed of resident physicians, preceptors, graduate students and interns in the Chinese Medicine-Acupuncture Group. We have four patient care rooms in the outpatient clinic building of Hospital São Paulo (HSP), located in the Vila Clementino neighborhood in the city of São Paulo, state of São Paulo, Brazil. Clinic is held Monday to Friday from 8 am-3 pm, except on holidays. Patients are referred by basic health units or present directly; they are attended to based on arrival order.

In our service, a minimum number of acupuncture points with immediate effect of analgesia is used, with emphasis on the Yamamura System techniques of Acupuncture (SYA/EPM).

Microsystems, or somatotopies, are representations of the entire organism in smaller areas of the body. When the organism is sick, reactive points emerge in the microsystem in the areas corresponding to the compromised region. Through the manipulation of these reflex points, it is possible to act positively on the disease or symptomatology in question. In our service, we use internationally-renowned techniques, such as Yamamoto New Scalp Acupuncture (YNSA), Chinese Scalp Acupuncture and Chinese Auriculotherapy, as well as exclusive techniques developed by Dr. Yamamura [16-18] including the Yamamura Nasal Bone Acupuncture System (Figure 1), Yamamura Acupuncture System Hair Implantation (SYALIC) (Figure 2), Yamamura Long Bone Acupuncture System (SYAOL) (Figure 3), Yamamura Occipital Bone Acupuncture System (Figure 4), Yamamura System of Cranial Sutures and 5 Zang in parietal suture (Figure 5). Some of the main techniques are described below, and may be used isolated or associated with systemic acupuncture. Image of the systems of the Yamamura Acupuncture System were kindly provided by Dr. Yamamura.

fig 1

Figure 1: Yamamura acupuncture system of nasal bone.

fig 2

Figure 2: SYALIC – Yamamura acupuncture system of hair implantation line.

fig 3

Figure 3: Yamamura acupuncture system of cranial sutures and 5 Zang on squamous suture.

fig 4

Figure 4: Yamamura acupuncture system of occipital bone.

fig 5

Figure 5: SYAOL – Yamamura acupuncture system of Long bone.

Methods

We collected data from the attendance records at the AES-HSP, between July-December 2019, using a standardized form completed by the attending physician. The parameters evaluated included gender, age group, complaint, technique(s) used, percentage of improvement reported by the patient and Visual Analogue Scale before treatment (VASb) and after treatment (VASa).

We considered the total number of visits, not discriminating whether the same patient was seen on more than one occasion, and the main and associated complaints. Regarding treatment, we grouped the different approaches into isolated systemic therapy, non-systemic techniques or a combination of both.

A focused anamnesis and physical examination was performed for each patient and was directed to the patient’s complaint in order to correctly select treatment points and techniques. Local asepsis was performed with cotton soaked in 70% alcohol, and sterile, disposable, 0.30 mm x 40 mm stainless steel acupuncture needles supplied by HSP were used. Needle insertion at specific points was performed until the Te Qi sensation was obtained, according to the depth characteristics. In auricular acupuncture, we used mustard seeds affixed to tape and manipulated with the aid of surgical tweezers.

Statistical analysis was performed descriptively, denoting average, median, minimum and maximum values, standard deviation, absolute and relative frequencies in percentage (%), using Microsoft Excel® 2019 software by Microsoft. The graphs of columns and lines were elaborated using Microsoft PowerPoint® 2019 software by Microsoft.

Results

We identified 7,647 visits, of which 78.3% (n=5986) were female and 21.7% (n=1661) were male. Regarding the age group, the mean age was (mean ± standard deviation) 60.8 ± 14.3 years, with a median of 64 years; 85.7% of participants were between 41-80 years (Graph 1), with a predominance in the range of 61-80 years, with a value of 53.4%. The average number of visits corrected for working days in the semester (120) was 63.7 visits/day. The average number of patients per operating time (7 hours) was approximately 9.1 patients/hour, resulting in a duration of care of approximately 6.5 minutes/patient.

graph 1

Graph 1: Distribution by age group (%) (n=7647).

Regarding complaints, low back pain (26.4%), followed by shoulder pain (17.5%), knee pain (14.8%), neck pain (11.7%), upper back pain (5.9%), lower limb pain (5.4%), upper limb pain (4.9%), foot pain (4.9%), polyarthralgia (4.3%), hip pain (2.7%), polymyalgia (2.3%), wrist pain (1.3%), non-restorative sleep (1.3%), hand pain (0.9%), finger pain (0.7%), facial palsy (0.7%) and ankle pain (0.5%). This data is depicted in Graph 2.

graph 2

Graph 2: Percentage of most prevalent pain sites.

In the analysis of the VAS, the data referring to the index in VASb (n=4080 visits) corresponds to an average of 6.29, with a median of 6 and standard deviation of 2.17. For the index in VASa (n=3913), there was an average of 1.44, median of 1 and standard deviation of 1.42. There was a failure to register 46.6% (n=3567) of the VAS in relation to the total number of cases in the semester. The total visits (n=6423) analyzed from the perspective of the degree of response to the treatment perceived by the patient were grouped into five categories: worsening (0%), without improvement (2%), less than 50% improvement (4.3%), more than 50% improvement (72.2%) and 100% improvement (21.4%). This information is presented in Graphs 3 and 4.

graph 3

Graph 3: VAS before treatment (VASb) and after treatment (VASa).

graph 4

Graph 4: Continuous comparison of pain level before treatment (VASb) and after treatment (VASa).

Considering the total number of visits, non-systemic techniques were used 2,430 times. These techniques included: the Bregma craniometric point (22.2%), Anatomical Trains (14.6%), Auriculotherapy (13.2%), Yamamoto New Scalp Acupuncture-YNSA (12.1%), Pterion craniometric point (9.1%), Symmetry (7.8%), Lambda Craniometric point (6.7%), Asterion craniometric point (4.6%), 5 Zang in parietal suture (2.8%), Yamamura Acupuncture System Hair Implantation-SYALIC (1.7%), Yamamura Long Bone Acupuncture System-SYAOL (0.8%), Yamamura Occipital Bone Acupuncture System (0.5%), Yamamura Nasal Bone Acupuncture System ( 0.4%), Yamamura Acupuncture System of the Musculoskeletal System of Sutures (0.4%), Vertebral Points (0.3%), and Chinese Scalp Acupuncture (0.1%) [15-17]. Graph 5 depicts this information.
graph 5

Graph 5: Distribution of non-systemic techniques most used (n=2430).

Systemic acupuncture techniques were used in 7,032 cases, corresponding to 91.9% of total cases. The use of non-systemic techniques alone occurred in 615 cases, corresponding to 8% of the total. Microsystems and systemic acupuncture were combined in 1815 cases (23.7%).

Discussion

Our study identified a female prevalence rate three times higher than males. This information is in agreement with other studies, which state that the prevalence of women reporting chronic pain is generally higher than men, which can be influenced by the way men and women experience pain [19]. Another possible explanation is the social expression of each gender. Women are usually taught to express emotions and seek help, while men are generally inhibited from expressing themselves [20]. Thus, male patients are less likely to report chronic pain and seek medical assistance.

When we analyzed age group, we found that more than half of patients were between 41-80 years of age. According to the literature, older patients have a higher prevalence of chronic pain than younger patients. This may result from the increase in number of comorbidities presented in the elderly [21].

According to the Global Burden of Disease Study in 2016, low back pain and neck pain are the main causes related to disability worldwide [22]. Another study highlights low back pain as the main cause of disability globally [23]. The present study is in agreement with this worldwide incidence since the most frequent complaint was low back pain. Regarding shoulder pain, we found involvement in 17.5% of individuals. This data differs from the Brazilian meta-analysis by Miranda et al. (2012) that assessed the prevalence of musculoskeletal disorders in the elderly population in Brazil and found the spine as the most affected location and the lower limb the second-most affected [5]. Chronic knee pain presented as an important highlight in the visits, since it was the third most prevalent complaint.

Patients suffering from chronic pain often have more than one affected site, as demonstrated in a British demographic survey, in which only one-third of the participants with pain had localized symptoms [2]. Thus, in the prevalence chart of the most frequent complaints, the statistics of different sites of pain must be interpreted separately, only in relation to the total number of cases once the sum of painful sites exceeds the number of visits, because patients usually had more than one complaint.

The VAS was chosen to assess the degree of pain before (VASb) and after (VASa) the treatment with acupuncture because it is a validated instrument of easy applicability and reproducibility, low cost, and widely used in global literature, which allows comparison of the results [24,25]. Despite the failure to complete the VAS in almost half of patient visits, it was possible to perceive a clear reduction in the degree of pain, according to the mean and median between VASb and VASa registered in the graphs, implying an effective analgesia with acupuncture. Such efficacy was also reinforced by the degree of improvement reported by patients.

The failure to register VAS can be explained by the fact that it is an academic service and has a considerable turnover of people who required a new adaptation to the routine of functioning and data recording. Another possibility is the socioeconomic level of many patients who had difficulties understanding the VAS and unable to adequately grade their pain, occurring often enough to compel the attending physician to only ask about degree of pain improvement.

As it is an Emergency Service, highly effective techniques with few acupuncture points and manual stimulation are recommended, in the goal of obtaining a good response in a short period of time. In this way, microsystems are a very effective tool for simplicity in application and good resolution to pain, as well as in the selection of traditional systemic points of high effectiveness. The Chinese Medicine-Acupuncture Group has developed treatment techniques validated by wide use in the AES-HSP that has proven to be highly effective, with some points being more used than traditional microsystems. Of the total number of consultations, the use of non-systemic techniques occurred 2,430 times, either alone or in combination with systemic points. The most used point for treatment was one of the craniometric points idealized by the Chinese Medicine-Acupuncture Group, Bregma, which was used in a total of 539 visits.

Patients are aware of the service we offer, based on referral from general practitioners, family doctors and specialists, or through information obtained from acquaintances who have previously been assisted or the internet. As a result, they directly seek care, which assists a large population of patients awaiting care in outpatient clinics, where there is often a waiting list with months of delay. Due to the volume of patients, we had to consider the total number of visits, and new patients were not distinguished from return patients.

One of the difficulties with the present work was the lack of standardization of completing the attendance forms by the doctors of the service, resulting in some missing information, as occurred in the registration of the VAS. During the transfer of information in written form to Microsoft Excel®, the complaints were summarized in the key terms that motivated the patient visit in order to facilitate statistical analysis in the evaluation of the cases, which could represent a registration bias due to data simplification. However, this may be counteracted by the transcribing physician, who performs the role of organizing symptoms and signs in validated medical terms.

The services provided to these patients is important due the provision of immediate pain relief, reducing the demand for patients with chronic pain to utilize other emergency services. As a result, the physical and emotional impact of pain on patients’ work and personal routine are minimized. The AES-HSP also reduces the time patients spend obtaining non-pharmacological pain therapy, for example, as in the Brazilian public unified health system, which has a waiting list for physiotherapy, which is another approach commonly used to manage MSP.

Conclusion

Acupuncture treatment to acute and chronic pain may reduce the use of self-medication, what decreases the risks of side effects of pain killers.

Our acupuncture emergency service provides effective care in pain relief in a fast and focused manner, resulting in significant demand from patients. Over its 22 years of existence, the services of the AES-HSP is considered an alternative approach to provide analgesia to patients with chronic pain and serves as a model for the creation of new emergency care in acupuncture in public health systems.

Authors’ Contributions

José Udevanier Rebouças da Silva Júnior M.D., Lorena Anunziato Sant’Ana M.D., and Mary Clea Ziu Lem Gun M.D. wrote the manuscript, constructed the graphs and translated image subtitles to English.

João Roberto Bissoto M.D., Ysao Yamamura M.D., PhD., Marcia Lika Yamamura M.D., MSc., and Silvana Maria Silva Fernandes M.D., PhD. reviewed the manuscript, assisted in writing the manuscript and are supervisors of our Medical Residency Program.

Ysao Yamamura M.D., PhD. is also the author of many techniques (microsystems) used in our service and owner of the pictures of the microsystems.

References

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Revision of Sex Hormone Replacement Therapy for CKD Pediatric Cases

DOI: 10.31038/EDMJ.2021541

Letter to the Editor

According to the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS), children with Chronic Kidney Diseases (CKD) have considerable height deficits in comparison to the normal children. Additionally, short stature and poor growth of CKD children are associated with an increased risk of death [1]. Although complex medical regimens including bicarbonate therapy, iron, erythropoietin, salt-water supplementation, and Growth Hormone (GH) can improve final height, however, these children experience progressive height deficit after the age of 6 y compared to their normal counterparts [2]. We believe that CKD pediatric cases with short stature and delayed puberty should receive Sex Hormone Replacement Therapy (SHRT) at the same time when majority of the normal boys and girls have started maturation. We thus propose that SHRT should be started in CKD cases with the same rationale as in hypo/hyper-gonadothropic hypogonadism patients to improve their final height as adults.

Puberty

Ninety five percent of contemporary normal girls start their Thelarche by the age of 11 y [3] and the mean age of puberty stage 2a and 2b in contemporary normal boys are 12.1 and 12.7 y, respectively [4]. Sex hormones (estrogen and testosterone) have an essential role in pubertal growth spurt by enhancing synthesis and secretion of IGF1 that has anabolic effects on bone growth plates [5]. Despite good acid-base management and nutritional support, CKD can interfere with the hypothalamic-pituitary-gonadal axis at different levels which leads to delay in onset of puberty [6]. Pulsatile secretion of Luteinizing Hormone (LH) is impaired along with serum LH level elevation in CKD children due to uremia. Lack of nocturnal LH secretion causes delay in puberty in these patients [7]. Pediatricians should evaluate pubertal delay in CKD children, if no Thelarche starts by the age of 11 y in girls and no sign of puberty at 13 y in boys.

In normal children, standardized height averagely increases 1.3 SDS from pre-puberty to post-puberty, while patients with delayed puberty have significantly less increase in standardized height (+0.9 SDS) [7]. CKD Children have approximately 2.5 years lag in the onset and progression of gonadarche in comparison with their peers. In addition, their pubertal growth spurt is shortened by 1.5 y, and at start of the pubertal spurt, they have less mean height velocity in comparison with the healthy adolescents [7-9]. Thus, an irreversible height deficit occurs during puberty in CKD children [9] because of disturbed puberty and impaired pubertal growth spurt.

Growth Hormone

Practitioners have tried to enhance CKD children growth deficit with GH, however, optimal final height was not achieved with this treatment. In CKD children who received GH from late pre-pubertal stage, GH therapy had no overall effect on the improvement of pubertal height gain and they still had a prominent height deficit [8,10]. Also, the mean peak height velocity during the pubertal growth spurt was not significantly higher in GH treated CKD children compared to the control CKD children [8].

Conclusion

According to the best of our knowledge, CKD girls and boys with short stature who do not start puberty till 11 and 13 y respectively are at high risk of height deficit in spite of GH therapy. As 20 to 25 cm of FH was obtained by pubertal growth spurt [11], experts have referred this height deficit to the delayed puberty and shorten pubertal growth spurt duration in CKD children [7]. SHRT in boys with CKD and delay puberty is challenging and needs more personalized decision making because Testosterone could aggravate uremic side effects [12,13]. However, we recommended SHRT in short CKD girls with delay puberty at 11 y to enhance their final height besides improving bone density.

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Keywords

Growth retardation, Delayed puberty, GH treatment, Estrogen replacement therapy, Chronic Kidney Disease

References

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