Monthly Archives: January 2023

Hormone Replacement Therapy Treatment for Depression in Perimenopausal Women

Leave a reply

DOI: 10.31038/JPPR.2022522

 

The National Institute of Mental Health (2018) defines depression as a “serious mood disorder that causes severe symptoms that affect how individuals feel, think, and handle daily activities, such as eating, sleeping, working (p.1).” Many signs and symptoms accompany depression, such as persistent sad and anxious behavior, irritability, feelings of worthlessness or hopelessness, decreased energy and fatigue, feeling restless or inability to sit still, and difficulty sleeping, to name a few [1]. Depression costs about 210 billion dollars a    year in America [2]. Perimenopausal women are at an increased   risk for depression due to various factors such as menopause itself, obesity, heart disease, and diabetes. That leads to the initial question surrounding this project: among perimenopausal women, is hormone therapy is effective in treating depression than antidepressant medications. Obtaining information about hormone therapy treatment in conjunction with the CES-D depression screening tool will allow providers to appropriately treat and assess perimenopausal women for depression [2].

Perimenopause

Perimenopause is defined as the final years of a woman’s reproductive life and begins at the first onset of menstrual irregularity and ends after one year of amenorrhea with an  age range is approximately 44-54 years old [3,4]. There are two stages  of perimenopause: early and late transition. Early transition women typically experience hot flashes, poor sleep, depression, and increased anxiety [3]. One-third of perimenopausal women exhibit different depression side effects during the transition periods of perimenopause that can lead to depression, such as hot flashes, sleep changes, vaginal dryness, and adverse moods; these symptoms worsen in the late stages in perimenopause and will not subside without treatment [3]. A decrease in serotonin does not cause perimenopausal depression; low estradiol is the contributing factor [4]. The lack of estrogen contributes to degeneration of ovarian function, sweating, insomnia, palpitations, mood swings, fatigue, headache, anxiety, and depression [4]. Therefore, hormone therapy is the treatment of choice for perimenopausal women [4].

Depression Management and Screening

Standard of Care

The  current  standard  of  care  for  individuals  between  12 and 65  is  screening  and treatment  with  the  PHQ-9  depression  scale and medication selective serotonin reuptake inhibitor (SSRI)  [1]. The criteria for depression diagnosis and treatment is as follows: 1) depression symptoms must be present for most of the day or nearly every day for at least two weeks; 2) depression screening will be conducted with the Patient Health Questionnaire-9, (PHQ-9); 3) determine patients score of depression with a scoring range of zero to three per item, a score ≥10 indicates depression; 4) treatment with an SSRI medication; 5) follow up in four weeks [1,5]. SSRI signs and symptoms include sleep disturbances, gastrointestinal upset, concentration problems, and a range of moods throughout the tapering process [1]. It is frowned upon to stop these medications due to withdrawal symptoms, and the patient must be followed closely by a health care provider [1]. Treatment of depression should be individualized and tailored specifically to the patient, or remedy will not be effective.

Hormone Replacement Therapy

Hormone replacement therapy in perimenopausal  women  is  more effective than SSRI medications because these women have degeneration of ovarian function and reduced estrogen levels [4]. Hormone therapy addresses low estrogen levels that cause depression [6]. Symptoms of low estrogen levels are poor mood, impaired sleep, and poor response to stress [6]. Hormone replacement therapy comes in different forms, such as Transdermal Estradiol, Raloxifene, and Tibolone [7,8]. Transdermal Estradiol, Raloxifene, and Tibolone share the side effects of an increased risk of endometrial cancer, heart attack, stroke, and blood clots [9]. Due to these adverse side effects, a thorough past medical history and frequent follow-up are necessary for women before treatment is started. Depending on the obtained brand, the Transdermal Estradiol Patch can be applied once or twice a week [9]. The patch is worn daily for a month, or it can be rotated on a schedule for three weeks with one week off [9]. It is recommended to obtain serum estradiol levels and appropriately screen with a reliable depression screening tool before treatment. Gordon [6]. CES-D. The Center for Epidemiologic Studies Depression Scale, CES-D, is a 20-question questionnaire rating each question on a scale of one to four; a score >16 is considered at risk for depression [10]. Many studies show that the CES-D scale is more effective in diagnosing perimenopausal depression [6,8,11]. In addition, the CES-D scale considers the interpersonal factor, which resonates positively with patients, and patients feel as though they are being assessed more efficiently [5].

Barriers to Depression Treatment

One barrier to depression treatment for perimenopausal women is human error.  Estradiol patches (n=6) contributed to four out of   46 reports of human error application (ISMP, 2021). Human errors come from applying and removing old and new patches (ISMP, 2021). Patients lack awareness of the patch on the skin, causing dosage errors and incomplete treatment (ISMP, 2021). Within the Odyssey House, to prevent human errors, a daily check of the removal and  the application of the Estradiol patch will need to be conducted at morning and night medication pass and charted in Kareo. Another barrier to the treatment of depression with hormone therapy is changing the mindset of healthcare providers from the standard of care, SSRI medication, to the Estradiol Transdermal patch. This barrier decreases the ability to implement new ways of thinking and reduces new forms of treatment coming into practice. To break this barrier, proper education and statistical data of success will need to be provided to allow this study to be successful [12].

Theories in Practice

Due to healthcare constantly changing due to advancements in medicine and technology, new treatments and education are available to help healthcare providers treat and diagnose their patients. It can be daunting to adopt new knowledge, implement a new treatment,  or even implement a new diagnostic tool into practice. However, adapting to new methods of diagnosing and treating patients is a practice that health care providers need to be implementing to provide more effective outcomes for their patients. Two main theories can help with education implementation: Carper’s Knowing and Behavioral Theory. These two theories will help shape how healthcare providers think and change their practices.

Carpers Way of Knowing

Carper’s Way of Knowing is a theory introduced by Barbra Carper in 1978 [13]. Four different types of knowledge are highlighted in this theory: empirical, aesthetic, ethical, and self-knowledge [13]. These four ways of knowing were initially presented as nursing education but can be used to provide a well-rounded way to shape and condition healthcare practice [13]. Each different section of knowing acts as a guide for healthcare providers to modify and grow their practice. Empirical knowing is a way to incorporate reading, listening, observations, and research into practice [13]. Aesthetic knowing includes interpreting input into one’s mind, exploring a healthcare provider’s current practices with patients, sharing with colleagues, and implementing and interpreting previous actions with other cultures and patients [13]. Ethical knowing is implementing ethical situations into practice and analyzing what they can offer patients and future patients [13]. Lastly, self-knowledge takes in the personal experiences of values, spirituality, and accepting uncertainty [13]. These four ways of knowing shaped how Carper introduced learning to the nursing community [13].

Behavioral Theory

John B. Watson brought about Behavioral Theory in 1913,  which implies that all behaviors are acquired by conditioning an individual [14]. When individuals learn something new, this theory proposes that an individual can learn and change behavior with the proper conditioning [14]. Watson’s theory suggests two types of Conditioning: Classical and Operant  [15].  Classical  Conditioning is when a stimulus allows an individual to produce a behavior or trigger an action such as an addiction to alcohol; just the smell can bring back feelings and desire to drink once more [15]. This theory can be related to Ivan Pavlov and using a bell to stimulate the dog’s reactions [15]. Operant Conditioning links consequence and behavior [14]. The effects can be positive or negative, with the right action producing a positive reinforcement and a lousy behavior having a negative result [14]. Operant conditioning links B. F. Skinner and his rats. These theories can be applied when individuals learn something new and implement it into their everyday practice. Behavioral Theory implementation tries to change the way of thinking of an individual or group. Unfortunately, healthcare providers tend to be reluctant when changing their practices unless given positive reinforcement for the change. Positive reinforcement in healthcare is happy patients, proper treatment, or immediate quality care provided in their approach [14]. Therefore, utilizing behavior theory to capitalize on this positive feedback is paramount to helping smooth introducing any new practices or methods to the healthcare field [14,15].

Framework

Proper presentation and rational thinking are two ways healthcare providers can be educated to change their behaviors [12]. When submitting a new type of education in a healthcare setting, it is imperative to present knowledge so that the audience receiving the information will enjoy and relate to it [12]. If the audience does not like the presentation or connect, they can reject the information and not continue practice implementation [12]. Carpers’ way of knowing adds a different framework for this project. Aesthetic and Empirical knowing will be implemented in this project when a healthcare provider assesses, listens, observes, and completes research [13]. Implementing these two ways of knowing will allow for significant progress in healthcare providers’ treatment and diagnosis approaches. Behavior Theory allows physicians to see results that have been applied to other practices and begins the operant conditioning of using a complementary treatment to produce a positive outcome [14]. Implementing a new diagnostic tool and treatment options can be intimidating and time-consuming. However, providing better treatments to patients and updated screening tools for depression will help implement positive reinforcement to change patient outcomes. Using the Carpers Way of Knowing and  Behavior  Theory  will allow healthcare providers to see positive results caused by positive reinforcement before their implementation.  Education  provided  will catch the healthcare providers’ attention and make them feel as though they will be successful in their practice. Good examples of appropriate knowledge will allow healthcare providers to change their thought processes and then change their medical practice. However, change can take time, and provider buy-in is essential [12].

Contributions to Practice

Not all diagnoses of depression need medications to subside its side effects. Being treated for depression appropriately can change a patient’s life [4]. Depression is a very complex disease, and diagnosis that may require different treatments because patients respond to treatment differently [4]. Implementing new therapies and a new screening tool will allow perimenopausal women to be diagnosed and treated for depression appropriately.

Advanced Nursing Practice

Providing care as an advanced practice nurse requires ongoing education and adaptation. Healthcare providers must be willing to grow and adapt to the changing literature and treatment guidelines based on current evidence in the literature. Operant Conditioning    of learning allows an advanced practice nurse to see the negative  and positive effects of implementing new and  current  diagnoses and screening [14]. The education received must be appropriate and delivered correctly for the advanced practice nurse to see the positive outcome in implementation [14]. Incorporating Carper’s Way of Knowing, specifically empirical and aesthetic knowing, allows an advanced practice nurse to listen, observe, reflect, and implement new strategies [13]. Incorporating this practice enables the advanced practice nurse to remember how they take care of patients and understand the importance of continuing education. This way of thinking promotes professional growth as well as improved evidence- based care.

Literature Search

PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were the databases used to complete this literature search. The following keywords were used: perimenopausal depression, perimenopausal women, depression screening tools, PHQ-9, CES-D, perimenopausal depression hormone treatment, CES-D perimenopausal women treatment, perimenopausal midlife depression education, depression education, depression medications, chronic disease, depression non-pharmacological treatments, midlife women depression, and depression statistics. The initial search yielded 35 studies. Twenty-nine articles were rejected because they did not use a depression screening tool, did not focus on perimenopausal women, did not incorporate hormone therapy compared to SSRI, and did not use any of the following scales CES, PHQ-9, or MENO-D. The remaining six studies were retained for the literature review. The studies discussed in this review are four randomized clinical trials [6- 8,11] and two cross-sectional surveys [16,17]. These studies support hormonal therapy as the recommended treatment for depression in perimenopausal women. Additionally, these studies provide evidence that supports the use of the CES-D depression screening tool for perimenopausal women.

Research Definitions

  • CES-D. A 20-question depression questionnaire rating each question on a scale of one to four, a score >16 is considered at risk for depression [10].
  • PHQ-9. A nine-question depression questionnaire with a zero to three scoring A score of > to 10 indicated depression [5].
  • MENO-D. A depression questionnaire using twelve symptoms divided into five categories with scores from zero to four. A score of ≥ to 20 indicates an individual to be at  risk for depression [7]. The five categories are Self (paranoid thinking, self-esteem, isolation, anxiety), Sexual (Sexual Interest and Low Energy), Somatic (Somatic Symptoms and Weight), Cognitive (Memory and Concentration), and Sleep (Irritability and Sleep Disturbances) [7].
  • Selective Serotonin Reuptake Inhibitor. This medication promotes the reuptake of serotonin more effectively in the brain, alleviating the symptoms of depression (NHS, 2021) [18].
  • Time in a women’s life preceding menopause (cessation of menses for at least 12 months), typically occurring during the fourth decade of life, lasting four or five years [7].
  • Depression in Perimenopausal Symptoms may include muscle pain, weight gain, low energy levels, decreased self-esteem, feelings of isolation, cognitive fogginess, and low sex drive [7].

Screening Tools for Depression

Available depression screening tools include the PHQ-9, MENO-D, and CES-D. Ps [16] conducted a cross-sectional study using the cluster sampling technique with 594 women between 40 and 60 years of age for depression using the PHQ-9. This study took place in rural Kerala, at the Govt. T.D. Medical College [16]. The results of this study were that depression prevalence was 26.09% in perimenopausal women with a PHQ-9 cut-off score of ≥ 10 [16]. This study failed to provide inter-rater reliability to determine the effectiveness of the PHQ-9 in this rural setting [16]. Using the MENO-D scale, [7] conducted a randomized control trial with 82 perimenopausal women ages 43 and 54.  In addition, women were divided into focus groups due to their symptoms of depression [7]. The MENO-D scale yielded a high-internal consistency of a cut-off point of p=0.70 [17]. However, like Ps [16], interrater reliability of the MENO-D depression scale was not provided. Additionally, the MENO-D was time-consuming, and patients grew tired during the survey and could not effectively be screened for depression [7]. Shae [17] conducted a cross-sectional study that divided 13,216 women ages 45 to 64 into three groups based on their socio- economic status, educational background, and if they were nulliparous. This study used a placebo, hormone replacement treatment, and an SSRI medication [17]. The prevalence of depression was found to be 18.4%. An initial study showed that hormone replacement therapy was effectively managed using the CES-D depression screening tool. However, with further research, Shae et al. 2020, using the CES-D scale, showed that participants had 1.45 (1.07-1.97) and 1.21 (1.02- 1.44) greater odds of having depression. Unfortunately, further data is unavailable as the study is still being conducted [6, 17] conducted a double-blind, placebo-control randomized trial at the University of North Carolina with 172 perimenopausal women from October 2010 through February 2016, with a mean age of 51 years. This study was conducted over 12 months, and the women were screened at months one, two, four, six, eight, ten, and twelve [6]. The CES-D scale was used to obtain depression scores. Interrater reliability was calculated to be statistically significant, p < 0.05 [6]. Cronbach’s alpha was not given in the study [6]. Using the CES-D, the intervention group treated with transdermal estradiol was found to have 15% higher depression scores than the control group, p=0.03. Participants that scored a score of 16 or higher upon initial assessment were a mean of 22.0 (6.5) (Gordon et al. 2018). After treatment was completed, the mean score was 4.2 (5.3) (Gordon et al. 2018). CES-D determined effective depression treatment with an n=55; p=0.005 [6]. Maki [11] demonstrated the effectiveness of the CES-D depression screening tool in perimenopausal women [11]. Four small, randomized groups of 169 women participated over a 24- week trial [11]. Interrater reliability was completed in conjunction with The North American Menopause Society (NAMS) and the National Network of Depression Centers Women and Mood Disorders Task Group (NNDC) that formed an 11-person panel to review the CES-D scale validity and effectiveness [11]. Fifty-five percent of the participants showed decreased depression symptoms using the CES-D in a pretest- posttest design [11]. In addition, Cronbach’s alpha was not stated in this study. Therefore, Maki [11] concluded that the CES-D depression screening tool is valid and reliable for this patient population.

Limitations of Screening Tools

The MENO-D scale was lengthy and time-consuming for patients to complete. As a result, patients did not prefer this scale. Reliability testing was not calculated due to incomplete scoring by the study participants [7]. The PHQ-9 patient emotions are not adequately evaluated with the PHQ-9 compared to the MENO-D and CES-D [4]. Studies using MENO-D and the PHQ-9 lacked reliability data [7,16]. The timing of screening is another limitation cited in the literature. Kulkarni [7,11] and Schmidt [8] studied their participants for a limited period of eight to 24 weeks. When screening takes place too early after treatment, the scale may not be accurate [1]. Proper screening is just as important as a patient’s treatment. Screening intervals after treatment is critical not to evaluate too soon or too late. Time is needed to see if treatment is effective. Gordon [6] and Ps [16] allowed plenty of time for treatments to work. Screening too soon leads to a false statistic of treatment failure and higher depression scores [6].

Strength of Screening Tools

Frequent screenings completed with the CES-D  depression  scale allow accurate depression symptoms [6]. For example, Shae [17] screened their patients at  every  encounter  and  determined  that the depression symptoms increased steadily over time. Gordon [6] screened their subjects every other month and determined that depression symptoms decreased appropriately over time. Frequent screening is imperative when screening for depression and determining that treatment is effective. Since no inter-reliability data was given for the PHQ-9 or MENO-D, this quality improvement project will not use these tools. Instead, the CES-D tool will be used for this project as it is practical and straightforward to complete. The evidence shows it is a reliable and valid tool in the perimenopausal population.

Depression Treatment

Depression treatment is not one size fits all; it needs to be tailored to suit the patient. SSRI therapy is the standard for depression treatment in all individuals 12 years old and up [2]. Hormonal therapy, however, is the recommended treatment for depression in perimenopausal women [2]. Various methods of hormone therapy are available for treatment, such as transdermal Estradiol, Tibolone, and Raloxifene [7,8]. The randomized control study conducted by Gordon [6] evaluated patients using transdermal estradiol vs. placebo. The study was conducted over 12 months and included 172 perimenopausal women [6]. The author’s goals were to study the effects of estradiol in perimenopausal women to see if depression was decreased. This result was procured with a pre and post-test throughout treatment at every visit. As a result, using the CES-D depression screening tool, the treatment group had a 17.3% of depression score than the placebo group, resulting in a 32.3% of depression score [6]. After treatment was completed, the mean score was 4.2 (5.3) [6]. CES-D determined effective depression treatment with an n=55; p=0.005 [6]. In contrast, Maki [11] demonstrated the effectiveness of hormone replacement therapy in depressive disorders in perimenopausal women compared to antidepressant medications: Venlafaxine, Sertraline, and Fluoxetine. Four small, randomized groups of women with a mean age of 55 participated over a 24-week trial [11]. This study concluded that after 12 months, depression scores dropped from 32.3% to 17.3%, showing the effectiveness of hormone replacement therapy compared to depression scores staying at the same for SSRI medications (p ≤ 0.10), with a pre and post-test structure [11]. Maki and Gordon [6] hormone therapy effectively treated depression. The CES-D was the tool used to measure depression in both studies. Kulkarni [7] studied the effectiveness of Transdermal Estradiol hormonal replacements compared to an SSRI/SNRI in 82 perimenopausal women. This study was conducted with a pre and post-test design [7]. The p-values for the all-item factor loadings were p < 0.05 [7]. In comparison, the seven items of somatic, weight changes, and sexual interest showed poor factor loadings of p ≤ 0.40 [7]. The five-factor model loadings (p ≤ 0.001) were significant in the areas of paranoid thinking, isolation, anxiety, resulting in highly loaded changes of p ≥ 0.70 [7]. Transdermal estradiol therapy was shown to be an excellent treatment option for perimenopausal women than an SSRI/SNRI over six to eight weeks of treatment initiation [7]. In addition, results showed that depression was decreased by 50% for perimenopausal women [7]. Schmidt [8] used a small, randomized group of perimenopausal women to determine the effectiveness of hormone replacement therapy for treating depression. The study included 62 women divided into respective groups who were given three different hormone replacement treatments, Zolpidem, or a placebo, over eight weeks [8]. The p-value for the study was p=0.34. Results continued to show that perimenopausal women treated with transdermal estradiol had depression scores improve in comparison to Rimostil (p values=0.0008, 0.0011) [8]. In addition, transdermal estradiol showed improvement of depression with a drop in depression levels pretest was 15.3%, and the post-test was 5.2% over eight weeks [8]. The treatment score means respectively for pretreatment were the following: Transdermal Estradiol – 15.3 (4.5), Raloxifene – 16.0 (3.7), Rimostil – 14.0 (2.7), and placebo – 15.2 (3.0) (Schmidt et al. 2021). Post-treatment score means were the following: Transdermal Estradiol – 5.2 (1.1), Raloxifene – 5.8(2.3), Rimostil – 11.2 (1.4), and placebo – 7.8 (1.1) [8].

Limitations

Gordon [6-8] studies did not check estradiol levels before or after treatment. Measuring estradiol levels allows researchers to track fluctuations in estradiol levels and change the treatment as needed [6]. In addition, measuring estradiol levels allows for more effective treatment outcomes, for example, helping patients see their progress with their depression symptoms. Study length hinders the effectiveness of hormone therapy treatment [6,8], which had eight weeks for their entire study, concluded that only one medication, Transdermal beta Estradiol (T.E.), was deemed effective in treating depression. However, two other medications, Rimostil and Raloxifene, did not have time  to treat depression effectively [8]. When treatment such as hormone therapy is not implemented and followed for a significant time, it can fail treatment [6]. The treatment type of hormone therapy needs time to adjust and progress [6].

Strengths

Maki [11] allowed the study to monitor therapeutic levels. In addition, obtaining these levels before treatment allowed researchers to effectively monitor estradiol increases over time and change treatment accordingly [11]. The extended length of treatment was effective in assisting researchers in determining the efficaciousness of hormone therapy [6]. For example, Gordon [6] allowed a 12-month period to pass, and Ps [11,16] allowed six months to pass during their studies to examine the treatment effectiveness [6].

Evidence-Based Practice Model

The Johns Hopkins model for Evidence-Based Practice is used to help with problem-solving and clinical decision-making by using a three-step PET process: Practice Question, Evidence, and Translation [19]. In addition, this Evidence-based practice guide allows for research organization and provides for new practices to be incorporated into patient care effectively and safely [19]. This Evidence-based practice model will be the model to guide this quality improvement project.

Methods

Plan

Design. This quality improvement project will follow a descriptive study design with a retrospective review of lab work. This design will include a pretest-posttest design incorporating scores of the CES-D in perimenopausal women before starting hormonal and after three months of hormonal treatment. In addition, subjects’ estradiol levels will be collected before treatment.

Population. Subjects will be recruited via the non-probability convenience sampling method over three months. Included subjects will be adult perimenopausal women between the ages of 40 and 60 who will be starting hormonal therapy, Transdermal Estradiol Patch. Exclusions include adult males, menopausal females, and normal estradiol levels; if patients are on an SSRI or other medication, they will need to be off the medication for four weeks before the beginning of treatment to make sure treatment is not hindered or skewed or they will be excluded [8]. The minimum sample size of 13 is based on a student t-test’s power analysis based on an alpha of 0.05, power of 0.95, and medium effect 0.20.

Setting and Resources. This project will occur at the Odyssey House Martindale Clinic in Salt Lake City, Utah. The Odyssey House is an inpatient rehabilitation center for drugs and alcohol. In addition, this establishment has a Female Mental Health house that will be used explicitly for this project. There are multiple house populations in the Odyssey House, such as families, men, women, women’s mental health, and adolescents. These individuals are separated by their comorbidities. The Female Mental Health House will be the house used for this project. This house provides rehabilitation services combined with therapy to help with alcohol and drug rehabilitation. The Odyssey House Martindale Clinic is a Family Practice Clinic with Medical Doctors (M.D.), Physician Associates (PA), and Nurse Practitioners (N.P.) overlooking the patients’ overall health in the houses. The Odyssey House Martindale Clinic routinely sees and treats patients from various houses for multiple health reasons. On average, patients have monthly routine visits, including blood work, drug testing, and treatment. Serum estradiol levels are part of the bloodwork panel.

DO Measures. Permission will be obtained from the director of nursing at Odyssey House, Erika Bunnell RN, BSN, IRB approval will be obtained from Roseman University as per academic institution policy. IRB for Odyssey House will also be obtained. Perimenopausal women will be invited to participate in this project if they meet the inclusion criteria: perimenopausal women aged 40-60, no current SSRI prescription or recently appropriately weaned, and low serum estrogen levels. Once subjects agree to be enrolled in the project, they will complete a consent form and permit their chart to be reviewed for serum estradiol levels and pre and post-CES-D scores. Subjects’ information will be kept confidential and private through Kareo, a web-based medical charting system. Kareo is a password-protected system only to be accessed by Odyssey House Martindale Clinic employees. Additionally, subjects will complete a demographic survey to include DOB, age, gender, ethnic background, economic status, and education level. Providers and Medical Assistants (MA) will be educated about the project design. The providers will obtain consent and review the CES-D scores. MAs will verify estradiol levels and pre-treatment CES-D scores are available in the chart before the start of hormonal treatment. MAs will distribute the CES-D in three months as follow-up hormonal therapy.  PI will validate the scores  by performing a weekly retrospective chart review of the primary investigator. PI will also organize the paperwork for the project for ease of distribution. An Apple iPad will be obtained from a donor. The iPad will include the survey software, Qualtrics to obtain subject consent, demographic information, and CES-D scores. Subjects will not be able to save responses until all questions are completed. This eliminates missing data. Stakeholders of this project are the director, providers, medical assistants, and the PI. In addition, an in-service will be scheduled to educate the stakeholders on proper iPad use, CES-D, and Qualtrics training, and hormonal therapy protocol: 1)   A score >16 on the CES-D scale; 2) decreased estradiol blood levels; 3) treatment with transdermal estradiol patch; 4) follow up CES-D screening three months after initiation of transdermal estradiol patch treatment [10]. The CES-D depression screening tool will be used to screen perimenopausal women in the Odyssey House for depression before starting hormonal therapy. The Odyssey House uses the PHQ- 9, and the CES-D will be substituted. The CES-D depression screening tool is a 20-question depression questionnaire rating each question on a scale of one to four a score >16 is considered at risk for depression [10]. The CES-D depression screening tool is a free tool that health care providers can use to screen perimenopausal women appropriately (Fisher, 2009). Subjects’ estradiol levels will be used before the initiation of hormonal therapy. The CES-D will be given to the subject as the pre-test, then measured again as a post-test three months after hormonal therapy starts will allow P.I. to access medical records to review lab work and CES-D scores, which will be completed weekly.

Study

Data Collection. Data will be collected over 12 weeks. Subjects will be assigned an ID number. They will enter their demographic data and CES-D pre and post responses into the iPad via Qualtrics. As per the power analysis, the minimum sample size is 13.

Statistical Analysis. SPSS software will be used for the statistical analysis. Descriptive statistics will be used to illustrate the subjects. The student t-test will analyze the CES-D pre and post-scores.

ACT

Evaluation. Dissemination of data will be reviewed with the stakeholders in a post-briefing in-service. Provider feedback will be obtained. Perimenopausal women are at high risk for depression due to their low estradiol levels [4]. For patients with a confirmed low estrogen level before the start of Estradiol Transdermal therapy, based on the reviewed literature, it is assumed the CES-D depression scores will improve in the 12-week project period. The data from the study will show why a new process needs to be implemented and how using the CES-D and hormone therapy can improve depression scores in this patient population. Therefore, it will be recommended to continue monitoring perimenopausal women with the CES-D scale before hormonal treatment. Based on the results of this project, a protocol for the Odyssey House Martindale Clinic to utilize the CES-D for perimenopausal women and continue regular depression screening throughout the hormonal treatment longitudinally. An additional PDSA cycle will be to compare the PHQ-9 data to the CES-D in perimenopausal women to verify the CES-D should be the chosen tool to use in all perimenopausal women, not just women on hormonal therapy.

Human Subject Protection. Human subject protection was maintained by the IRB consent form and privacy of the information using the password protection system, Kareo, a web-based medical charting system. Kareo is a password-protected system only to be accessed by Odyssey House employees.

Strengths and Weaknesses. Weaknesses of this project might be 1) Estradiol patch not applied correctly or falling off during treatment, and 2) not comparing CES-D and PHQ-9, since the PHQ-9 is the standard screening tool used at this facility; 3) facility not understanding the use of the CES-D; 4) no further data about the patch and comparing it to an SSRI medication. Strengths of this project might be 1) frequent assessment will show improvement in symptoms; 2) Properly treating low estrogen levels with hormonal therapy instead of implementing an SSRI/SNRI medication; 3) population bias of only using women who are perimenopausal and between the ages of 40 and 60; 4) patch is not a controlled substance and can be given throughout the project.

Conclusion

Depression screening needs to be specific for the population it is evaluating. Having the right depression screening tool is paramount in providing quality care to perimenopausal women. Proper screening leads to appropriate medical management. Based on the evidence from this literature review, the appropriate screening tool is the CES-D for this population [6,8,11]. Lack of serotonin does not cause perimenopausal women’s depression symptoms [4], whereas a lack  of estrogen is the etiology of perimenopausal depression [4]. The evidence shows that perimenopausal women’s depression is served better with hormone therapy. This quality improvement project examines depression management of perimenopausal women using hormonal therapy and the CES-D to measure depression.

References

  1. NIMH (2018). National Institute of Mental Health (NIMH).
  2. Jones HJ, Minarik PA, Gilliss CL, Lee KA (2020) Depressive symptoms associated with physical health problems in midlife women: A longitudinal Journal of Affective Disorders 263: 301-309. [crossref]
  3. Santoro N (2016) Perimenopause: from research to practice. Journal of Women’s Health 25: 332-339. [crossref]
  4. Xiao C, Mou C, Zhou X (2019) Nan fang yi ke da Xue Xue Journal of Southern Medical University 39: 998-1002.
  5. Ng CW, How CH, Ng YP (2016) Major depression in primary care: making the diagnosis. Singapore Medical Journal 57: 591-597. [crossref]
  6. Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, et (2018) Efficacy of transdermal estradiol and micronized progesterone in preventing depressive symptoms in the menopause transition: A randomized clinical trial. JAMA Psychiatry 75: 149-157.[crossref]
  7. Kulkarni J, Gavrilidis E, Hudaib AR, Bleeker C, Worsley R, et (2018) Development and validation of a new rating scale for perimenopausal depression-the Meno-D. Translational Psychiatry 8. [crossref]
  8. Schmidt PJ, Wei SM, Martinez PE, Dor R, Guerrieri GM, et (2021) The short-term effects of estradiol, Raloxifene, and a phytoestrogen in women with perimenopausal depression. Menopause 28: 369-383. [crossref]
  9. ASHP (2016) Estradiol Transdermal Patch: MedlinePlus Drug Estradiol Transdermal Patch.
  10. Jiang L, Wang Y, Zhang Y, Li R, Wu H, et (2019) The reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D) for Chinese University Students. Frontiers in Psychiatry 10. [crossref]
  11. Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, et al. (2019) Guidelines for the evaluation and treatment of perimenopausal depression: summary and Journal of Women’s Health 28: 117-134. [crossref]
  12. Kelly MP, Barker M (2016) Why is changing health-related behavior so difficult? Public Health 136: 109-116. [crossref]
  13. Callen B, Smith C, Joyce B, Lutz J, Brown-Schott N, et al. (2010) Essentials of baccalaureate nursing education for entry-level community/public health nursing. Public Health Nursing 27: 371-382.
  14. Cherry, K. (2019, September 24). Why behaviorism is one of psychology’s most fascinating branches. Verywell Mind.
  15. Lumen Learning (2019) Behavioral and Cognitive Theories | Lifespan
  16. PS A, Das S, Philip S, Philip RR, Joseph J, et al. (2017) Prevalence of depression among middle-aged women in the rural area of Kerala. Asian Journal of Psychiatry 29: 154-159. [crossref]
  17. Shea AK, Sohel N, Gilsing A, Mayhew AJ, Griffith LE, et al. (2020) Depression, hormone therapy, and the menopausal transition among women aged 45 to 64 years using Canadian Longitudinal Study on aging baseline Menopause 27: 763-770. [crossref]
  18. NHS website (2021) Overview – Selective Serotonin Reuptake Inhibitors (SSRIs). NHS. UK.
  19. Dearholt S, Dang D (2018) Library: nursing: evidence-based practice: Johns Hopkins nursing EBP.

A Quick Review on Hydroxychloroquine in the Treatment of COVID-19

Leave a reply

DOI: 10.31038/JPPR.2022521

Abstract

The aim of this investigation is was to review briefly the literature of the anti-viral activity for hydroxychloroquine, how has been used in the treatment of the novel coronavirus disease COVID-19, pathogenesis of COVID-19, and the mechanism of action for hydroxychloroquine in treatment of COVID-19. Hydroxychloroquine likely to attenuate the sever progression of COVID-19, Inhibiting the cytokine storm by suppressing T cell activation, also act by increase the pH of intracellular organelles. The study concludes and gave a well-supported document for quick review of the anti-viral activity of hydroxychloroquine used in the treatment of novel coronavirus COVID-19.

Keywords

Hydroxychloroquine (HCQ), Chloroquine (CQ), SARS-COV-2, Antiviral, Pathogenesis

Introduction

The novel corona virus COVID-19 was first reported on the month of December 2019 in Wuhan city-China and it has rapidly spread to all over the world [1]. On February 2020 the world health organization (WHO) named it as (COVID-19), simultaneously the international virus classification commission announced that the new corona virus was named as sever acute respiratory syndrome cornoavirus-2 (SARS-coV2) [2,3]. COVID-19 belongs to the family of genera betacoronaviridae, it is enveloped, single stranded, positive sense RNA virus, the name corona virus derived from the spike proteins that surrounded the outer member of virus [4,5]. COVID-19 is not the first virus from the family of coronaviruses, in the year 2003 a severe respiratory diseases known as sever acute respiratory syndrome (SARS) was reported as an epidemic and 8000 of people being infected with total 10% of cases death. In 2012 another corona virus has outbreak in middle east called as middle east respiratory syndrome (MERS) and infected about 2500 clinical cases with total 35% death. COVID-19 incubation period is about 4-14 days, the shedding period of virus 8-37 days but in severe cases takes about 19 days and in the critical condition takes 24 days [5]. Hydroxycholorquine used as anti-malarial drug and autoimmune diseases such as lupus and rheumatoid arthritis, recently hydroxychloroquine reported in the treatment of novel corona virus (SARS-coV19) [6]. Hydroxychloroquine is a derivative of chloroquine that chemically belongs to 4-aminoqinolines, chloroquine discovered in the year 1934 as anti-malarial drug. Chloroquine also used in the treatment of various infectious diseases [7]. Both Chloroquine as well as hydroxychloroquine acts by the same mechanism of action on coronavirus (COVID-19), that both of chloroquine and hydroxychloroquine are weak bases and they know to increase the intracellular organelles acidic pH, also prevent the binding of virus spike glycoprotein with ACE2 receptors [6].

Hydroxychloroquine (HCQ)

Hydroxychloroquine has similar structure to that of chloroquine (Figure 1). Chloroquine shows inhibitory action on the novel corona virus, but due its several adverse drug reactions chloroquine not suite for the treatment of SARS-coV-2. Hydroxychloroquine has proposed due to its antiviral activity, it is also shows better effect comparing to chloroquine [8]. chloroquine-(N4-(7-Chloro-4-quinolinyl)-N1,N1-diethyl-1,4-pentanediamine) is an amnio acidotropic form of quinine and first synthesized in Germany in the year of 1934 and used in the treatment of malarial and many other autoimmune diseases. Chloroquine has antiviral activity against several diseases like HIV, hepatitis A and C viruses, Influenza A and B viruses, Influenza A H5N1 virus, Dengue virus, chikungunya virus, poliovirus, lassa virus and Zika virus. Hydroxychloroquine sulphate is a derivative of chloroquine and was first synthesized in the year 1946 by addition of hydroxyl group (OH) into chloroquine structure, so produced hydroxychloroquine with less toxicity in animal. Hydroxychloroquine share the same therapeutic uses as well as mechanism of action to that of chloroquine [6,9,10]. Both Hydroxychloroquine and chloroquine have been shown anti-viral activity in SARS-coV-2 when administrated as prophylactic – pre-treated as well as post-viral entry, indicating multiple mechanisms of action. HCQ and CQ are weak bases so they know to increase the pH inside the intracellular organelles including (lysosomes, endosomes and golgi vesicles ), specific enzymes present in the lysosomes active only at low pH around 4.5, as the novel coronavirus SARS-coV-2 needs that enzymes for the process of replication and survive, Chloroquine and hydroxychloroquine increases the pH of lysosomes and interfere the activity of this enzymes and inhibits the SARS-coV-2, help in the treatment of the virus. In addition to that hydroxychloroquine can inhibit SARS-coV-2 entry through the changing the glycosylation of angiotensin converting enzyme-2 (ACE-2) receptor as well as spike protein, experimentally confirmed that hydroxychloroquine inhibits the entry and post-entry steps of the virus. hydroxychloroquine and chloroquine also block the transport of SARS-coV-2 from early endosomes (EEs) to endolysosomes (ELs) which is important required in the release of genome in SARS-coV-2. Due to the altered pH of the endosomes and interfere the binding between tall-like receptors ( TLR7, TLR9) and their RND/DNA ligands, TLR signals suppressed due hydroxychloroquine. In the cytoplasm hydroxychloroquine interfere with the interaction of cytosolic DNA and the nucleic acid sensor cyclic (GMP-AMP) synthase. Hydroxychloroquine acts as immune modulator, inhibit receptor binding and membrane fusion, also it has been shown to down regulate pro-inflammatory cytokines including IL6 levels, and minimize cytokines release syndrome /ARDS. Dose of hydroxychloroquine in COVID-19 was recommended as 400 mg twice in a day for two days, then 200 mg twice per a day for another 3 more days. Hydroxychloroquine has better therapeutic approach compared to chloroquine in the treatment of SARS-COV-2 infection [5-8,11-13] (Figure 1).

FIG 1

Figure 1: Structures of chloroquine and hydroxychloroquine

Pathogenesis

The pathogenesis of SARS-COV-2 not clearly understood, but the mechanism of SARS-COV, and MERS give us a huge information to understand the pathogenesis of novel coronavirus SARS-COV-2 [2]. The genome structure of coronaviruses are well known compared with other RNA viruses.coronaviruses RNA contain encodes viral polymerase, RNA synthesis material and non-structural polyproteins which not involved in host response modulation. Additionally the genome encodes also contain 4 structural proteins these proteins are, spike (S), envelope (E), membrane (M) and nucleocapsid (N) [14] (2019 NOVEL COVID-19). The novel coronavirus SARS-COV-2 mainly act by targeting the respiratory system and cause severe pneumonia and acute cardiac injury with high blood levels of cytokines and chemokines [15]. Virus Enter into host cell, the envelope spike glycoprotein bind to angiotensin converting enzyme-2 (ACE-2) for SARS-COV-2, CD29L (a C-type lectin also known as l-SIGN). After the entry of SARS-COV-2 into the cell the viral RNA genome is release into cytoplasm and converted to 2 polyproteins and structural proteins, then genome begins replication process. The genome that newly formed inserted into the membrane of the endoplamic reticulum, the vesicles carrying the virus particles fuse with the plasma membrane to release the virus. Due to antigen presentation the body stimulate humoral and cellular immunity which are mediated by virus specific B and T-cells that similar to common acute viral infections the antibody profile against SARS-COV virus has typical of IgM and IgG production. The infected patient with SARS-COV-2 shows the number of CD4 and CD8 T-cells in the peripheral blood significantly reduced. The main death cause of novel coronavirus SARS-COV-2 due to the high levels of cytokines and chemokines that released by body immunity. The different types of cytokines that released (IFN-a, IFN-g, IL-1b, IL-6, IL-12, IL-18, IL-33, TNF-a, TGFb) and chemokines (CCL2, CCL3, CCL5 CXCL8, CXCL9, CXCL10). High levels of these inflammation mediators lead to multiple organ failure and finally may lead to death in severe cases in SARS-COV-2 [2].

Conclusion

The authors succeeded in compiling the data and made the brief literature survey. In summary, Hydroxychloroquine serve as a better therapeutic approach than chloroquine for the treatment of COVID-19, due to inhibition of cytokine storm by reducing CD154 expression in T-cell. Hydroxychloroquine showed fewer side effects, safe during the pregnancy.

Conflicts of Interests

Authors do not have any conflicts of interest with the publication of the manuscript.

Acknowledgment

None

References

  1. Yao X, Fei Ye, Miao Zhang, Cheng Cui, Baoying Huang, et al. (2020) In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis 71: 732-739. [crossref]
  2. Li, X., Manman G, Yizhao P, Liesu M, Shemin L, et al. (2020) Molecular immune pathogenesis and diagnosis of COVID-19. Journal of Pharmaceutical Analysis 10: 102-108. [crossref]
  3. Lai CC, Tzu-PS, Wen CK, Hung JT, Po Ren H, et al. (2020) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. International Journal of Antimicrobial Agents 55. [crossref]
  4. Coronavirus disease 2019 (COVID-19) Situation Report – 91.
  5. Srivatsan P (2020) Potential dual therapeutic approach against SARS-CoV-2/COVID-19 with Nitazoxanide and Hydroxychloroquine.
  6. Liu J, Ruiyuan C, Mingyue X, Xi W, Huanyu Z, et al. (2020) Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov
  7. Chang, R. and W.-Z. Sun, 2020.
  8. Zhou D, Dai SM, Tong Q (2020) COVID-19: a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression. J Antimicrob Chemother 75: 1667-1670.
  9. Devaux CA, Jean-MR, Philippe C, Didier R, et al. (2020) New insights on the antiviral effects of chloroquine against coronavirus: what to expect for COVID-19?. Int J Antimicrob Agents [crossref]
  10. Cortegiani, A., Giulia I, Mariachiara I, Antonino G, Sharon E, et al. (2020) A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 57: 279-283. [crossref]
  11. Touret F, X de Lamballerie (2020) Of chloroquine and COVID-19. Antiviral Res 177.
  12. Kearney J 2020.
  13. Colson P, Jean-MR, Jean-CL, Philippe B, Didier R, et al. (2020) Chloroquine and hydroxychloroquine as available weapons to fight COVID-19. Int J Antimicrob Agents 55. [crossref]
  14. Sahin AR (2019) Novel Coronavirus (COVID-19) Outbreak: A Review of the Current Literature. Eurasian Journal of Medicine and Oncology 4: 1-7.
  15. Rothan HA, Byrareddy SN (2020) The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of Autoimmunity 109.

Experiences of Student–Mothers during Distance Learning: A Sociobiological Perspective

Leave a reply

DOI: 10.31038/PSYJ.2023511

Abstract

Teenage pregnancy and parenting continuously becomes a pressing concern in basic education. A growing body of literature is pointing out that student mothers experience trouble in managing their varied responsibilities. To provide richer literature about the experiences of student mothers during distance learning framed in sociobiological dimension, this qualitative study was conducted. This phenomenological study aims to explore the experiences in Cainta Senior High School during distance learning and frame their narratives using sociobiological theories. An adopted but modified questionnaire was used to gather data from seven purposively chosen respondents. Interpretative Phenomenological Analysis was then utilized to analyze the data collected from focus group discussion (FGD) and electronic mail.

Data analysis revealed the emergence of four themes which included (a) struggles in managing their dual roles; (b) motivation for success through education (c) prioritizing baby’s welfare; and (d) people involvement before, during and after pregnancy. These four identified themes are also congruent to Kin Selection Theory, Evolutionary Life History Theory and Self-Regulation Theory in which narratives are analyzed. Academic institution may offer considerations in their academic workloads such as providing printed modular program, lessening requirements and homework, and counselling services. Future studies may concentrate on best practices schools may give to improve the welfare of student-mothers. Further research could be done to the sociobiological foundations of this paper especially if the experts and policy makers would like to possibly apply the results of this research in crafting interventions to curb school dropouts due to adolescent pregnancy and parenting.

Keywords

Qualitative, Phenomenology, Experiences, Distance learning, Teenage pregnancy, Student-mothers, Sociological, Biological, Theories 4

Introduction

Over 90% of learners in approximately 200 countries ranging from basic to tertiary education were affected by closing of schools due to CoViD-19 pandemic [1]. In the Philippines, lockdowns have been enforced throughout the Philippines since March 2020 to encourage social distancing and to restrict the spread of the virus [2,3]. The Department of Education has also moved the opening of classes to October 5, 2020 when Republic Act No. 11480 was signed [4]. Since then, emergency distance learning was initiated in basic education institutions to deliver education amidst global pandemic. UNESCO suggested the use of distance learning modalities such as online distance learning and modular distance learning to deliver education remotely. However, it was shown that the implementation of remote learning had brought about some negative effects on students [5] more so, to student-mothers [6]. As stated by UNESCO in 2020, school closures paved the way for an increase in child labor, sexual exploitation of young women, early marriages, and teenage pregnancies. The Department of Science and Technology – National Research Council of the Philippines also supported the statement of UNESCO and concluded that one of the effects of school closure to adolescent girls is being pregnant at an early age [7]. Pregnancy among teenagers has become a worldwide issue wherein both emerging and developed nations are affected. Most governments throughout the world are dealing with the issue of how to manage and prevent teenage pregnancy from increasing [8]. According to the World Health Organization [9] there are roughly around 12 million girls aged 15-19 years old that give birth every year in developing countries. In fact, according to the United Nations Population Fund (UNFPA) State of the World Population Report of 2018, the Philippines have the fifth highest adolescent birth rate among 11 Southeast Asian nations. DepEd Secretary Briones stated that 61.9% out of more than two million out of school children and youth ages 16-24 dropped out from school due to marriage/family matters. Briones also confirmed that currently, teenage pregnancy could already be considered as one of the main reasons of children dropping out of school [10]. According to Taukeni [11], student-mothers encounter several challenges in performing their dual role, as student and as parent. There is a growing body of literature that points out the serious and prevalent physical, emotional and mental challenges among student mothers especially if one is still a teenager [12]. Several authors have recognized a solid link between dual roles of student-mothers and their negative experiences [13,14]. Several studies are concentrated on student-mothers in regular tertiary education internationally [15-17]and locally [18-20]. However, very few studies have looked into experiences of student mothers in distance education [21]. This study, therefore, is unique considering its focus on socio-biological perspective and its possible connection to experiences of student- mothers during distance learning. There are socio-biological theories that are related to teenage pregnancy and parenting [22]. In this study, the researchers tried to frame the narratives of the student-mothers to sociobiology, Kin Selection Theory, Evolutionary Life History Theory, and Self-Regulation Theory to make the narratives of the participants more meaningful.

As such three compelling reasons why the researchers were inspired to explore the topic are given here. First is the rising cases of teenage pregnancy and parenting in the Philippines; second is the continuous dropping out of student mothers from basic education; and third, which is perhaps the most challenging aspect, is the very limited studies on distance learning experiences of student mothers in Philippine settings during the pandemic anchored on socio-biological foundations. A more enriched qualitative research was generated from this study and contributed to the much better understanding of the lived experiences of student-mothers and how their daily experiences, decisions, ambitions, and lifestyle are anchored from an evolutionary standpoint.

Literature Review

According to WHO (2004), teenage pregnancy, also known as adolescent pregnancy, is pregnancy in a female under the age of 20. In developing countries, there are an estimated 12 million girls aged 15-19 years that give birth each year [23]. Philippines, on the other hand, have seen a slight decrease in teenage pregnancy rate. From 10% in 2008, it decreased from to 9% in 2017 [24]. However, the Philippines still has one of the highest adolescent birth rates among the ASEAN Member States. This entails that more than 500 Filipino adolescent girls are getting pregnant and giving birth every day [25].

Government programs are continuously implemented to address the problems associated with teenage pregnancy. In fact, Department of Education, Department of Health, and Commission on Population and Development jointly initiated the Comprehensive Sexuality Education and Adolescent Reproductive Health (CSE-ARH) Convergence to respond on the ongoing challenges of reproductive health issues among young people including adolescent pregnancies. Revilla [26] also filed “Prevention of Adolescent Pregnancy Act of 2019” in the Senate addressing the concerns of teenage pregnancies and taking care of the welfare of teenage mothers. President Duterte also signed executive order (EO 141) announcing the prevention of teenage pregnancies a national priority of the country. Differing literature surfaced about the correlation of teenage pregnancy and education, although negative consequences outweigh positive ones. Predetermined pregnancy among 6 young individuals can compromise their education. However, in the study of Goodman and Reddy [27], many single student mothers pursue their education due to powerful motivation to improve the lives of their families and to be a positive example for their children. Their children serve as a consistent motivation for these student parents to persist in their education and career goals. According to Reichlin Cruse, Holtzman, et al., [28], as cited in the study of Pendleton and Atella [29], the median debt of undergraduate student parents is 2.5 much higher than the debt of those without children. This is primarily due to a lack of familiar support. They also added that teenage pregnancies cause young women to have different negative impacts on their studies, means of living and to their health.

According to the Philippine Statistics Office in 2019, Region IV-A (CALABARZON), recorded 344 live births in the civil registry among young ladies ages 10 to 14. Rizal province in 2019 ranked second in terms of registered live birth out of teenage pregnancy with 5,458 trailing Cavite province. In Cainta Senior High School, there are 58 cases of recorded teenage pregnancies that are currently enrolled for the school year 2021-2022. The issue of teenage pregnancy and parenting can be both viewed in the lens of biological and sociological dimension [30]. Sociobiology is a field of biology that aims to examine and explain social behavior in terms of evolution. Sociobiology is based on the premise that some behaviors (social and individual) are at least partly inherited and can be affected by natural selection [31]. In this study, the researchers framed the narratives of the student-mothers to sociobiology, Kin Selection Theory, Evolutionary Life History Theory, and Self-Regulation Theory to make the narratives of the participants more meaningful.

Evolutionary Life History Theory which was articulated by Stephen Stearns is anchored from the principles of Natural Selection by Charles Darwin. It essentially states that early reproduction can be correlated to harsh environmental conditions. According to this theory, girls who live in an environment where there is huge emotional stress will experience adolescence at an earlier age than her peers. In any situation where there is a threat of dying, there is also a pressure on the organism to reproduce. This is also supported by the notion that teenage childbearing has been the norm for most of human history especially in early civilizations [32]. Kin selection theory is the evolutionary strategy that favors the reproductive success of an organism’s relatives, even at a cost to the organism’s own survival and reproduction. The theory was also anchored from natural selection theory and popularized by Hamilton in 1963 and Smith in 1964.

Self-Regulation Theory as studied by Roy Baumeister explains that individuals operate like feedback systems, constantly regulating their relationships to the environment in order to bring their current state closer to their goal states. This theory involves concept on feedback system of self-regulation, coping procedures, and problem solving. They 7 also possess coping techniques where individuals are viewed as active problem solvers who tried to reach their desired goal.

Research Questions

This phenomenological study is guided by the following central research question: What are the significant experiences of student-mothers in Cainta Senior High School during distance learning? Specifically, the researchers would like to determine if the experiences of the participants can be analyzed through a sociobiological perspective.

Scope and Limitation

This study was limited only to the examination of the experiences of student-mothers during distance learning. This did not discuss the possible intervention strategies to curb teenage pregnancy; rather, this study is concentrated on examining the experiences of student-mothers in Cainta Senior High School during distance learning. This research is only concerned with Kin Selection Theory, Evolutionary Life History and Self-Regulation Theory. The data collection was conducted with seven student-mothers currently enrolled at Cainta Senior High School on school year 2021-2022 using focus group discussion. This study was conducted from March-April 2022. Data gathering employed several instruments which were constructed and modified by the researchers. Findings of the study, therefore, were true only for the subjects concerned and for the given period of time, although this could be used as a basis for similar studies that would be conducted at different schools in the country.

Significance of the Study

The researchers considered that the body of knowledge that was produced from this study added to the better understanding of the distance learning experiences of student-mothers framed in socio-biological dimension. Additionally, the researchers believed that this study will be valuable to the following group of people:

Students

This research intends to help regular students be properly educated on the experiences of student-mothers to make informed life choices about their life.

Parents

This research can help parents in addressing the issue of their daughter who needs proper support and guidance as it is difficult to study and take care of a child at the same time. This study may give them an idea on what kind of support they should provide or offer to their daughter to help them lighten the challenges they are facing as student-mothers.

School Administrators

Data from this study would give school administrators a better perspective about the circumstances of the student-mothers. This study might be used as a guide in developing future projects which help them manage their dual roles without dropping out of school.

DSWD and GAD

Concerned individuals from these agencies may want to look into the theoretical foundations of this research to evaluate if their current programs for student-mothers are effective. This research may shed light, where necessary, in understanding the roots of why student-mothers behave the way they do and therefore could propose socially appropriate programs to empower them and protect their welfare.

Future Researchers

With the growing number of student-mothers dropping out of schools, it is vital to engage in research to examine this rising phenomenon. Specifically, more exploratory research is needed to understand this overlooked population.

Research Methodology

Sampling

Qualitative method of research, specifically phenomenological research, was used in this study. To realize this research design, specific, purposively chosen participants played a crucial role in the data gathering procedure. This strategy is a kind of non-probability sampling technique, which targets a particular group of people [33]. Purposive sampling was used because the researchers believed that subjects were the most fitted to become respondents of the study. This type of sampling allowed the selection of participants who had experienced or were experiencing the phenomenon (teenage parenting) under study. This sampling technique also allowed the researcher to draw stories from student mothers about their actual life experiences [34]. In this study, the number of participants was seven (7). Morse in 1994 suggested at least six respondents for phenomenological research design. Manalang (2015) worked on a phenomenological study involving only three student-mothers. The increase in number of participants in this study was to ensure the richness of data that will be obtained from the focus group discussion.

Criteria were set to choose the possible respondents: a) student-mother; b) 16-20 years old; c) currently enrolled in school, d) willingness to participate in the study.

Data Collection Procedure

Health research has already accepted a qualitative type of methodology in the past years [35]. Authors identified the effectiveness of qualitative methodology in bringing out the greater depth of understanding on the complex phenomena faced by patients living with long term conditions [36]. One field under qualitative research is phenomenological research. This approach allows the researcher to frame significant themes from participants’ narratives and descriptions regarding the phenomenon [37]. This study utilized phenomenological research design. In gathering necessary data in realizing this design, focus group discussion (FGD) using an interview guide was done. The interview guide was adapted from the study of Erk [38] and modified by the researchers to fit the current study. Informed consent form for participants, permit letter for the parents of 9 participants who are under 18-year-old, and permit letter to conduct the study addressed to research adviser were prepared to address ethical issues regarding the FGD that took place. When the study was approved, the researcher talked to target participants and explained to them the nature, objective, and significance of the study. Once the target participants agreed to the interview, they were given an informed consent form. For participants who did not want to participate in the study, the researchers showed gratitude accordingly.

One (1) focus group was created. This focus group was composed of 6 (six) participants who participated in a focus group discussion (FGD). The date, time, and platform (whether face to face or virtual) of FGD was negotiated with the participants for their convenience. FGD started after the informed consent form and permit letter to the parents were filled out completely. As an opening activity to focus group discussion, the researchers asked the participants to draw their perception on themselves as student-mothers. The respondents were told that they can edit, add, or start the drawing over during the discussion. This technique was used to enrich the verbal narrative and “break the ice” between participants and researchers. Questions in FGD were also sent to one participant via electronic mail after confirming that there was a conflict on schedule. Responses were sent back to researchers a day after.

Data Analysis

There was a large amount of data obtained in the qualitative interview conducted and it was necessary to use a structured framework. Therefore, collected narratives were examined using the Interpretative Phenomenological Analysis (IPA). IPA intends to look at details of how respondents are making sense of their personal and social world. According to Smith and Osborn [39], IPA aims to explore in detail how participants were making sense of their personal and social world” which captured and explored the life of the participants assigned to their experiences. The steps in IPA were summarized as follows: a) reading transcripts; b) taking notes of significant statements; c) statements to codes; d) grouping clustered codes to themes; e) making table of themes.

To validate the findings, researchers adopted the seventh step on Collaizi’s Seven Step Method [40]. Participants were asked to validate the themes that were extracted from their narratives through their personal messengers.

Ethical Issues

Before the start of study, the researchers sought permission for conducting the study through a letter given to the research adviser. Since the study concerns a subject that is considered sensitive, several potential ethical issues were addressed. For purposively chosen participants, the entire consent form was given to them. This action allowed them to carefully read the purpose of the study, risks and discomfort the group discussion may bring, benefits of the 10 studies, and confidentiality of the information. Consent letter for the parents of participants was also given to ensure that the parents of the minors allowed them to partake in the said study. The focus group discussion was held at the most convenient time of the participants. The researcher also explained to each of the participants that participation in the study is not compulsory, and they may stop the interview at any time if they feel uncomfortable or embarrassed. Before conducting the FGD, the researcher reviewed the consent form and reminded the participants that the discussion will be tape recorded.

In the manuscript, participants were tagged as Respondent 1, Respondent 2, and so on for anonymity.

Discussion of Results

This phenomenological study primarily aimed to explore the experiences of student-mothers in Cainta Senior High School during distance learning. The result and discussion section was presented with identifying themes from participants’ narratives and sociobiological dimensions where narratives were framed. According to Auerbach & Silverstein [41], themes may emerge as a result of the repeating concepts which are mutually shared by participants.

It is found out that the identified themes were congruent to the central research question as follows:

  1. Struggles in Managing their Dual Roles
  2. Motivation for Success through Education
  3. Prioritizing Baby’s Welfare
  4. People Involvement Before, During and After Pregnancy

These four identified themes are also congruent to Kin Selection Theory, Evolutionary Life History Theory and Self-Regulation Theory in which narratives are framed. The artistic representations of the respondents on how they view themselves as student-mothers also reflected the themes that emerged from the narratives of the participants. As the student-mothers used their art to represent themselves, themes emerged organically from the art that reflected the student-mother’s lived experience during distance learning. The art itself conveyed emotion, priorities, and struggle and provided another way of communicating their lived experience as a student-mothers. Five out of six participants included their child in the portrait. Five out of six participants included their different roles in life. Four out of six participants also included studying or education (Figure 1).

FIG 1

Figure 1: Collage of Student-Mother Portraits

Struggles in Managing their Dual Roles

Student mothers have experienced a lot of struggles that may lead to interrupt their academic accomplishments [42]. It is similar to the experience of one participant in which she shared her experiences in distance learning. According to her,

“Actually po, mahirap para sa akin kasi nagtatrabaho na tapos nag-aalaga pa, tas mag-aaral ka pa siguro nagsasagot na lang ako ako kapag walang ginagawa saka kapag hindi masyadong pagod saka kapag tulog yung baby ko tapos ngayon nga medyo late na ako sa mga activities pero kailangang habulin kasi hindi ako makaka graduate. Kailangan ko maka graduate kasi gusto ko na makahanap ng mas maayos na trabaho, yun lang.” (Respondent 2; 00:42:58-00:43:31)

She also shared her experiences in deciding what to prioritize to her obligations. She commented,

“Ako po kasi sa tingin ko kasi sa lahat ng bagay kailangan kang may isa kang isasakripisyo, para sa akin dumadating kasi ako sa point na malapit na yung pasahan ng module tas nagrarush din kami ng mga tahi tapos andiyan pa yung baby na aalagaan. Kailangan ko talagang may isa munang hindi gagawin kaya ang ginagawa ko na lang since pwede namang malate ng konti sa pasahan yun na lang muna yung ano hindi ko muna ginagawa tapos kapag may time na ako yun na yung ginagawa ko. Yung doon po sa pag-aaral or pagiging magulang syempre nasimulan na yung pagiging magulang kaya itutuloy na po yon, kasi yung pag-aaral pwede mo namang ulitin pero yung pag-aalaga 12 alagaan mo hanggang baby pa siya kasi kapag lumaki na siya hindi mo na siya maaalagaan gaya nung baby pa siya.” (Respondent 2; 00:46:22-00:47:00)

Evidence pointed out that student mothers have trouble towards their academic journey during the implementation of distance learning. It was exemplified by one participant who shared her her daily routine in distance learning. According to her,

“Ganon din po lagi yung routine ko everyday kapag syempre sa morning po asikaso po muna ng baby and then kapag medyo okay na po nakatulog na po siya, saka lang din po ako gagawa ng modules ko and lahat po ng schoolworks. Kapag face to face naman po uhm iniiwan ko din po siya sa parents ko po para po makapasok. Saka okay na din po yung half day lang po yung pasok para po maalagaan ko din po siya pagkauwi ko.” (Respondent 4; 00:42:13-00:42:48)

Struggling with their varied roles also prompted three respondents to suggest that school may help them with their situation especially, time management if they will be given using printed modules or Learner’s Packet (LeaP). As one respondent suggested,

“Para po sakin siguro ano po kung yung ibabalik po yung may printed module po kasi po pag sa online po kumukuha parang ang hassle po kasi minsan syempre po minsan yung iba walang panload. Although po may libreng wifi sa school pero paano naman po yung mga walang pamasahe, hindi po kayang mamasahe, hindi po kayang magload? Yung iba po kasi nakikisabay lang po ng module diba, nakikipasa lang.” (Respondent 6; 01:09:56-01:10:28)

Motivation for Success through Education

Participants stated that they continue studying for their child’s future as well as to provide their needs and serve as their child’s role model. As stated by Goodman and Reddy, single mother-students demonstrate exceptional determination to overcome obstacles to their education, and they are powerful role models for their children where their children serve as a consistent motivation for them to persist in their education and career goals. One participant said that,

“So as a single mom po, syempre po mas gugustuhin ko pong ipagpatuloy po yung pag-aaral ko kasi para po mas mabigyan po ng mas magandang future yung baby ko na kahit wala akong katuwang e mapupuna ko po yung mga pangangailangan niya at the same time po mafufulfill ko rin po yung ano yung dreams ko po na makapagtapos at makahanap ng magandang trabaho para sa po sa kanya.” (Respondent 4; 00:55:25-00:56:20)

Another participant also shared her insight

“Dati po yung rason mo kung bakit ka nag aaral is para makatulong sa pamilya, ngayon po ang iniisip ko na yung future ng anak ko yung para den sa family ko para pagdating ng 13 araw kung may maganda na kong trabaho mabigay ko at masuklian ko den yung mga hirap ng magulang ko na kahit maaga ako nagkaanak pinupush pa rin nila na makatapos ako.” (Respondent 6; 00:52:15-00:52:43)

Prioritizing Baby’s Welfare

Wilson and Cox [43] found out despite the fact that student-mothers understood the value of their schooling for the benefit of their family, their children were their top priority. One of the participants explained that her time in a day isn’t enough to complete her daily responsibilities. According to her,

“Ako po kasi sa tingin ko kasi sa lahat ng bagay kailangan kang may isa kang isasakripisyo, para sa akin dumadating kasi ako sa point na malapit na yung pasahan ng module tas nagrarush din kami ng mga tahi tapos andiyan pa yung baby na aalagaan. Kailangan ko talagang may isa munang hindi gagawin kaya ang ginagawa ko na lang since pwede namang malate ng konti sa pasahan yun na lang muna yung hindi ko muna ginagawa tapos kapag may time na ako yun na yung ginagawa ko. Yung doon po sa pag-aaral or pagiging magulang syempre nasimulan na yung pagiging magulang kaya itutuloy na po yon, kasi yung pag-aaral pwede mo namang ulitin pero yung pag-aalaga alagaan mo hanggang baby pa siya kasi kapag lumaki na siya hindi mo na siya maaalagaan gaya nung baby pa siya.” (Respondent 2; 00:46:22-00:47:00)

On the other hand, another participant shared that the other mothers would surely agree. She said,

“Mas pipiliin ko po maging ina, at alagaan ang aking anak dahil isang beses lang po sya bata at kailangan nya pong matutukan.” (Respondent 7)

People Involvement Before, During and After Pregnancy

In the course of pregnancy until child rearing, several individuals play crucial part on student-mothers life. When a teenage daughter gets pregnant, parents are usually disappointed (Furstenberg, 1980 as cited by East, 1999). One of the participants mentioned how her parents have high expectations from her, but suddenly it leads to disappointment when they find out that she got pregnant. She said,

“Actually honor student po ako since elementary and high school. In fact, I graduated when I was in grade 6 as the 5th honorable mention of our batch. Sobrang laki ng expectations sakin ng family ko, kaya nung nabuntis ako sobrang laki din ng disappointment nila sakin. Nagka boyfriend po ako when I was in grade 10 and sya din ung father ng baby ko now. Nakatira po kami sa parents ko now pero planning na lumipat.” (Respondent 2; 00:32:54). 14

While other participants shared her experiences by frequent socializing with her friends before getting pregnant. According to her,

“Dati po nung bago ako manganak, bago po ako mabuntis ano po mabarkada po talaga ako marami po akong kaibigan tapos yung partner ko po ano na po talaga siya nagtratrabaho na po siya working student po talaga siya eh ngayon ano po hindi po kami nagsasama dun pa din po ako sa bahay namin nakatira kasi po nagpapatuloy po ako ng pag-aaral ngayon hopefully po na makatapos po ako this year magsasama po kami, maghahanap na rin po ako ng trabaho, siya din po kasi mahirap po talagang maging ano nag-aaral ka tapos may anak ka mahirap pong pagsabayin.” (Respondent 6; 00:28:28-00:29:16)

Regardless of the failure or judgements they had encountered, student mothers still want guidance and care from their family. Anwar and Stanistreet [44] supported those teenage moms depend mostly on their family, trusted friends, to the people who are always on their side and who they feel can support them. Participant also gave advice from the other student’s mother who experienced the same treatment. She added,

“Ako naman po maadvice ko sa kanila is wag silang makikinig sa mga sinasabi nung mga chismosa ganun marites, wag silang maniniwala na “ay nabuntis yan ng maaga kasi ang landi landi niyan” ganun. Kasi ganun yung mindset nung ibang tao porket nabuntis ng maaga malandi ka na agad. Yun po yung wag nating inormalize kasi hindi naman po totoo yun na porket nabuntis ka ng maaga malandi kana. Kasi may mga iba na bumababa yung self confidence dahil dun kasi nagpapadala sila sa mga sinasabi ng iba. Kaya advice ko lang talaga sa kanila wag silang maniniwala dun, paniwalaan nila yung sarili nila, sa pamilya nila kasi lagi nilang tatandaan na nandyan yung pamilya wag silang maniniwala jan sa mga wala namang ambag sa buhay.” (Respondent 6, 00:57:39-00:58:34)

Two respondents mentioned their family members who are taking care of their child while they are busy with schoolworks. They said,

“Nagagawa kopong pag sabayin kapag po tulog sya o di kaya naman ay aalagaan sya ng lola nya.” (Respondent 7).

“Ako naman po, yung baby ko po iniiwan ko sa family ko po, sa mama ko lalo na kapag nagsasagot po ako ng module or assessment.” (Respondent 5).

Sociobiological Dimensions of Participants’ Experiences

Sociobiology is the systematic study of how natural selection shapes the biological basis of all social behavior. Sociobiology was used to frame the narratives of the participants in the study.

Sociobiologists predict that mothers will care for their children more than fathers (they have more invested in them and are more certain of their maternity. All of the student mothers in 15 this study have the custody of their child providing nourishment and support to the child, consistent with the findings of Craig [45] which exemplifies that those mothers were more likely to do more multi-tasking, more physical labor, more responsibility for their care than the fathers. Women often perceived as more nurturing in the society and many people thinks that women are better at taking care of children than men are (Craig, 2006).

Sociobiologists also predict that helping decreases with kinship distance in what known as kin selection theory. Kin selection theory asserts that humans are predisposed to ensure the survival and replication of their genes which they share with their offspring [46] Caring and helping is evident when it involves children, parents, spouses, or other close relations. This sociobiological perspective is evident in the narratives of the student-mothers; whether they said that they wanted to finish studies or wanted to work, this shows deep care and affection. Likewise, kin selection theory can be seen in one theme of study which is prioritizing their baby’s welfare. It shows that student-mothers wanted to take care the needs of their baby first before anything else, a good manifestation of kin selection theory. Life situations wherein student-mothers do not have internet load to download necessary learning materials, do not have transportation allowance to go to school for school requirements, struggle with their time and finances, are confused with their roles, sacrifice one task to perform the other, needs to work while taking care of the child and studying all points out to the postulates of Evolutionary History Theory which correlates early pregnancy and parenting to hardships in life. Juntereal [47] wrote that several studies have already proven that too-early childbearing has several negative impacts for young women including poverty and lower educational attainment.

Evolutionary Life History Theory also postulates that in the animal kingdom, investing in one’s growth may mean that an animal attains a larger body size before reproduction, allowing them to acquire better mates, a larger territory, or more resources. For humans, self-investment may mean delaying reproduction to further one’s education to secure a higher income in the future. This postulate is in contrast with the lived experiences of student-mothers who experienced early pregnancy and therefore have the difficulty in providing the needs of their child. Self-Regulation Theory can also be traced from the narratives of the respondents. Student mothers became problem solvers when face with difficult situations such as balancing their time with their child and academics. One respondent shared that there are instances that as student-mother, they should sacrifice something. Schooling, in this sense, does not win over taking care for the baby. Welfare of the baby comes first before anything else.

Even when there are cases where submission of school requirements is not prioritized, all of the student-mothers want to finish their studies to support their child’s future. This situation exemplifies that all actions of the student-mothers are for the attainment of their desired goal – for their child to have a good future. This situation is also a classic manifestation of Self-16 Regulation Theory where individuals regulate their relationships / responsibilities to the environment to achieve their goals. In a study by Wilsey [48], student-mothers pushed through with their education and professional growth despite the challenges to realize their self-fulfillment. They also have seen that education is relevant to their lives in order to achieve their human goals.

Recommendations

Based on the results of the narratives, this phenomenological research framed in sociobiological perspective, affirms that student-mothers are struggling with their multiple roles in life. Academic institution may offer considerations in their academic workloads such as providing printed modular program, lessening requirements and homework, and counselling services. Basic education services, especially in junior high school and senior high school may provide support groups that could serve as assistance and information resource of these student-mothers. Future studies may concentrate on best practices schools may give to improve the welfare of student-mothers. Further research could be done to the sociobiological foundations of this paper especially if the experts and policy makers would like to possibly apply the results of this research in crafting interventions to curb school dropouts due to adolescent pregnancy and parenting.

References

  1. UNESCO (2020) Reopening schools: When, where and how?
  2. Orlanday D, Jennifer R (2020) Inside the world’s longest and strictest coronavirus lockdown in the Philippines. The Telegraph ISSN 0307-1235.
  3. Viner RM, Russell SJ, Croker H, Packer J, Ward J et al. (2020) School closure and management practices during Coronavirus outbreaks including COVID-19: A rapid systematic review. The Lancet Child & Adolescent Health. 4: 397-404. [crossref]
  4. Aguilar, Krissy (2020) DepEd moves opening of classes to October 5. Philippine Daily Inquirer.
  5. Nugraha R (2020) Nadiem Makarim Launches Online Learning Internet Quota Subsidy. co.
  6. Cohen AM, Brawer F (2008) The American community college (5th ed.)
  7. Daquioag JL (2021) NRCP-DOST. Retrieved from What Causes Early Pregnancy in the Philippines during the Pandemic?
  8. Okumu J (2020) Erk, T (2013) Effects of Teenage Pregnancy on the Academic Performance of Girls in Secondary Schools in Ukwala Ward, Ugenya Sub County Siaya County, Kenya.
  9. World Health Organization (2020) Adolescent Pregnancy.
  10. Reganit J (2019) Retrieved from DepEd highlights need for RH education in public schools. Philippine News Agency.
  11. Taukeni S (2014) The Main Challenges Student Mothers Experience to Manage Their Dual Roles. International Journal of Advances in Psychology 3: 94-98.
  12. Egenti MN, Omoruyi FEO (2011) Challenges of Women Participation in Continuing Higher Education Programme: Implications for Adult Women Counselling and Education. Edo Journal of Counselling 4: 131-143.
  13. Adofo S (2013) Challenges and Coping Strategies of Student Nursing Mothers in Tertiary Institutions in the Greater Accra Region of Ghana.
  14. Najjuma S M, Kyarugahe DT (2006) Studying and Parenting: Experiences of Student Mothers in Ugandan Universities. Monograph Series.17: 1-22.
  15. Amoabea J E, Abigail O Y, Adei H V, Yaa ANN (2020) Marriage, family and schoolwork: A case of married female undergraduate students at the University of Ghana Gender & Behaviour 18: 15476-15486.
  16. Bruening M, Argo K, Payne-Sturges D, Laska MN (2017) The Struggle Is Real: A Systematic Review of Food Insecurity on Postsecondary Education Campuses. Journal of the Academy of Nutrition and Dietetics, 117: 1767-1791. [crossref]
  17. Smith S (2019) Student-Mothers in Community College: A Populous and Overlooked Demographic in Critical Need for Support and Understanding. Doctoral Dissertation.
  18. Gatbonton RR (2021) Educational Experiences of Adolescent Mothers. IAFOR Journal of Education: Inclusive Education, 41-58. [crossref]
  19. Manalang D (2015) The Lived Experiences of College Student Mothers in Managing their Dual Roles. Retrieved from ResearchGate.
  20. Shaik AS (2018) Lived Experiences of Teen-aged Maguindanaon Student Mothers in South Central Mindanao. International Journal of Engineering Trends and Technology 64-65.
  21. Dankyi J K, Dankyi L A, Minadzi VM (2019) Struggles and Coping Strategies of Student Mothers at the University of Cape Coast Distance Education, Ghana. Creative Education, 10: 2484-2494.
  22. Brindis CD, Sattley D, Mamo L (2005) From Theory to Action: Frameworks for Implementing Community-Wide Adolescent Pregnancy Prevention Strategies. Bixby Center for Reproductive Health Research & Policy.
  23. Girlhood, not motherhood: Preventing adolescent pregnancy (2015) UNFPA.
  24. Pinilla B, Muñoz S (2005) Educational opportunities and academic performance: A case study of university student mothers in Venezuela. Higher Education 50: 299-322.
  25. POPCOM (2021) POPCOM calls for prevention of repeat teenage pregnancy. The Philippine Information Agency news.
  26. Revilla R (2019) Prevention of Adolescent Pregnancy Act of 2019. Quezon City, Philippines.
  27. Goodman S, Reddy M (2019) No matter what obstacle is thrown my way: Report from the single mothers’ career readiness and success project. The National College Transition Network, World Education, ECMC Foundation.
  28. Reichlin CL, Holtzman T, Gault B, Croom D, Polk P (2019) Parents in college by the numbers. Institute for Women’s Policy Research.
  29. Pendleton V, Atella J (2020) Academic Outcomes of Undergraduate Student Parents Served by the University of Minnesota’s Student Parent Help Center.
  30. Rozman, Anna (2015) Life History Theory and School-Age Pregnancy: Review and Application. Honors Scholar Theses 425.
  31. Wilson, Edward O (2000-03-24), The Social Insects. Sociobiology, Harvard University Press.397–437.
  32. Stearns S (1992) The Evolution of Life Histories. Oxford: Oxford University Press.
  33. Creswell JW (2008) Educational Research. New Jersey: Pearson Education Inc.
  34. Polit D, Beck C (2008) Nursing research: Generating and assessing evidence for nursing practice (8th ed. ) Philadelphia: Lippincott.
  35. Murphy E. Dingwall R, Greatbatch D, Parker S, Watson P (1998) Qualitative methods in health technol-ogy assessment: A review of the literature. Health Tech-nol Assess.2: 16. [crossref]
  36. Neergaard M. Olesen F, Andersen RA, Sonder-gaard J (2009) Qualitative description— The poor cousin of health research? BMC Medical Research Methodology 9: 52-57. [crossref]
  37. Sanders C (2003) Application of Colaizzi‘s method: Interpretation of an auditable decision trail by a novice researcher. Contemporary Nurse 14: 292-302. [crossref]
  38. Erk T (2013) The College Student as Mother: A Phenomenological Examination of Community College Student Experiences. Doctoral Dissertation.
  39. Smith J, Osborn M (2007) Interpretative phenomenological analysis. Qualitative Psychology: A practical guide to research methods. SAGE 53-80.
  40. Colaizzi P, Valle RS, King M (1978) Psychological research as a phenomenologist view it. Existential Phenomenological Alternatives for Psychology.
  41. AuerbachC F, Silverstein LB (2003) Qualitative data: An introduction to coding and analysis. New York University Press.
  42. Taukeni S (2014) The Main Challenges Student Mothers Experience to Manage Their Dual Roles. International Journal of Advances in Psychology, 3: 94-98.
  43. Wilson K B, Cox EM (2011) No kids allowed: Transforming community colleges to support mothering. NASPA Journal About Women in Higher Education, 4: 218-241.
  44. Anwar E, Stanistreet D (2015) ‘It has not ruined my life; it has made my life better’: A qualitative investigation of the experiences and future aspirations of young mothers from the northwest of England. Journal of Public Health (Oxford, England) 37: 269-276. [crossref]
  45. Craig L (2006) Does Father Care Mean Father Share? A Comparison of How Mothers and Fathers in Intact Families Spend Time with Children. Gender and Society 259-281.
  46. Palomo-Vélez G, Buczny J, Van Vugt M (2020) Encouraging Pro-Environmental Behaviors Through Children-Based Appeals: A Kin Selection Perspective. Sustainability 12: 748.
  47. Juntereal C (2019) POPCOM: Teenage pregnancy may cause ‘intergenerational poverty’. Retrieved from Manila Bulletin.
  48. Wilsey SA (2013) Comparisons of adult and traditional college-age student mothers: Reasons for college enrolment and views of how enrolment affects children. Journal of College Student Development 54: 209-214.

An Update on the Situation of Women Human Rights Defenders in Medicine – A New Case Example

Leave a reply

DOI: 10.31038/AWHC.2022533

Abstract

Women Human Rights defenders encounter increasing dangers, as demonstrated by our case example, the renewed arrest of Prof. Sebnem Korur Fincanci, a leading human rights expert and defender, in Turkey. Many countries with autocratic regimes have in fact increased their attacks on women, especially those from ethnic minorities, such as Kurdish minorities, in spite of all efforts by the UN, World Medical Association, and other international umbrella organisations. Support for WMA and UN activities and local women’s organisations are to be seen as crucial to face these raising challenges.

Keywords

Human Rights, Istanbul Declaration, Istanbul Protocol, Turkey, Iran, Afghanistan

As a follow-up to our article from 2021 in this journal [1], we have to note, that the situation of women as human rights defenders has not improved.

In our opinion, autocratic regimes and dictatorships have started to encourage each other, also in the face of usually complete impunity in order to persecute women standing up for women, and in general, human rights. Women can have a strong symbolic role in public if they publicly support human rights and humanitarian standards, that clash with grandiose, mostly male dreams of empire and unlimited power. The denying of important documents protecting women [2], such as the Istanbul convention, that was developed in Turkey, but suspended in this land by its present autocratic ruler (with “effect of 1 July 2021, Turkey withdrew from the Istanbul Convention and is no longer a state party to this convention”), is apparently part of this strategy targeting especially women. In spite of the creation of a special rapporteur on human rights defenders by the UN (“Special Rapporteur on the situation of human rights defenders”, at present the highly respected Ms. Mary Lawlor), apparently not much progress was made in some countries since our last critical analyses in this journal, probably to the overwhelming challenges in the global rise on violence, as demonstrated by the present situation of women speaking out in countries such as Iran and Afghanistan.

This is further underlined by the renewed [1] arrest of Professor Sebnem Korur Fincanci [3], former head of Istanbul University Department of Forensic Medicine, president of the Turkish Medical Association, world-renowned expert on forensic investigation of severe human rights related crimes such as torture, coauthor of the UN and WMA supported “Istanbul Protocol” [4-6] (for the documentation and investigation of torture supported by the UN and other organisations). She also received the German “Hessian Peace Prize” among other international decorations honoring her dedication to peace and human rights. She was arrested and accused of “supporting terror propaganda” after her proposing an independent investigation into the alleged use of poison gas in Kurdish regions. At the same time, the Turkish government took steps to discredit and take control of the Turkish Medical Association that should be guaranteed to have an independent status, following World Medical Association guidelines. This has created a massive international wave of solidarity and the demand to release and end persecuting her. It was published by nearly all international professional organisations, foremost the WMA, the World Psychiatric Association, national medical associations, and a large number of NGOs.

The World Medical Association leadership for example on October, 26, 2022 quoted Dr. Frank Ulrich Montgomery, Chair of the WMA Council: ‘It is totally unacceptable that Dr. Korur Fincancı has been detained and that members of the Turkish Medical Association are being threatened with suspension.” and confirms:

“The World Medical Association has issued a strong condemnation about the arrest in Turkey of Dr. Şebnem Korur Fincancı, President of the Turkish Medical Association.”

WMA has recently updated this international appeal stating that:

“Millions of physicians around the world have joined forces to demand the release of Turkey’s physician leader, Prof. Şebnem Korur Fincancı. Dr. Fincani, President of the Turkish Medical Association, has been held in prison for almost two months after calling for an independent investigation into allegations about the use of chemical weapons. This week, the Istanbul 24th Heavy Penal Court will hold the first hearing of Dr. Fincani on charges of ‘propaganda for a terrorist organisation’. WMA, together with the Standing Committee of European Doctors (CPME) and four other European medical organisations, has already earlier written again to the President of Turkey protesting that Dr. Fincani was in detention for merely expressing an opinion.”

Dr. Frank Ulrich Montgomery, further comments: ‘Such denial of liberty constitutes a gross violation of the freedom of speech. Her detention is arbitrary, abusive, and contrary to the most elementary fair trial rules, guaranteed by the International Covenant on Civil and Political Rights that Turkey has ratified in 2003’.

He further reminds the Turkish President that the use of chemical weapons was prohibited under international law ratified by Turkey in 1997.

He concludes: ‘It seems to us incongruous at the least that the Turkish authorities punish one of its citizens for recommending an investigation into the use of weapons which they precisely committed to prohibit.

The international medical community urges you to deliver justice fairly and impartially and calls for the immediate release of Prof. Şebnem Korur Fincancı and to drop all charges against her.’

This can be seen as the global position of medical doctors in this case, applying also to similar cases of medical doctors active as human rights defenders and human rights in general. The persecution of women human rights defenders in Iran and observations on their torture, sexual abuse, lack of adequate medical care and on the other hand, abuse of medicine, have been raised and should be investigated with urgency, using international standards of medical examination and investigation such as the already mentioned recently updated UN “Istanbul Protocol” [7-9], making use of the option of an independent investigation by the UN, for example by the Special Rapporteur on Torture.

So far, UN has already excluded Iran from the UN Commission on the Status of Women. Women of ethnic minorities, such as Kurdish groups appear to be at special risk for all acts of persecution [10,11].

We further want to note, that also other professions, such as especially journalists [12], are part of the defense of human rights. In addition to the protection given to defenders, being the primary necessary intervention, both legal and psychological support should be offered to all groups, such as medical doctors, care givers [13], journalists and also witnesses that give testimony in international and national courts.

References

  1. Siroos Mirzaei JK, Reem Alksiri, Thomas Wenzel (2022) Women as Human Rights Defenders at Risk. Archives of Women Health and Care 5: 1-2.
  2. Haneck S, Hahn D (2022) [Effects of Cooperation on Health Care after Domestic and Sexualised Violence in Hesse and its Impact on the Implementation of the Istanbul Convention]. Gesundheitswesen. [crossref]
  3. Heisler M, Lin J, Modvig J, Esdaile C, Iacopino V (2022) Free Sebnem Korur Fincanci and end systematic silencing of health professionals. Lancet 400: 1843-1844. [crossref]
  4. Moreno A, Crosby S, Xenakis S, Iacopino V (2015) Implementing Istanbul Protocol standards for forensic evidence of torture in Kyrgyzstan. J Forensic Leg Med 30: 39-42. [crossref]
  5. Akar FA, Arbel R, Benninga Z, Dia MA, Steiner-Birmanns B (2014) The Istanbul protocol (manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment): implementation and education in Israel. Isr Med Assoc J 16: 137-141. [crossref]
  6. Iacopino V, Ozkalipci O, Schlar C (1999) The Istanbul Protocol: international standards for the effective investigation and documentation of torture and ill treatment. Lancet 354: 1117. [crossref]
  7. Koseoglu Z (2022) Launch of the revised version on the Istanbul Protocol. Torture 32: 89. [crossref]
  8. Perez-Sales P (2022) The 2022-revised version of the Istanbul Protocol: orientation kit for people in rush. Torture 32: 3-15. [crossref]
  9. Iacopino V, Haar RJ, Heisler M, Lin J, Fincanci SK, Esdaile C, et al. (2022) Istanbul Protocol 2022 empowers health professionals to end torture. Lancet 400: 143-145. [crossref]
  10. Kizilhan JI, Friedl N, Neumann J, Traub L (2020) Potential trauma events and the psychological consequences for Yazidi women after ISIS captivity. BMC Psychiatry 20: 256. [crossref]
  11. Kizilhan JI, Noll-Hussong M (2017) Individual, collective, and transgenerational traumatization in the Yazidi. BMC Med 15: 198. [crossref]
  12. Feinstein A, Feinstein S, Behari M, Pavisian B (2016) The psychological wellbeing of Iranian journalists: a descriptive study. JRSM Open 7: 2054270416675560. [crossref]
  13. Denkinger JK, Windthorst P, Rometsch-Ogioun El Sount C, Blume M, Sedik H, et al. (2018) Secondary Traumatization in Caregivers Working With Women and Children Who Suffered Extreme Violence by the “Islamic State”. Front Psychiatry 9: 234. [crossref]

The Synthesis of Medical Intermediate Adamantane

Leave a reply

DOI: 10.31038/JPPR.2022542

 

Adamantane is a highly symmetrical clathrate  hydrocarbon  with a ring-tetrahedral structure. It is a camphor-smelling colorless crystalline solid with a density of 1.07 kg/L at room temperature. As the structure is highly symmetrical and compact, and the hydrogen atoms are easily replaced by other groups, it has a wide range of applications in these fields: medical intermediate, high-density fuel, lubricant, new photoelectric material et al. Therein, for the medical intermediate field, adamantane can be used to synthesize amantadine, rimantadine, amantanium bromide, memantine et al., which shows the talents to treat diseases effectively such as influenza virus, parkinson’s syndrome, chronic hepatitis C and  more.  At  present, the method to synthesize adamantine is to use dicyclopentadiene produced in refinery as the raw material, which would experience the hydrogenation to tetrahydrodicyclopentadiene firstly and further isomerization  to  adamantine.  For  the  hydrogenation  process,  the typical hydrogenation catalysts like Raney Ni, Pd/Al2O3 can be qualified for completing the reaction. While for the isomerization process, it possesses more technical problems and attracts more research attention correspondingly. There are four main isomerization methods based on four different types of catalyst: (1) AlCl3; (2) super acid; (3) ionic liquid; (4) zeolite.

AlCl3 method is the current industrial production method of adamantine with autoclave as the reactor. It has the positive characteristics of easy operation, high catalytic activity and high yield of adamantane, but this method would produce a large amount of black tar. Further, AlCl3 is highly toxic and acidic, easily causing body damage to the operators, and the post-reaction treatment is so complicated that more processes and cost are required. Therefore, from the perspective of the green and sustainable development trend, this method will be phased out in the future. Super acid method uses super acid as catalyst for example CH3SO3H-SbF5 to synthesize adamantane. Super acid is more acidic than 100% sulfuric acid, so it shows high catalytic activity and high adamantane yield. However, the super acid owns these disadvantages: high synthesis cost, strict requirements for the equipment, the poor stability, causing a large distance to the practical application as a result. Ionic liquid method uses ionic liquid as catalyst to synthesize adamantane. Ionic liquid is a kind of liquid salt composing of anions and cations at room temperature. Due to  its almost no vapor pressure, good solubility, good conductivity and stable properties, it has been widely studied in many fields. For the synthesis of adamantane, the most outstanding characteristics of ionic liquid method are mild reaction conditions, good selectivity of adamantane, and solvent free. But the synthesis of ionic liquid  itself is difficult and high-cost, as well as the weak tolerance to impurities, which limits its further industrial large-scale application.

Zeolite method makes use of zeolite to synthesize adamantine. Zeolite is a kind of synthetic or natural crystalline silicate or silicaluminate. It has achieved great successful applications in the field of purification, oil refining, separation etc. Due to the characteristics of mature synthesis technology, low cost, easy regeneration, easy separation and low pollution, it has been widely investigated in many relevant researches, and been considered to replace the existing intermittent method and realize continuous synthesis into adamantane. However, zeolites have to face the problems of low catalyst activity, poor product yield, and easy coking. Once these issues are solved, this method would have more widely practical applications.

What’s New in Rehabilitation Post Orthopaedic Trauma?

Leave a reply

DOI: 10.31038/IJOT.2023611

 

Traumatic bone and joint injury is a significant cause of morbidity – particularly in the working population. Trauma can be because of multiple reasons may be accidents, sports injury or fall during work etc. Rehabilitation services provide treatment to improve mobility, increase strength, pain management and mental health difficulties after a major trauma incident. Rehabilitation after trauma facilitates safe and speed recovery by eliminating the patient’s inhibitions and providing holistic care. Hereby we shall see what the recent advances which have happened in upper limb segment. Let us take by each area.

Shoulder

Subacromial impingement syndrome is very common cause of shoulder pain and accounts for 44%-65% of all shoulder complaints in people older than 40 yrs. The pathophysiological mechanism is the mechanical impingement of the rotator cuff tendons as they pass through the subacromial space, which leads to a condition of inflammation and irritation [1-3]. So a meta-analysis was done to compare injection through ultrasound guided technique and anatomic landmark based injections. In this study there is moderate to very low evidence that USG corticosteroid injection results in significant pain relief and improvement in physical function. Short-term retention between 6 and 8 wks after injection and the type of corticosteroid used potentially affect the treatment efficacy of ultrasound as reported in this study. Adverse events were relatively low in both groups, which justify the safety and efficacy of USG injection [4].

Another new method of using diagnostic ultrasound in adhesive capsulitis was evaluated in 65 patients and found that coracohumeral ligament thickness had significant inverse correlations with shoulder range of motion in external rotation and internal rotation but not in abduction or flexion. This study done by Wu et al, published a novel use of diagnostic ultrasound with adhesive capsulitis. Also coracohumeral ligament thickness showed significant correlation with disease duration. Utilizing diagnostic ultrasound in this way can help to confirm diagnoses such as adhesive capsulitis, leading to early intervention and treatment.

Hand

Osteoarthritis of the first carpometacarpal joint is common disease, especially in postmenopausal women. First carpometacarpal joint osteoarthritisis quite distressing as it can result in pain and functional limitations. In a cohort study done of 308 patients who underwent nonoperative treatment with exercise therapy, an orthosis, or both, Hoogendam et al. investigated how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months. They concluded that positive pre-treatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months. But satisfaction after nonoperative treatment of first CMC osteoarthritis is not yet optimal, positive expectations of treatment outcomes are associated with higher satisfaction. Therefore, optimizing patient expectations may further improve treatment expectations and outcomes [5,6]. In another systematic review and meta-analysis which included 11 RCTs, Marotta et al. compared the effectiveness of 4 different orthoses (short thermoplastic CMC splint, long thermoplastic CMC-metacarpophalangeal [MCP] splint, short neoprene CMC splint, and long neoprene CMC-MCP splint) with that of no splinting for first CMC osteoarthritis. All splints were superior to no splinting at reducing pain. Based on outcomes measured at 3 to 6 months following the index treatment, the long thermoplastic CMC-MCP splint was the first choice for reducing pain, and the short thermoplastic CMC splint was the first choice for improving function; both effects were significant compared with no splinting [7].

References

  1. Garving C, Jakob S, Bauer I (2017). Impingement syndrome of the shoulder. Dtsch Arztebl Int 114: 765-76 [crossref]
  2. Andersson HI (2004). The course of non-malignant chronic pain: a 12-year follow-up of a cohort from the general population. Eur J Pain 8: 47-53. [crossref]
  3. Creech JA, Silver S (2021). Shoulder impingement syndrome. StatPearls Publishing LLC. [crossref]
  4. Deng X, Zhu S, Li D, Luo Y, Zhang X, et al. (2021). Effectiveness of ultrasound guided versus anatomic landmark-guided corticosteroid injection on pain, physical function and safety in patients with subacromial impingement syndrome: a systematic review and meta-analysis. Am J Phys Med Rehabil. [crossref]
  5. Hoogendam L, van der Oest MJW, Wouters RM, Andrinopoulou ER, Vermeulen GM, et al. (2021). Hand-Wrist Study Group. Patients with higher treatment outcome expectations are more satisfied with the results of nonoperative treatment for thumb base osteoarthritis: a cohort study. Arch Phys Med Rehabil 102: 1533-40.
  6. Wu PY, Hsu PC, Chen TN, Huang JR, Chou CL, et al. (2021). Evaluating correlations of coracohumeral ligament thickness with restricted shoulder range of motion and clinical duration of adhesive capsulitis with ultrasound measurements. PM R. 13: 461-9. [crossref]
  7. Marotta N, Demeco A, Marinaro C, Moggio L, Pino I, et al. (2021). Comparative effectiveness of orthoses for thumb osteoarthritis: a systematic review and network meta-analysis. Arch Phys Med Rehabil 102: 502-9.

Myristolated Serotonin 2A Receptor Peptide Promotes Long-Lasting Blood Pressure-Lowering and Reno protection in Hypertensive Rat Species

Leave a reply

DOI: 10.31038/EDMJ.2022631

Abstract

Aim: The aim of the present study was to test whether conjugation of a synthetic peptide corresponding to a fragment of the second extracellular domain of the human serotonin 2A receptor substantially alters the in vivo pharmacodynamic blood pressure-lowering profile of the peptide in different hypertensive rat strains.

Methods: Sertuercept (SCLLADDN) was synthesized and modified using pegylation or myristolation. The two different peptide conjugates were tested in male Zucker diabetic fatty rats for acute and long-lasting blood pressure-lowering effects following single intraperitoneal administration. The myristolated Sertuercept was administered intraperitoneally to female Zucker fatty and male spontaneously hypertensive rats (SHR) and blood pressure was monitored either using tail cuff measurement (female Zucker) or by telemetry (SHR) rats. Plasma immunoglobulin G obtained by Protein G affinity chromatography in 25-week-old female Zucker or male spontaneously hypertensive rats was tested for binding to a linear synthetic peptide corresponding to the second extracellular loop of the serotonin 2A receptor. A cohort of male Zucker diabetic fatty rats was randomized to seven weeks of once-weekly myristolated Sertuercept or scrambled peptide (injections) and the kidneys were examined histologically for differences in total kidney lesions or fibrosis.

Results: Pegylated Sertuercept promoted substantial blood pressure-lowering lasting approximately 30-48 hours in male Zucker diabetic fatty rats. Blood pressure-lowering following a single injection of Myristolated Sertuercept was much longer-lasting (6-11 days) and it was effective in male Zucker diabetic fatty rats, male spontaneously hypertensive rats and in a subset of hypertensive female Zucker fatty rats. Seven weeks’ treatment with once-weekly Myristolated Sertuercept (2mg/kg) was associated with significantly fewer kidney lesions and less interstitial fibrosis compared to scrambled peptide in 25-week-old male Zucker diabetic fatty rats. Male spontaneously hypertensive rats (4 of 4 tested) harbored plasma IgG which bound significantly to serotonin 2A receptor peptide, and a subset of female Zucker fatty rats harboring IgG were responsive to blood pressure-lowering from the myristolated Sertuercept peptide.

Summary: Myristolated-Sertuercept, an epitope-specific peptide comprised of a portion of second extracellular loop of the human serotonin 2A receptor was safe, well-tolerated and effectively lowered blood pressure for one week or longer in two different strains of male hypertensive rats. These data provide proof-of-concept that once-weekly systemic drug administration is feasible to achieve not only long-lasting hypertension control, but also substantial renoprotection.

Introduction

According to the Global Epidemiology of Hypertension Study, in 2020, hypertension was the leading cause of global death and disability [1]. Hypertension prevalence is increasing worldwide, it already exceeds 1 billion affected persons, and is especially prevalent in persons living in low- and middle-income countries Although hypertension treatment and control has improved significantly in the past several decades in high-income countries, awareness and treatment/control still lag significantly in less developed parts of the world.

Hypertension is a major modifiable risk factor for cardiovascular disease (ischemic heart disease, stroke, congestive heart failure) and chronic kidney disease occurrence. One of the key factors contributing to poor hypertension control in treated patients is nonadherence to medication regimen(s). The underlying causes of nonadherence are multifactorial but include a need for higher vs. lower frequency of dosing [2]. In a recent systematic review and meta-analysis that compared once-daily vs. once-weekly dosing in the treatment of chronic diseases, once weekly dosing was associated with a 1.9-fold higher odds ratio of long-term medication adherence [3].

We previously reported on a first-in-class, novel anti-hypertensive peptide (Sertuercept) having amino acid sequence corresponding to a subregion of the second extracellular loop of the human 5-HT2A receptor [4]. The serotonin 2A receptor is normally expressed on arterial vascular smooth muscle cells where it mediates 5-HT induced arterial vasoconstriction [5]. In experiments conducted in male Zucker diabetic fatty rats (ZDF) [4], a genetic model of obese, hypertensive, type 2 diabetes, unconjugated Sertuercept had an in vivo pharmacodynamic half-life of approximately 24 hours, caused rapid, potent systolic and diastolic blood pressure-lowering (in ZDF rats) and was well-tolerated. Chronic every other daily intraperitoneal administration of Sertuercept (vs. scrambled peptide) significantly decreased renal glomerulosclerosis in male ZDF rats [4].

The aim of the present study was to test whether modification of Sertuercept via attachment of a pharmacologic carrier can extend the in vivo blood pressure-lowering effect of the peptide drug leading to a long-acting analogue that is safe, well-tolerated, efficacious and could be administered in a once-weekly chronic regimen that reduces end-organ dysfunction associated with poor, long-term hypertension control.

Animal and Methods

Animals

All procedures were conducted according to the National Institutes of Health (NIH) Guide for the Care and Use of Laboratory Animals and approved by the Institutional Animal Care and Use Committee of the Veterans Affairs Medical Center (East Orange, New Jersey). Male ZDF (N=12) female Zucker fatty rats (N=21) and male spontaneously hypertensive rats (SHR) were obtained from Charles River Laboratories (Kingston, NY) at approximately 6 weeks of age. All rats were single housed upon arrival, with modest enrichment (a PVC tube). Rats were provided ad libitum access to food and water and maintained in a 12 h light/dark cycle with lights on at 0630. All procedures occurred during the light phase of the cycle.

Synthetic Peptides

Unconjugated Peptide

Synthetic peptides were synthesized at Lifetein Inc. (Hillsborough, NJ). The lyophilized peptides were aliquoted and stored (under desiccated conditions) at −40°C prior to use. On the day of intraperitoneal (IP) administration, an aliquot of lyophilized peptide was reconstituted in sterile saline at the indicated concentration.

Lyophilized peptide was stored for up to 4 weeks (at −40°C) prior to obtaining newly-synthesized peptide needed in chronic drug administration experiments.

Unconjugated Peptides

Sertuercept (Decoy Receptor Peptide)

A linear synthetic peptide, SCLLADDN, having amino acid sequence identical to that of a fragment of the second extracellular loop region of the human 5-hydroxytryptamine 2A receptor was synthesized and had ≥ 95% purity.

Scrambled Peptide Sequence LD.8

The scrambled peptide had a sequence of LASNDCLD (LD..8) and a purity of 96.37%, MW 849.91.

Conjugated Peptides

Pegylated SCLLADDN-‘Pegsertuercept’

The starting material, PEG2K-or-above DBCO is a mixture of polyethylene glycol (PEG) and the average molecular weight is 1K. The purity of the free peptide is ≥95%. The mechanism for generation of pegylated Peptide 2 is as follows: Lys(Azide)-SCLLADDN + DSPE-PEG2000 (or above)-DBCO. The click chemistry occurs between azide and DBCO. The sequence of the final product is K(DBCO-DSPE-PEG2K)-SCLLADDN. The purity is >95% and the MW is 1004.09.

Myristolated SCLLADDN or ‘Myr-Sertuercept

The synthetic SCLLADDN (Sertuercept) peptide was myristolated on the N-terminus at Lifetein Inc; it had >91% purity. It was reconstituted in sterile saline containing 10% DMSO to improve solubility prior to intraperitoneal administration in rats.

Non-survival surgery (25-weeks of age)

Rats were anesthetized with xylazine/ketamine prior to undergoing non-survival surgery during which they were perfused with 4% paraformaldehyde in PBS. The kidneys (male ZDF rats) were post-fixed for 24-48 hours in 4% paraformaldehyde and then stored in 70% ethanol at 4°C prior to shipment to Histoserve, Inc. (Germantown, MD). Kidneys were sectioned and stained with H&E and Masson’s trichrome. Blood (male SHR, female Zucker fatty rats) was obtained by cardiac puncture immediately before non-survival surgery for isolation of plasma IgG autoantibodies.

Tail-cuff Blood Pressure Monitoring

Tail cuff blood pressure measurement was performed using an automated CODA noninvasive blood pressure system (Kent Scientific, Torrington, CT) in male Zucker diabetic fatty and female Zucker fatty rats, as previously reported [4].

Telemetric Blood Pressure Monitoring

Surgical Placement of Blood Pressure Implant and Telemetry Device

Stellar telemetry, real-time implants (TSE Systems, Chesterfield, MO) were placed in the left femoral artery of three male, 16-week-old SHR rats and one 16-week-old male Sprague-Dawley rat using procedures described in the Stellar Surgical Manual (TSE Systems, Chesterfield, MO). Correct placement was verified by the blood pressure waveform. The telemetry device was placed in a subcutaneous pocket on the dorsal surface between the shoulder blades, and the device was secured to the surrounding muscle with non-absorbable suture. The rats were allowed 7 days to recover post-operatively before initiation of blood pressure data acquisition.

Real-time Blood Pressure Implant Data Acquisition

The Stellar Telemetry, real-time implants are supported in Notocord-hem software (Instem). The software was programmed to acquire blood pressure data at 20-second intervals (up to ten measurements at each timepoint) before and for up to 12 days after IP administration of Myr-Sertuercept or scrambled peptide.

Renal Histology

Comparisons between male ZDF rats randomized to 7 week’s treatment with (Myr-Sertuercept vs. scrambled peptide) were made by Dr. Jerrold M. Ward (veterinary pathologist) using Masson’s trichrome fibrosis score and total kidney lesion score. The fibrosis score ranged from 0-4, where 0: no fibrosis, 1: minimal fibrosis, 2: mild fibrosis, 3: moderate fibrosis, and 4: severe fibrosis. An individual glomerular score and an interstitial score (for the one kidney examined from each individual rat) was determined separately. Twenty-forty glomeruli were examined in each kidney, both in areas involved or not involved by interstitial fibrosis. A total kidney lesion score (from H&E sections) was based on presence (or absence) and severity of hydronephrosis, dilated tubules, glomerular and/or interstitial fibrosis. The veterinary pathologist examiner was unaware of the treatment assignment group during examination of histologic sections of rat kidneys.

Protein G affinity Chromatography

Rat plasma samples obtained in (25-week-old female Zucker fatty or male SHR) rats were subjected to Protein G affinity chromatography for isolation of IgG as previously reported [6]. Enzyme linked immunosorbent assay (ELISA) for serotonin 2A receptor second extracellular loop peptide. Rat IgG specimens were tested for binding to the serotonin 2A receptor peptide corresponding to the second extracellular loop domain (QN..18) (Lifetein, Inc) in an ELISA performed as previously reported [6].

Statistical Analysis

Comparisons were made using Student’s unpaired t-test; or time series analysis.

Results

Long-lasting Blood Pressure-lowering Effect of Pegsertuercept

A single 1 mg/kg IP dose of Pegylated-Sertuercept caused statistically significant 8.9 mm Hg mean lowering in systolic blood pressure (Table 1) and a statistically significant 9.8 mm Hg mean lowering in diastolic blood pressure (Table 2) compared to 2 mg/kg scrambled Peptide 2 (P<0.01) in 12-week-old male ZDF rats. There was no significant effect of time on blood pressure-lowering effect from the two drugs (not shown in Table 1 or 2).

Table 1: Comparison of systolic blood pressure-lowering effect from Pegsertuercept (1 mg/kg) vs. scrambled peptide LD.8 (2 mg/kg) intraperitoneal injection in 12-week-old male ZDF rats.

Treatment

Estimate

SE

DF

t Value

Pr>t

Effect
Intercept

141.66

5.4602

5

25.94

<.0001
Trt PegSertuercept

-8.9162

2.5229

38

-3.53

0.0011
Trt Scrambled Peptide

0

Single Pegsertuercept (1 mg/kg) IP injection caused -8.9 mm Hg reduction in mean systolic blood pressure compared to scrambled peptide (2 mg/kg IP). SE: Standard Error.

Table 2: Comparison of diastolic blood pressure lowering effect from Pegylated Sertuercept (1 mg/kg IP) vs. scrambled peptide LD..8 (2 mg/kg IP) in 12-week-old male ZDF rats.

Treatment

Estimate

SE

DF

t Value

Pr>t

Effect
Intercept

98.1654

4.376

5

22.43

<.0001
Trt PegSertuercept

-9.7771

0.5121

40

-19.09

<.0001
Trt Scrambled Peptide

0

0

Single Pegsertuercept (1 mg/kg) intraperitoneal (IP) injection caused mean -9.8 mm Hg reduction in mean diastolic blood pressure compared to IP injection of scrambled peptide (2 mg/kg). SE-standard error.

A single IP injection of either 1 mg/kg (shown in Figure 1) or 0.75 mg/kg pegylated Sertuercept (not shown in Figure 1) caused significant and long-lasting decline(s) in mean systolic and diastolic blood pressure in male (12-week-old) ZDF rats. The effect was sustained for at least 30 hours and less than 48 hours (Figure 1). Scrambled peptide sequence LD..8 (2 mg/kg IP) had no significant effect on systolic or diastolic blood pressure in age-matched male ZDF rats (grey line, Figure 1).

fig 1

Figure 1: Single intraperitoneal dose of Pegsertuercept (1 mg/kg) (arrow) caused significantly greater systolic (A) and diastolic blood pressure-lowering (B) vs scrambled peptide (2 mg/kg) IP in 12-week-old male ZDF rats (n=4 per group). Each point is the mean ± SD.

Significantly Longer-lasting Blood Pressure-lowering Effect of Myristolated Sertuercept

A single 2 mg/kg IP dose of Myr-Sertuercept caused statistically significant 17.4 mm Hg mean systolic blood pressure-lowering and statistically significant 12.0 mm Hg mean diastolic blood pressure-lowering compared to 1 mg/kg scrambled Peptide 2 (P<0.02) (Table 3A and 3B). There was no significant effect of time on blood pressure-lowering effect from the two drugs (not shown in Table 3).

Table 3: Time series analysis of difference in systolic (A) and diastolic (B) blood pressure lowering effect after administration of single IP dose of Myr-Sertuercept vs. scrambled peptide 2 in two groups of 12-week-old male Zucker diabetic, fatty rats (N=4 rats per drug treatment group).

A) Systolic
Drug

Estimate

Standard Error

DF

t Value

Pr>lti
Myr-Sertuercept

-17.439

5.0163

5

-3.48

0.0177
Scrambled Peptide

0
B) Diastolic
Drug

Estimate

Standard Error

DF

t Value

Pr>lti
Myr-Sertuercept

-12.0471

3.23

5

-3.73

0.0136
Scrambled Peptide

0

Single Myr-Sertuercept (2 mg/kg) intraperitoneal (IP) injection caused mean -17.4 mm Hg reduction in mean systolic and mean -12.0 mm Hg reduction in diastolic blood pressure vs. IP scrambled peptide (2 mg/kg). The model included adjustment for difference in baseline mean blood pressure. SE-standard error.

Next, the blood pressure-lowering effect of Myr-Sertuercept at doses ranging from 1.0-2.5 mg/kg was tested (for up to nine days) following a single IP injection in male ZDF rats. Blood pressure-lowering by 1 mg/kg Myr-Sertuercept was not only rapid in onset, but substantial (Figure 2). Both younger (12-week-old) and older (25-week-old) male ZDF rats experienced similar significant blood-pressure lowering following IP injection of 2 mg/kg Myr-Sertuercept (Table 4). At doses ranging from 1.0-2.5 mg/kg, IP Myr-Sertuercept dose-dependently lowered blood pressure and the effect (at higher doses) was sustained for 7-9 days (Table 4). Myr-Sertuercept was safe and well-tolerated. None of the male ZDF rats experienced acute hypotension even at the highest dose tested. Vehicle (10% DMSO) alone or scrambled peptide in sterile saline had no discernable effect on blood pressure in age-matched male ZDF rats (data not shown).

fig 2

*P<0.05 compared to baseline mean arterial pressure
Figure 2: Rapid- onset and sustained blood pressure-lowering effect of low dose Myr-Sertuercept peptide following IP injection in 13-week-old male ZDF rats. Results are mean ± SEM of multiple determinations at each timepoint in each of two male ZDF rats that received either 1 mg/kg Myr-peptide or Scrambled peptide; *P<0.05 compared to baseline MAP.

Table 4: Change in Blood pressure in response to IP administration of scrambled (LN..8) or Myr-Sertuercept: each at 2 mg/kg in 25-week-old male Zucker diabetic fatty rats.

Peptide

 Day 0

 Day 2

 Day 5

 Day 7
Systolic
Scrambled (LN..8) (N=3 rats)

140 ± 6

148 ± 1

147 ± 10

151 ± 12
Myr-Peptide 2 (N=5 rats)

144 ± 9

121 ± 7**

125 ± 12*

134 ± 9
Diastolic
Scrambled (LN..8) (N=3 rats)

95 ± 10

94 ± 7

101 ± 8

105 ± 7
Myr-Peptide 2 (N=5 rats)

103 ± 6

77 ± 4**

82 ± 10*

92 ± 7*

Results are mean ± SD; **P<0.01 vs. day 0; *P<0.05 vs. day 0.

Male SHR Rats

The spontaneously hypertensive rat (SHR) is an inbred strain derived from Wister-Kyoto rats selected for successive matings based on having spontaneously-occurring hypertension. The SHR rat is a recognized model of essential hypertension that is neither obese nor diabetic. Unlike male ZDF rats, male SHR rats do not develop early, moderate-severe proteinuric nephropathy [7], however, they are known to exhibit certain cell-mediated and humoral immunologic defects [8] including harboring autoantibodies to several unknown vascular antigens [9]. Myr-Sertuercept (2.0 mg/kg IP) had little or no significant blood pressure-lowering effect in three SHR rats. Myr-Sertuercept (5.0-10.0 mg/kg IP) dose-dependently lowered blood pressure, and the effect was long-lasting (up to 9-11 days) at the 7.5 or 10.0 mg/kg dose, respectively (Figure 3, Tables 5 and 6). Myr-Sertuercept was safe and well-tolerated; none of the rats experienced any untoward effect (e.g. acute hypotension) after single-or repeated dose administration over a four-week testing period. A single normotensive male SD rat (monitored telemetrically) did not experience any significant blood pressure-lowering (or adverse effect) at any dose of Myr-Sertuercept tested including the highest (10 mg/kg) dose. Vehicle (10% DMSO) or scrambled peptide (in sterile saline) had no discernable effect on blood pressure in age-matched male SHR rats (data not shown).

fig 3

Each (time)point represents the mean of five-ten telemetric determinations (Stellar implant, TSE Systems Inc) having standard error of approximately 1%.
Mean MAP-lowering (%) at the indicated timepoint compared to baseline MAP
Figure 3: Dose-dependence and sustained blood pressure- lowering effect of Myr-Sertuercept in twenty-week old male SHR rats.

Table 5: Summary of dose-dependence and durability of mean arterial blood pressure-lowering following single IP administration of myristolated Sertuercept at indicated doses Myristolated.

Myristolated Sertuercept Dose

Acute Peak blood pressure-lowering (%)

Duration of Action (days)

Mean arterial BP
1 mg/kg

6-8%

4-6
1.5 mg/kg

14%

7
2.0 mg/kg

14-22%

3; 7
2.5 mg/kg

19-30%

9

Results represent average of treatment in two, 11-13-week-old male ZDF rats at each specific dose

Table 6: Summary of dose-dependence and durability of mean arterial blood pressure-lowering effects after single IP administration of myristolated Sertuercept in 25-week-old male SHR rats.

Myristolated Peptide 2 Dose

Acute Peak blood pressure-lowering (%)

Duration of Action (days)

Mean arterial BP
2.0 mg/kg

1-3%

5
5.0 mg/kg

5-10%

5
7.5 mg/kg

9-23%

8
10.0 mg/kg

17-22%

11

Results represent average of treatment in three male SHR rats at each specific dose

Female Zucker Fatty Rats

Unlike their male counterparts, female Zucker fatty rats do not develop diabetes mellitus on the same diet fed to male ZDF rats; female ZDF rats exhibit a much milder form of hypertension and proteinuria is mild. A single IP injection of Myr-Sertuercept (2 mg/kg) caused rapid significant systolic and diastolic blood pressure-lowering in approximately 60% (12/21) of female Zucker fatty rats tested at 24-hour after drug administration. The magnitude and time course of blood pressure change in representative ‘responder’ and ‘non-responder’ female Zucker rats following a single 2 mg/kg IP dose of Myr-Sertuercept is shown in Figure 4. Mean arterial blood pressure-lowering was substantial (23-27%) 1-3 days after Myr-Sertuercept (2 mg/kg) in a ‘responder’ female Zucker fatty rat (Figure 4). Blood pressure-lowering was sustained for up to 6 days in this and other female Zucker rat responders (not shown). There was no effect of scrambled peptide (2 mg/kg) following IP injection in three female Zucker fatty rats tested (data not shown).

fig 4

Each point is the average of three of more determinations which varied by <15%
Figure 4: Mean arterial blood pressure-lowering following a single 2 mg/kg IP dose of Myr-Sertuercept in three representative ‘responder’ and ‘non-responder’ 20-week-old female Zucker fatty rats. Results are the mean of three or more determinations which varied by < 15%.

Reno-protection from Chronic, Once-weekly Treatment with Myr-Sertuercept for Seven Weeks

Chronic once-weekly IP administration of Myr-Sertuercept (vs. scrambled peptide) (each at 2 mg/kg concentration) for seven weeks was associated with significantly lower renal interstitial collagen score (P<0.02) and total kidney lesion score (P<0.003) (N=14 male ZDF rats, Figure 5). Kidneys from rats treated with scrambled peptide not only had significantly more interstitial fibrosis (vs kidney from Myr-Sertuercept-treated rats), but the areas of fibrosis were larger than in Myr-Sertuercept-treated rats. Rats randomized to Myr-Sertuercept vs. scrambled peptide did not differ significantly in their baseline body weight or plasma glucose concentration prior to initiation of treatment (data not shown).

fig 5

*P<0.05, mean OD in IgG from two male SHR rats vs. two female Zucker fatty rats Dashed line is the background optical density (0.032 absorbance units).
Figure 5: Level and titer of Rat IgG binding to synthetic peptide QN.18 identical to the second extracellular loop of the serotonin 2A receptor.

Serotonin 2A Receptor Plasma IgG Autoantibodies in Different Rat Strains

We next tested plasma IgG from male SHR rats (n=4) and female Zucker fatty rats (N=7) for binding to a synthetic peptide identical to the second extracellular loop of the serotonin 2AR receptor. In a prior study, male ZDF rats harbored IgG autoantibodies that displayed significant binding to the 5-HT2AR, second extracellular loop peptide, QN…18 [6]. Here, we report that IgG in all four of four male SHR rats tested displayed significant binding to the 5-HT2AR peptide, but IgG in only 2 of 7 female Zucker fatty rats tested displayed increased binding to the 5-HT2AR peptide (data not shown). Plasma IgG binding to the serotonin 2A receptor second extracellular loop peptide was significantly increased (P<0.05) in the IgG from male SHR rats (n=2) compared to female Zucker fatty rats (n=2) (Figure 6). The female Zucker rat having plasma IgG which exhibited relatively higher binding in the 5-HT2AR ELISA also had a robust blood pressure-lowering response to Myr-Sertuercept (data not shown in Figure 6).

fig 6

Figure 6: Chronic (7-week) once weekly IP administration of Myr-Sertuercept (2 mg/kg) significantly reduced A) renal interstitial collagen score and B) total lesions compared to identical dose and course of scrambled peptide in 16-23-week-old male ZDF rats. Results are mean ± SD.

Safety

There were few if any acute or chronic side effects from Myr-Sertuercept administered IP at doses ranging from 1-10 mg/kg in male ZDF (N=16), female ZDF (N=21) or male SHR rats (N=10). Two male Zucker diabetic fatty rats who were severely hyperglycemic (capillary glucose >500 mg/dL) developed a syndrome of inability to gain weight and failure to thrive. Both rats had been randomized to seven weeks’ treatment of once weekly Myr-Sertuercept and died at approximately 20-22 weeks of age. A limited necropsy performed in one of the rats revealed severe diabetic gastroparesis, a known complication in the hyperglycemic rodent [10].

Discussion

Two different conjugated forms of the synthetic peptide SCLLADDN (Sertuercept) substantially lowered systolic and diastolic blood pressure in male Zucker diabetic fatty rats. Blood pressure lowering following IP administration of Peg-sertuercept (2 mg/kg) was sustained for ~ 30 hours consistent with the known effect of pegylation on prolonging circulation time and decreasing proteolytic degradation in other modified proteins [11]. Myristolation of Sertuercept (SCLLADDN) on the amino terminus led to an even longer duration of blood pressure-lowering ranging from 6-11 days or longer depending on the strain and dose administered. This is consistent with enhanced lipid solubility and perhaps slower release into the circulation of myristolated vs. pegylated proteins.

Most FDA-approved medications to treat essential hypertension are available for oral administration. However, owing to their relatively short half-lives in vivo, even the most potent classes of oral anti-hypertensive medication require once or twice daily dosing. Presently, there is no FDA-approved class of anti-hypertensive medication whose duration of action extends substantially beyond 24 hours following a single (oral) dose. According to the World Health Organization, approximated 26-29% of the world population suffers with hypertension [1]. Hypertension is the single leading risk factor for global death and disability. Roughly one-half of treated hypertensive patients do not reach their target desirable blood pressure goal in part because of the need to take more than one medication at (daily) or more frequent intervals. Patient nonadherence to anti-hypertensive medication use is the leading cause of residual morbidity and mortality due to hypertension [2]. It could be substantially reduced through the advent of a potent, long-lasting blood pressure-lowering medication requiring only once-weekly self-administration.

The present data suggest that myristolated Sertuercept (Myr-Sertuercept) is a first-in-class, anti-hypertensive medication which meets the goal of safety and efficacy in a once-weekly formulation that can be self-administered. Once weekly Myr-Sertuercept not only provided long-lasting blood pressure control, but a short 7-week course of (once-weekly) injections significantly reduced the incidence of renal interstitial fibrosis and all kidney lesions in the male Zucker diabetic fatty compared to age-matched ZDF rats treated with scrambled peptide. These data are in agreement with an earlier report that alternate daily administration of unconjugated Sertuercept peptide (for ten weeks) significantly reduced glomerular fibrosis in the male ZDF rat compared to ZDF rats treated with scrambled peptide [4].

Male SHR rats suffer with a severe form of hypertension, and they required 3-5 fold higher concentration of Myr-Sertuercept (IP) to promote substantial blood pressure-lowering compared to male ZDF rats. On the other hand, not all female Zucker fatty rats (which generally exhibit a milder form of hypertension compared to male ZDF rats) experienced significant blood pressure-lowering in response to Myr-Sertuercept. Differences in endothelial injury, and endothelial nitric oxide synthase expression between male and female Zucker rats may account in part for the observed sex difference. For example, estrogen is known to augment endothelial nitric oxide synthase important in mediating vasodilation (Figure 7) [12].

fig 7

Figure 7: Representative Masson’s trichome-stained kidney section from male ZDF rat treated with either (A) Myr-Sertuercept or (B) scrambled peptide (2 mg/kg) for seven weeks.

Another contributory factor may be reduced level of plasma serotonin 2A receptor IgG in female Zucker compared to either male SHR or male ZDF rat. Our in vitro studies suggested that Sertuercept may interfere with the ability of agonist serotonin 2A receptor IgG autoantibodies to bind and activate the serotonin 2A receptor [4]. Sertuercept was designed as a structural mimic of the sub-region of the second extracellular loop of the 5-HT2A receptor most avidly targeted by ZDF rat and human pathologies IgG autoantibodies [13]. Male SHR and ZDF rat IgG not only bound to a serotonin 2A receptor peptide fragment, but the male ZDF rat IgG [6] and human pathologies’ IgG harbored endothelial cell toxicity in vitro that could be prevented by treatment with highly selective 5-HT2A receptor antagonists [14].

In summary, myristolation of Sertuercept on the amino terminus led to a novel long-lasting, safe and effective ‘first-in-class’ drug which potently lowered blood pressure in male Zucker fatty rats, and in male spontaneously hypertensive rats and substantially prevented renal interstitial fibrosis in male ZDF rats. Myr-Sertuercept may be a game-changing, once-weekly, anti-hypertensive, renoprotective medication particularly well-suited to address the problem of poor long-term medication adherence in patients on complex regimens.

References

  1. Mills KT, Stefanescu A, He J (2020) The global epidemiology of hypertension. Nat Rev Nephrol 16: 223-237. [crossref]
  2. Moise N, Schwartz J, Bring R, Shimbo D, Kronish IM (2015) Antihypertensive drug class and adherence: an electronic monitoring study. American Journal of Hypertension 28(6): 717-721. [crossref]
  3. Iglay K, Cao X, Mavros P, Joshi K, Yu S, et al. (2015) Systematic Literature Review and Meta-analysis of Medication Adherence With Once-weekly Versus Once-daily Therapy. Clin Ther 37(8): 1813-1821. [crossref]
  4. Zimering MB (2021) A Serotonin 2A-Receptor Decoy Peptide Potently Lowers Blood Pressure in Male Zucker Diabetic, Fatty, Hypertensive Rats. Endocrinol Diabetes Metab J 5(2). [crossref]
  5. Watts SW, Morrison SF, Davis RP (2012) Barman SM Serotonin and blood pressure regulation. Pharmacol Rev 64(2): 359-388. [crossref]
  6. Zimering MB, Grinberg M, Burton J, Pang K (2020) Circulating Agonist Autoantibody to 5-Hydroxytryptamine 2A Receptor in Lean and Diabetic Fatty Zucker Rat Strains. Endocrinol Diabetes Metab J 4(3): 413. [crossref]
  7. Feld LG, Van Liew JB, Brentjens JR, Boylan JW (1981) Renal lesions and proteinuria in the spontaneously hypertensive rat made normotensive by treatment. Kidney Int 20(5): 606-614. [crossref]
  8. Kim JY, Lee E, Koo S, Kim CW, Kim I (2021) Transfer of Th17 from Adult Spontaneous Hypertensive Rats Accelerates Development of Hypertension in Juvenile Spontaneous Hypertensive Rats. Biomed Res Int. [crossref]
  9. Ofosu-Appiah W, Huang LY, Kuhnle M, Sfeir G, Kennel A (1996) Autoantibodies against arterial antigens: characterization by ELISA and immunoblot analysis in the spontaneously hypertensive rat. Clin Exp Hypertens 18(1): 21-35. [crossref]
  10. Chang FY, Lee SD, Yeh GH, Wang PS (1996) Influence of blood glucose levels on rat liquid gastric emptying. Dig Dis Sci 41(3): 528-532. [crossref]
  11. Veronese FM, Mero A (2008) The impact of PEGylation on biological therapies. BioDrugs 22(5): 315-329. [crossref]
  12. Lekontseva O, Chakrabarti S, Jiang Y, Cheung CC, Davidge ST (2011) Role of neuronal nitric-oxide synthase in estrogen-induced relaxation in rat resistance arteries. J Pharmacol Exp Ther 339(2): 367-375. [crossref]
  13. Zimering MB (2019) Autoantibodies in Type-2 Diabetes having Neurovascular Complications Bind to the Second Extracellular Loop of the 5-Hydroxytryptamine 2A Receptor. Endocrinol Diabetes Metab J 3(4): 118. [crossref]
  14. Zimering MB (2018) Circulating Neurotoxic 5-HT2A Receptor Agonist Autoantibodies in Adult Type 2 Diabetes with Parkinson’s Disease. J Endocrinol Diabetes 5(2). [crossref]

Fayoum Portraits

Leave a reply

DOI: 10.31038/NAMS.2022534

 

The Fayoum portraits owe their name to the place of their discovery in the necropolises of the Fayoum Oasis in the northwest of Egypt, 45 meters below sea level. The name Fayoum is Coptic, FIOM, and meaning “sea” probably because of the large lake there known today as Birket Quaroun. When the Arabs came to Egypt, it became Al Fayoum. The portraits date back to the first century AD, but the bulk belongs to the 2nd and 3rd centuries and only a few to the 4th century. Egypt became a Roman colony in 30 BC after the death of Cleopatra Mostly Greeks, Macedonians, Romans, Hebrews, and Syrians settled the region. Since, the time of Alexander the Great, the newcomers had been gradually merging with the local milieu. It soon rivalled Alexandria for the vineyards and gardens that abandoned on its soil, the most fertile in Egypt. It became a trade center for cereals and vegetables, and was renowned for its figs and roses. Fayoum also became an artistic center for Egypt, during the Greco-Roman period (Figure 1).

FIG 1

Figure 1: Fayoum portraits

While preserving many of the original features of their own culture and way of life, the settlers who became rich owners of large estates borrowed much from the Egyptians. In particular all of them had at an early stage adopted the peculiar, characteristically Egyptian beliefs with regard to death and their meticulously elaborated rituals. The Egyptians attached tremendous importance to the belief in life after death, and developed the art of embalming to a high degree of perfection. The aims of embalming were to preserve the body and to make a lasting portrait of the deceased. The embalmed corps was carefully wrapped and enclosed in several richly decorated coffins that were mummiform in shape. Badly preserved portraits were not included in this review.

Under the Romans (1st century BC – 4th century AD), the procedure became less elaborate. The mummy was carefully wrapped in a special way and the mummiform coffin was made simply of carton. Later, this technique was simplified further and a portrait of the deceased was attached to the mummy’s head. Initially people used for this funeral rite portraits that had been painted from life, had been framed and hung in the houses. While the ancient Egyptians, the Greeks, and the Romans excelled in architecture, sculpture, and painting, the art of portraits was not common. A typical ancient Egyptian or a Greek painting of a human face was generally shown in the profile. The obvious analogy of the Fayoum portraits are the Roman wall paintings of the first centuries AD found in the ruins of Pompeii. The Greeks had also fresco in their temples, but none of them survived; they were described in ancient writings. What survived was the painted pottery, which were made to hold water, wine, or oil. The importance of the Fayoum paintings is that the portrait became an art that had religious significance and not for decorative purposes as the frescoes. When Christianity came to Egypt the pagan tradition was gradually abandoned and the art of the portrait took a different form namely that of the icons, i.e., a religious portrait; icon is a Greek word meaning portrait.

The Fayoum portraits are a fascinating collection of people who lived during the first two centuries AD. They have an important historical as well as artistic values. They are dispersed now in at least one hundred museums worldwide either on display or in storage. Only few of the portraits in the books available are in colour and are usually arranged according to the countries holding them or some other archaeological criteria. The ankh or key of life is an ancient Egyptian symbol used in Egyptian art and writing to represent the word for “life”. It was used by at least three ancient mummies of ladies and one in men. Two special techniques were used in the Fayoum portraits. In both cases, the pigment was not mixed with water as in the frescoes but either in egg white or in wax and set by passing a hot iron over the painting. The last process became known as the “encaustic wax process”. After all, is it not true that there is life after death? Thanks to archaeologists who are digging the remains of the ancients and bringing them back to life. Here are their portraits filling museums and books. According to R. Shurinova of the Pushkin Museum of Fine Art, the Fayoum portraits are “a major contribution made by Egypt to the treasures of world culture”.

Smart Phones Surveillance Methods

Leave a reply

DOI: 10.31038/NAMS.2022533

Introduction

Smart phone surveillance is a sensitive issue, so topical and important, which is about everyday life of all of us, I am talking about the smart phones, small smart phones, these small but powerful computers that everybody use them everyday by doing more internet browsing rather than doing calls. The questions that arise about the security of smart phones are many, for example: may someone watch us? May the government hear what we saying and what messages we send? May they know our location? How much important meta-data is and to what extent it can reveal important information about the subscribers identity and how it relates to privacy and personal data. Finally, it is worth mentioning the participation of mobile phone providers in various government monitoring projects of the citizens either with targeted software which is not detectable, or with the direct access to the Servers of the providers for copying sensitive information without of course the consent of the subscribers. Such projects are the Carnivore, Prism, and other projects, and the countries involved in information exchange programs are behind lists identified as 5 Eyes, 9 Eyes, and 14 Eyes.

Keywords

Smart phones, Surveillance, Monitoring, Mobile networks, Security, Privacy

Surveillance Methods

When referring to a smart phone surveillance, refer to 6 spy methods, which are:

  • Signal interception & MITM
  • Hardware circuit.
  • Spy phone application.
  • Use of specific software for Servers.
  • Meta-data analysis.
  • Government monitoring projects.

    • Case 1

    On this case, requires expensive equipment that is not legally sold on the market to be purchased by an interested customers, there are various approaches to low-cost material, but these tapping systems are cumbersome and complex in their operation, also may consider that the advent of 4G/5G networks that offer more security than the old 2G/3G these cheap eavesdropper devices partly useless, say in partly because should consider that in smart phones devices in the choice of the network allows the following option 5G/4G/3G/2G which means that where there is no 5G/4G network coverage the smart phone will operate on the 3G/2G network and this is a security hole as the network is over vulnerable to cheap type of interceptor devices since the 3G/2G network encryption algorithm provide low security. An expensive stolen state equipment would also be useless since its use keys that should be renewed regularly. Thus, state-owned services that have legal co-op equipment have the ability to make legitimate signal interception, here at this point, someone might think of this, an employee who has access to the system could be tapping someone else phone? the answer is aware of it. Legally signal interception systemss are divided into 2 categories, those located in central buildings where sometimes require the assistance of the telecom provider and the base stations where, depending on the needs of the service, they move.In both of the above categories, the subscriber does not realize the monitoring of his/her telephone line or the interception of the transmitted data. In the first category in which data interception is involved the telecommunications company the process is the easiest and simplest as extract information directly from the Servers. In the second category, which is popular in the secret services, mobile base stations are used which are used at close distances from the target victim base station to proceed with data collection. The target victim does not perceive the difference in communication as the deceptive base stations are added to the network with a normal antenna ID so as not to affect the quality of communication or services so that the target victim understands the monitoring.

    Detecting deceptive mobile base stations can be detected with specialized software, but most of them are not detected as they appear as transponders and not as communication antennas and even if they have received a normal antenna ID. Once a successful connection to a monitoring system is achieved, or with a deceptive mobile base station, the information extraction as well as the sending of commands to the mobile phone begin, where it is indicated, recording conversations, copying messages, modifying messages, browsing websites, receiving emails, collecting messages from network messaging applications, locating, opening the camera, and opening the microphone. These practices are commonly used to support criminal evidence in courts or in cases of terrorisn and national security. Figure 1 shows a deceptive mobile base station.

    FIG 1

    Figure 1: Deceptive Mobile Base Station

    Case 2

    On this case, could be said to be based on the ignorance of the subscriber, at this point say ignorance because in this case the smart phone has to be opened and a micro chip is placed inside, which will collect everything while the phone will be send it back to the target-victim person. Device data usage either when the smart phone is in close proximity to a mobile transceiver, the connection is made and the data is transferred. Detecting such a micro chip is very difficult, and with the breakthrough of Internet of Things this technology is evolving. That’s why we need to buy smart phones from trusted places, also a smart phone that is a gift from someone is an easy way to deceive, but not always. Under no circumstances should be considered safe and reliable a sealed cell phone that is in its original jelly in brand new condition, just simillar as the ones cell phones selled in stores. This is a practice of the secret services, when there is a restriction on access for data mining in other ways, for the success of the mission there is usually cooperation with some traders so that the desired modified device falls into the hands of the target victim in such a way that perceived by the target victim. Even if the target victim somehow realizes that their communications are being monitored he/she will focus on either switching network providers or buying a new SIM card under another name from the same or different network provider, the most likely scenario is to use the same mobile device as the suspicion that the mobile phone device is modified will hardly cross his/her mind, on the one hand due to lack of knowledge and on the other hand he/she bought the device sealed from a store. The success of this method is based on this logic.

    Case 3

    On this case presented the simplest and most widespread, based on the naive and ignorant of the target victim about the security and use of smart phone and applications. Some security tips are:

    • Do not leave the smart phone exposed to third parties.
    • Use lock screen application.
    • Keep both operating system and software applications updated.
    • Use antivirus software with real time protection enabled, keep the antivirus database updated.
    • Do not use VPN software.
    • Do not install APK files from unknown sourcs.
    • Do not ROOT your smartphone.
    • Do not use software apps with low reputation.
    • Do not open messages that do not know.
    • Do not click hyperlinks that do not know.
    • Do not open files from strangers.
    • Smart phones are not as safe as you may believe.

    Generally, the signs that a smart phone is being taped are:

    • The battery discharge quickly after data is being used continuously, so check the applications. It can also be a coincidence.
    • Interrupting calls while talking, also this could cause by interference in the connection, automatically changing location while trying again to set the correct location but still changed may be interference only at that specific area.
    • Noise during speech, this is a sign of a interference, but keep in mind that with professional signal interception devices there is no noise, also the noise someone may hear may be either a device damage or is from Interference.
    • The smart phone is warm, this meaning several processes are running.
    • The smart phone crashes and becomes slow, this is due also to other reasons, depending on the smart phone and depending on the monitoring software sometimes the monitoring software is “heavy” and the smart phone can not respond.
    • Text messages that are received by irrelevant numbers, messages that have been sent, and the recipient has received a different message than than the one that have been sent should be suspected of monitoring or network interference that may be due to other infections.
    • The smart phone works alone and does not turn off. Surveillance spy software do not allow the user to have full control over the device for the simple reason that they are trying to keep the spy software on the device.
    • Removal of software apps are not permitted or this operation is disabled.
    • There is mysterious activities in social media networks which tere is access from the infected smart phone, also, my serious activities may occur in mobile apps of exchanging messages.
    • Nothing from the above.

    The above are the few rules that apply, continue reading.

    • Surveillance software does not appear in installed applications.
    • Resetting to factory settings may not permanently eliminate the surveillance software.
    • Scrambled applications are easily localized, while well-designed applications run on Stealth Mode and are extremely difficult to detect even with anti-malware
    • A smart phone surveillance software can be downloaded to the smart phone through another application.
    • Modern surveillance software is very difficult to detect while also provides no annomalies with operating system.
    • Smart phone ROOTING makes easier the installation and proper use of surveillance software.
    • A smart phone which its operating system is updated will prevent from the installation of various surveillance software which is installed into smart phones by using various well known security holes.

    Case 4

    In this case, the well-known Pegasus spyware is introduced. Pegasus is spyware software for smartphones that install on iOS, Android, Blackberry O/S and any other Android O/S based operating system (custom Android versions). This software has interesting features both in the way it is installed on the target smartphones and the possibilities it offers to its operators. The target victim first receives an SMS with a link if then the target victim by clicking on the link then the smart phone becomes infected with Pegasus. In the previous pages among the security tips it has been mentioned that the operating system must be updated, the reason is that to install Pegasus on a Smartphone it exploits zero-day vulnerabilities of the operating systems, which means that an updated operating system from alone is not able to deal with Pegasus, so additional security measures are required, such as a very reliable antivirus/antispyware with application installation lock capabilities and avoiding ROOT may to some extent prevent the installation or smooth operation of Pegasus. Once Pegasus is installed on the target smartphone, then the ability to fully control the smartphone begin with capabilities to monitor and record phone calls, read emails, take screenshots, record keystrokes, generally have the general management of the Smartphone in to such an extent that the remote Pegasus operator has physical access to the Smartphone. As expected from such software with huge capabilities, it is expensive, complex software that remains installed on the smartphone completely invisible, undetectable even by antivirus and antispyware. The specific software is used when there is a need to monitor important people and personalities; it is not used for monitoring children as parental control software for example or for low important purposes of low interest.

    At this point it is worth noting two things, the first is that in dark net there are lists of zero-day vulnerabilities that can be used to create software spies similar to Pegasus. The second is that Pegasus is software that is constantly updated and new features are added. An important peculiarity of its innovation is the way of installation which changes, as it has been mentioned above for the installation of the software the target-victim receives a link via SMS, this is the basic way of installation, but there is also an invisible way of installation, in this case the target-victim does not realize the existence of SMS nor do require by someone to click on a link to install Pegasus, because it is possible exploitation of zero-day security vulnerabilities that allow Pegasus to install on the target-victim’s smartphone without the target-victim realizing anything. This is one of the features that make Pegasus software so special.

    Case 5

    Meta-data is everywhere in our electronic activities, meta-data is also present in the non-digital world. For the implementation of an activity or the execution of a service – function presupposes the execution of various functions which will be used to complete a process. All these processes that are required for the completion of a service – function in each stage of their implementation are accompanied by a significant number of data which is necessary for the completion of the final process. The data that is transferred and processed at each step of the implementation is of great and special importance-value, both because they contain important personal information and because determine the activities of mobile subscribers. Mobile telephony service providers that participate in government information exchange of meta-data programs distribute the meta-data content to government agencies for analysis. The secret services have the ability to process meta-data to a large extent. To create profiles with the habits of each subscriber. The meta-data collection can of course be performed with the cases mentioned above. The collection and analysis of meta-data is very important and the information extracted can be more important than the information itself. The reason is that neta-data contains subscriber information which contains:

    • Mobile network code.
    • ΙΜΕΙ of Smartphone.
    • Device location.
    • Subscriber code.
    • Frequency of manipulations.
    • Social media preferences.
    • Duration and frequency of calls.
    • The destination of the calls.
    • Duration of internet usage.
    • Frequency of visits to websites.
    • Frequency of use of the telephone.
    • Determining the country of operation of the telephone.
    • Determining the use of the mobile telephony antenna.
    • Frequency of telephone connection per antenna.

    The above are some of the information that can be extracted from the meta-data. This information can be used as a first step before implementing a cell phone tracking method. It is worth noting at this point, the use of a simple non-smartphone mobile phone significantly reduces the chances of tracking, as there is a significant limitation to the use of tracking methods, while from the point of view of the created mta-data, eta-data is clearly less in terms of the size of the value of the information. The government services, and especially the secret services, are able to know about the information circulating in the interior of the country, the secret services that are active in the collection and analysis of information abroad (foreign intelligence) are able to know in globally the information that is circulated as meta-data, how this is done will be mentioned below.

    Is important advantage of meta-data is the sale of information that can be extracted for advertising purposes, it is not uncommon for subscribers to accept calls by marketing companies to promote their products, when subscribers ask marketing companies where they found their phone numbers they answer that the subscribers themselves subscribed to information lists, someone else wrote them on their behalf, knowing that this is not the case, they just try to calm the subscriber by reassuring them that they have not received their contact details illegally extracting information from meta-data. Meta-data is also created by mobile antenna towers, these meta-data include subscriber connections from antenna to antenna, the distance of the subscribers from the antenna, the data transferred, and other useful information that needs analysis, which I further analysis will reveal other sensitive information.

    Case 6

    On this case presented the biggest threat regarding data security and privacy in the digital world is that the majority of data transferred on the Internet is not encrypted well, the existing security infrastructure in an environment of not well encrypted information must be considered totally inadequate. Not well encrypted communication means the government easy may have access to intercept any information. Government agencies and organizations knowing the telecommunication weaknesses, information intercepted by subscribers from offensive websites, the non-encrypted information, not well encrypted information, VPN servers that offers fake anonymity that is essentially Honey Pot systems with examples the secret services who collect information from the servers inside in the country or third countries that participating in the PRISM project.

    Security agencies have access in data of any internet and smartphone subscribers in the world. This practice on several countries is legal and is based on several privacy protection laws This laws gives the freedom to governmental agencies to store and to process huge amounts of data without exception if these people are criminalized or not. The PRISM project became quite popular and reinforced worries of the world on the violation of privacy and data. The Project PRISM named after the word outlet means mirror – reflection and this is because the data pass through an internet node continue their route but the items are copied (reflection) from the PRISM project without harming their quality neither have been some form of alteration to worry the subscriber that something is wrong. Below in Figure 2 is a simple example of Project PRISM.

    FIG 2

    Figure 2: Example of Project PRISM

    As shown in the figure above, to make a data breach between nodes the data must be copied without the subscriber knowledge. Usually this makes it coherent with telecoms operators and other services that there are active subscribers. All of the above would be useless if there was not the necessary data mining tool and statistical tests, called XKEYSCORE by pressing a few keys are able to know everything related to a human, such as telephones, e-mails, habits, searches has done in search engines, behaviors, internet of Things activities (IOT) and of course building electronic profile “e-profile”. The security services have advanced already on potential networking devices controls and firewalls of known companies manufacturing such devices. The XKEYSCORE, used in conjunction with another program called TURBULENCE, the TURBULENCE are two subsystems the TURMOIL and TURBINE. Briefly mention that TURMOIL is an information collection system of satellite and cable communications, while TURBINE unleashes attacks on serial systems (Greenwald, 2015). From the above could not be missing collection of information from social media, Cookies, Internet services, Internet of Things, etc. Once the target is locked: the next step is the QUANTUMTHEORY attacks and QUANTUMNATION which will give full control of the remote device, even is a smart phone, Internet of Things, computer, or anything else. In Figure 3 shows how is working the intermediary fake Server.

    FIG 3

    Figure 3: Working of intermediary fake Server

    The data collection and processing is performed by each device connected to the Internet, the mobile network providers collect personal data transferred to Servers of their infrastructures, telecommunications providers know all about digital life and human conversations, applications for smart phones collect personal data and data about subscribers behavior. Imagine a Smart phone devices which will send personal data to the manufacturer or other organizations and then those organizations to have remote access to Smartphone and opened the camera, or perform real time data analysis. Many automated bot trying to break different kinds of access codes to gain access. interception of data is shown in Figure 4 and 5 below. A smartphone that work exclusively on 4G/5G and not in 2G/3G networks would be the best option. No security method can prevent the monitoring of a smartphone, as long as the subscriber tries to protect his/her smartphone, as the methods presented in this chapter are practically impossible, even if the subscriber uses an old mobile phone device no that is, a smartphone. No cell phones and no security methods should be considered secure, subscribers should consider their smartphones to be insecure and that their activities are not confidential, even if point-to-point encryption communication applications are used [1-5].

    FIG 4

    Figure 4: Interception of data

    FIG 5

    Figure 5: Interception of data

    References

    1. Glenn Greenwald (2015) No Place to Hide: Edward Snowden, the NSA, and the U.S. Surveillance State.
    2. Christos Beretas (2018) Security and Privacy in Data Networks. Research in Medical & Engineering Sciences.
    3. Christos Beretas (2018) Internet of Things and Privacy. Journal of Industrial Engineering and Safety.
    4. Christos Beretas (2020) How Really Secure is TOR and the Privacy it Offers. Nanotechnology and Advanced Material Science.
    5. Christos Beretas (2020) Cyber Hybrid Warfare: Asymmetric threat. Journal of Nanotechnology and Advanced Material Science.

Advances, Prospects and Concerns in Nanomaterials for Food Processing

Leave a reply

DOI: 10.31038/NAMS.2022532

 

The advent of nanotechnology has boosted various sectors of human endeavors including food processing and packaging, the medical sector, and environment amongst others. It has improved the food industry significantly through enhanced food packaging, nutrient bioavailability and food preservation [1,2]. Nanomaterials generally are considered as those particles having particle dimensions lower than 100 nanometers at which their novel physicochemical properties make them significantly different from their bulk counterparts making them useful for various applications. Various investigations have been carried out and many more are in progress focusing on the potential usage of nanotechnology in the area of food packaging. Nanofood is a concept that is applied to food materials generated through the use of nanotechnology in production, processing, securing and packaging. Nanotechnology has outstanding potential in post-harvest processing of food [3,4]. The application of nanomaterials ensures food consistencies, which is attained through particle size modification, formation of desired clusters as well as the surface charges of the food nanoparticles. Furthermore, the emergence of nano-mediated delivery systems for nutraceuticals, and the synergistic actions of nanoparticles in food security as further aided the advancement of this area. More recently, there are numerous consumable nano-coatings that are used in fruits, cheese, meat, bakery foods and fast food. Nanofilters have been adopted for the removal of undesired colours from beetroot as well as lactose from milk to make nano-modified milk available for patients that are lactose intolerant [5]. The introduction of bio-active nanomaterials into polymeric matrices further enhances the efficiency of the packaging materials and makes provision for enhanced functional components and attributes such as scavenging, antimicrobial and antioxidant potentials. The formulation of various nanocrystalline particles has aided in the reduction of carbon dioxide inflow in beers. Oxygen carrier in alcohol production is enhanced through the use of clay nanomaterials. There foregoing shows that nanotechnology has remarkable superiority over the conventional approaches to food processing with an enhanced shelf life of the products, production of high quality food and prevention of contamination [6].

Presently, millions of dollars are spent at a global scale for food security and safety. The utilization of nanomaterials has the unique potential of improving food processing and packaging and also enhancing their taste and nutritional values. Nanotechnology can be utilized for the enhancement of food texture and flavor, reduction of the contents of fat, encapsulation of various nutrients, and prevent the degradation of vital nutrients and bioactive components during storage. The introduction of intelligent food packaging through the integration of nanosensors can further provide consumers with reliable details on the food present. The food packages are enclosed with nanomaterials thereby giving an immediate alert to the consumers on the safety levels of the food [7].

Despite of the recent advances in this direction, most of such applications are at present in their elementary stage, with most aimed at products of high value. Also, the evaluation of nanofood safety has not been fully established. It is paramount for various regulatory agencies to set pragmatic standards to be followed in the evaluation of food safety, packaging as well as the supplementary usage of nanomaterials [8]. There are limited studies on the exploration of naturally occurring nanostructures and their potential benefits in food processing. It is therefore not easy to conclude in the overall merits and demerits of nanotechnology in this regard. Currently, nano-modified foods are not usually labeled making it difficult for potential consumers to identify which is modified or not and make the decision to consume such food products. It is vital for standard testing of such nano-modified food prior to their discharge into the market. There is therefore pressing need for novel and reliable approaches to studying the effects of nanomaterials on human cells with the intent of assessing their inherent hazardous impacts. It is envisaged that nano-modified food products will be increasingly available to consumers at a global scale [9].

More recently, there are numerous emerging concerns in the application of nanomaterials in the food industry.  One of the major areas of interest to researchers is their toxicological and environmental impacts. Although the nanomaterials present in the surfaces of food do not pose harm directly from some available studies, however their transportation and integration in the food can affect human health adversely. The toxicological concerns associated with these nanomaterials are primarily due to their non-dissolvable nature, non-biodegradability and persistency in living cells and the environment [10]. Their poor consumer awareness, government policies, and methods of detection for risk assessments of nanomaterials deter detailed understanding of toxicity inherent with the utilization of nanotechnology. The toxicity associated with a nanomaterial has been reported to increase with a decrease in the sizes of the nanoparticle. Due to the high reactivity of nanoparticles they readily passed through the membrane bringing about various toxicodynamic and toxicokinetics effects. There is a need for extensive studies in this regard. Although there are wide applications of nanomaterials only a highly limited study exists on the in vivo toxicological effects using nanoparticles in mammalian models [11,12].

Nanomaterials are currently being applied in various parts of the world, although there are few countries in the world with reliable regulatory policies and standards for the use of nanotechnology in the food sector. There is a dearth in the scientific exploration of the various nanosystems thereby creating challenges in reaching a good conclusion about their efficacy. There is a paramount need for efficient labeling of packaged nanofood so that consumers can make their choice. The utilization of nanotechnologies if effectively managed and regulated would play a remarkable role in the improvement of food processing technology for the well-being of humans.

References

  1. Inobeme A, Adetunji CO, Ajai AI (2022) Future perspectives in nanomaterials for environmental and medical applications. Int J Nanomater Nanotechnol Nanomed 8: 005-006.
  2. Assey G, Malasi W (2021) Advances in Nanomaterials Sciences and Nanotechnology for Sustainable Development: A Review Tanzania Journal of Science 47: 1450-1463
  3. Noah N (2020) Design and Synthesis of Nanostructured Materials for Sensor Applications, Journal of Nanomaterials.
  4. Adetunji CO, Ogundolie FA, Olaniyan OT, Mathew JT (2022) Nanobiomaterials for Food Packaging Sensor Applications.
  5. Sharma C, Dhiman Rokana R, Panwar H (2017) Nanotechnology: An Untapped Resource for Food Packaging. Front. Microbiol Sec. Food Microbiology.
  6. Peidaei Ahari H. Anvar S, Maryam Ataee (2021) Nanotechnology in Food Packaging and Storage: A Review 2: 123-153.
  7. Sharma P, Pandey V, Sharma M, Patra A, Husen A (2021) A Review on Biosensors and Nanosensors Application in Agroecosystems. Nanoscale Res Lett. 16: 136. [crossref]
  8. Peidaei M, Panigrahi C, Vishwakarma S, Kumar J (2022) A Review on Nanotechnology: Applications in Food Industry, Future Opportunities, Challenges and Potential Risks. J Nanotechnol Nanomaterials. 3: 28-33.
  9. Tirado-Kulieva V, Sánchez-Chero M, Jimenez D. Sánchez-Chero J. Garcia L.(2022) A Critical Review on the Integration of Metal Nanoparticles in Biopolymers: An Alternative for Active and Sustainable Food Packaging.
  10. Inobeme A, Mathew JT, Adetunji CO (2023) Recent advances in nanotechnology for remediation of heavy metals. Environ Monit Assess 195: 111.
  11. Subhan M, Choudhury K, Neogi N (2021) Advances with Molecular Nanomaterials in Industrial Manufacturing Applications. Nanomanufacturing 1: 75-97.
  12. Adetunji CO, Ogundolie FA, Olaniyan OT, Mathew (2022) Bio-and Nano-sensing Technologies for Food, Royal Society of Chemistry. Nanobiomaterials for Food Packaging Sensor Applications. 167-180.