Monthly Archives: April 2023

What Became of Horse Y?

DOI: 10.31038/GEMS.2023521

 

“For the accommodation of myself and my wife, the missionary of the American Baptist Mission, Mr. Priest, had kindly provided two horses of pure African breed. Mine was so small that my feet nearly touched the ground and it was with great difficulty, when I went down a steep place that I could keep from falling over his head on to mine. But this equine pigmy carried me seven miles with so much ease that at times he was even unruly. His strength and endurance were truly wonderful”.

What Happened To The Yoruba Horse? This is a veritable equestrian whodunit! [1]

This is a very interesting question. Yorubas had tamed the horse for centuries, nay millennia. Mounted terracotta Nok figures dating to 2,000 years ago have been unearthed.[2] At the 1886 peace treaty British officials recorded the presence of many horses and their “colourful trappings” [3]. So what happened to the Yoruba horse? Here the British government is to blame again. We have to understand that when Britain took Yorubaland in 1886, the motor car was in its infancy. Horse riding was the prerogative of the white upper class British and a symbol of colonialism. The British did not like the idea of black, colonized people cavorting on horses. Before British colonization there were two species of horses in Yorubaland. The homegrown Yoruba horse and the Arabian horse. The majority of Yorubas rode the homegrown Yoruba horse which was short compared to the Arabian horse which was taller [4]. The Yoruba elite [Yoruba kings, chiefs and military commanders] rode the Arabian type. Kurunmi of Ijaye and Ogunmola of Ibadan are recorded to have ridden Arabian horses. The Yoruba middle class rode the shorter Yoruba horse. The American Baptist missionary William H Clarke compared this horse breed to the American mustang which is a short horse. This horse was so short that when the six feet tall American missionary Richard Henry Stone rode one, he reported that his legs were nearly touching the ground! It is safe to say that this species of horse does not exist again today. At least not in its pristine form. A few years ago I took riding lessons at the Ibadan Polo club. I dropped out after a few weeks because I could no longer afford it. While I was there all the horses I saw at their stables were the tall Arabian types. Although I saw some I suspected were hybrids.

BADA

Before colonization, mounted Yoruba soldiers were called “Bada” [knights]. The British did not like the idea of Yoruba knights or Yoruba cavalry of any kind. I suspect that the same way the British collected Snider rifles, rockets and The Gatling gun from Ogedengbe and his soldiers in 1895 is the same way the British rounded up and shot all The Yoruba horses. I can’t put it past them. The British told The Yorubas they would now ride the railway. This was at best a half-truth because the railway was mostly used to transport raw materials. Only Yoruba kings were allowed to keep their [Arabian] horses. It will be a task for a future historian to investigate what exactly the British did to the Yoruba horse. SHAME ON BRITAIN! In the 1852 dictionary of the Yoruba language compiled by Bishop (then still Reverend) Ajayi Crowther “Bada” is defined as “a title” [page 51]. All references to the horse and militarism has been erased. This was just a year after Britain took Lagos. The British did not want Yorubas having any “funny” ideas. In the 1913 Dictionary of Yoruba printed by the Church Missionary Society the word “bada” is not featured at all. The British wanted Yorubas to forget about the horse.

References

  1. Richard Henry Stone, Page 19, In Afric’s Forest and Jungle or six years among The Yoruba, Fleming H. Revell Company, 1899, The Caxton Press, New York.
  2. Seun Ayoade (2019) The Nok Smoking Gun. Peer Re J Foren & Gen Sci 3 PRJFGS.MS.ID.000159.
  3. Mister Seun Ayoade (2021) A Tale of Two Empires: A Forensic Analysis of How and Why the Ethiopians Escaped Colonization but the Yorubas Did Not. Anthropol Ethnol Open Acc J 4.
  4. ©Seun Ayoade (2023) Page iv, How Britain Brought Poverty To The Yorubas 1886-1951, ISBN 978-978-58691-6-3, The 199 Palace.

Bone Graft Materials and Substitutes

DOI: 10.31038/IJOT.2023612

Abstract

There have been great advances in the bone-grafting field. Grafts to enhance porosity, mechanical strength, and compatibility are currently being created and studied. As has been stated in previous literature, porosity of a bone-grafting scaffold is essential for the infiltration of cells and nutrients; which will enhance the compatibility. Currently, most researchers are looking at the introduction of various calcium phosphates to scaffolds and the use of bioactive glass to enhance the mechanical integrity of the graft. Reviews on such bone grafts are described in this article (Figure 1).

fig 1

Figure 1: Classification of bone graft and substitute materials used in dentistry, broadly classified into five categories and showing their associated sub-categories [30].

Bone grafting is a surgical procedure that rebuilds bone by transplanting bone tissue. A dental bone graft is often required, if a patient has lost one or more adult teeth or has developed gum diseases as both problems can cause bone loss. After tooth loss, bone resorption is irreversible, leaving the area without adequate bone volume for successful dental procedures. Bone grafting is the only solution to reverse dental bone loss and is a well-accepted procedure. Bone grafts are used as pillar and scaffold over which regeneration and healing takes place. A dental graft adds volume and density to the jaw in areas where bone loss has occurred. Bone Grafting techniques have been used by specialists for more than 100 years. Many factors are involved in the successful incorporation of a graft material, including graft type, preparation site, vascularity, mechanical strength and pore size of the materials. These parameters make the use of bone substitutes challenging in terms of reliability and Predictability.1 Bone grafts are generally evaluated based on their osteogenic, osteoinductive or osteoconductive potential. Materials to be grafted can be obtained from the same person (autograft), from a different person of the same species (allografts), or from a different species (xenografts) (Table 1).

Table 1: Some of the common advantages and disadvantages associated with autograft [29]

tab 1

History

The use of bone grafts for reconstructing intra-osseous defects produced by periodontal disease dates back to Hegedus in 1923. It was then revived in 1965 by Nabers and O’Leary.Buebe and Silvers used boiled cow bone powder to successfully repair intra-bony defects in humans. Force berg used Ox purum in 11 human intra-bony defects. Melcher and Dent used an organic bone in bovine bone in bone defects, which showed sequestration and slow resorption militated against the use of organic bone. Scopp used Boplant bovine bone and reported pocket depth reduction at 6 months. Now, with the introduction of advanced bone grafting techniques, it is possible to increase the volume, width, and height of bone in deficient areas [1-5].

The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis [6].

Osteogenesis

Osteogenesis is the ability of the graft to produce new bone and this process is dependent on the presence of live bone cells in the graft i.e. It occurs when vital osteoblast, originating from bone graft material, contributes to the new Growth of new bone along with bone formation. Osteogenic graft material contain viable cells with the ability to form bone (osteoprogenitor cells) or the potential to differentiate into bone forming cells including Osteogenic precursor cells. Osteogenesis is a property found only in fresh autologous bone and in bone marrow cells.

Osteoconduction

It is a physical property of a bone graft material to serve as a scaffold for viable bone healing and new bone growth, which is perpetuated by the native bone. It allows for the growth of neovasculature and infiltration of osteogenic precursor cells into the graft site.Osteoconductive properties are found in cancellous bone autograft and allograft demineralized bone matrix, hydroxyapatite, collagen and calcium phosphate. Osteoblast forms the margin of defect that is being grafted, Utilizing the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.

Osteoinduction

Osteoinduction is the ability of graft material to induce stem cells to differentiate into mature bone cells.The process is typically associated with presence of bone growth factors within the graft material or a supplement to bone graft.It Involves stimulation of osteoprogenitor cells to differentiate into osteoblast and then begin formation of new bone. The most widely studied type of osteoinductive cell mediator is BMP.4 A bone graft material that is osteoconductive and Osteoinductive will not only serve as a scaffold for currently existing osteoblasts, but will also trigger formation of new osteoblasts promoting faster integration of the graft.

Osteo Promotion

It involves Enhancement of osteoinduction without possession of osteoinductive properties.For example, enamel matrix derivative enhances the osteoinductive effect of the demineralized freeze dried bone allograft (DFDBA) but will not stimulate bone graft alone (Figure 2).

fig 2

Figure 2: Schematic representation shows the process of bone graft substitutes [29]

Classification of Bone Graft [7]

Based on the type of graft used:

  • Particulate
  • Putty
  • Block.

These are available as large or small particles, a combination of porosities, and from specific locations of origin (e.g. cortical, cancellous).

Based on the source (Table 2):

  • Autograft
  • Allograft
  • Xenograft
  • Alloplast

Table 2: Common advantages and disadvantages associated with an allograft [29]

tab 2

Based on Bone Graft Substitutes (Laurencin):

  • Allograft based
  • Factor based
  • Cell based
  • Ceramic based
  • Polymer based.

Allograft based:

  • Allograft bone used alone or in combination
  • For example: allegro, orthoblast, graft-on
  • Action: osteoconductive, osteoinductive

Factor based:

  • Natural and recombinant growth factor used alone or in combination
  • For example: Transforming growth factor-beta, platelet-derived growth factor, fibroblast growth factor, BMP
  • Action: Osteoinductive, osteoinductive, and osteoconductive with carrier materials.

Cell based:

  • Cells used to generate new tissue alone or seeded onto a support matrix • For example: Mesenchymal stem cells
  • Action: osteogenic, both osteogenic and osteoconductive with carrier materials.

Ceramic based:

  • Includes calcium phosphates, calcium sulfate, and bioactive glass used alone or in combination
  • For example: Osteograft, osteoset, Novabone • Action: Osteoconductive, limited osteoinductive when mixed bone marrow.

Polymer based:

  • Includes degradable and nondegradable polymers used
  • For example: Cortoss, OPLA, Immix
  • Action: Osteoconductive, bioresorbable in the degradable polymer (Table 3).

Table 3: Bone graft and bone graft substitutes

tab 3

Indications of Bone Grafts

  1. Deep intraosseous defects-two-walled and three-walled defects
  2. Tooth retention
  3. Support for critical teeth-abutment tooth
  4. Bone defects associated with juvenile periodontitis
  5. Esthetics (shallow intraosseous defects)
  6. Furcation defects-Grade II, III furcation
  7. Ridge augmentation
  8. Sinus lifting procedure
  9. Regeneration around implants
  10. Filling donor site bone defects (Figure 3) [8].

fig 3

Figure 3: Use of structural scaffolds to restore bony defects. Diagram shows placement of a bone graft scaffold within a bony defect in alveolar bone following surgical generation of an access flap.

Ideal Requisites of Bone Grafts

  • Osteoinductive property
  • Non-toxic
  • Resistant to infection
  • No root resorption or ankylosis
  • Non-antigenic and biologic compatibility
  • Easily adaptable and available
  • Predictability
  • Strong and resilient
  • Require minimal surgical intervention
  • Rapid vascularization
  • Should stimulate new attachment and be able to trigger osteogenesis [9].

Bone Morphogenic Protein (BMP)

BMP’s are members of the family of transforming growth factors. 15 different bmp’s have been identified all having different degrees of cellular activity, including cartilage or bone inducing properties. Two recombinant proteins are available at present- recombinant human bone morphogenic protein (rhBMP-2) and (rhBMP-7). Two rhBMP associated carrier systems have received approval from the US Food and Drug Administration. 1) Osteogenic protein-1 (OP-1) consists of rhBMP-7 and bovine collagen (Stryker Biotech Hopkinton, Massachussetts) 2) InFuse System (Medtronic Sofamor Danek Warsaw, Indiana) consists of rhBMP-2 on an absorbable bovine type I collagen sponge carrier. BMP product is packaged as a lyophilized powder in a sterile vial which can be reconstituted with sterile water and applied to the carrier (Table 4) [10].

Table 4: Bone graft Substitutes [31]

tab 4

Platelet Rich Plasma (PRP)

PRP is a source of platelet derived growth factor (PGDF) and transforming growth factor beta (TGF-b) that is obtained by sequestering and concentrating platelets by a process of gradient density centrifugation [11].

Platelet Derived Growth Factor (PDGF)

PDGF, a glycoprotein has a molecular weight of approximately 30kd. It was first described in the alpha granules of platelets, but can also be synthesized and secreted by cells like macrophages and endothelium. There are approximately 0.06ng of PDGF per one million platelets, a fact that emphasizes this molecule’s great potency. Its mechanism is to activate cell membrane receptors on target cells, which results in the development of high-energy phosphate bonds on internal cytoplasmic signal proteins which then activate the signal proteins which initiate a specific activity within the target cell. The most specific activities of PDGF are mitogenesis, angiogenesis and macrophage activation [12,13].

TGF-b

The term transforming growth factor beta is applicable to the superfamily of growth and differentiating factors. Bone morphogenic protein (BMP) is a member of this family and contains at least 13 BMPs. TGF-b1 and TGF-b2 are proteins that have molecular weight of approximately 25kd [14]. Like PDGF, they are synthesized and found in macrophages as well as in other cell types. When released by platelet degranulation or actively secreted by macrophages, they act as paracrine growth factors and affect cells such as fibroblasts, marrow stem cells and preosteoblasts. Each of these target cells has the ability to synthesize and secrete its own TGF-b proteins. TGF-b therefore represents a mechanism for sustaining a long term healing process and even develops into a bone remodeling factor. The most important functions are chemotaxis and mitogenesis of osteoblast precursors. They also have the ability to stimulate osteoblast deposition of the collagen matrix of wound healing and bone. In addition TGF-b inhibits osteoclast formation thus favoring bone formation over resorption [15].

Biocompatible Bone Graft Material

Erbe developed a biocompatible bone graft material with a biocompatible, resorbable polymer and a biocompatible, resorbable inorganic material exhibiting macro, meso, and microporosites. This invention incorporates the benefits of inorganic shaped bodies having a macro, meso, and microporosity and polymers such as collagen. Different stoichiometric compositions of calcium phosphate such as hydroxyapatite (HaAP), tricalcium phosphate (TCP), tretacalcium phosphate (TTCP), and other calcium phosphate salts and minerals, have all been employed to match the biocompatibility, structure, and strength of natural bone. The role of pore size and porosity in promoting revascularization, healing, and remodeling of bone has been recognized as a critical property for bone grafting materials. To enhance porosity, this invention includes an oxidation- reduction product of at least one metal cation, at least one oxidizing agent, and at least one oxidization precursor anion. The reaction-product may be inorganic compositions comprising calcium phosphate, biphasic calcium phosphate, or beta tri-calcium phosphate (􀀁-TCP). The oxidationreduction product gives the present invention graft material macro, meso, and microporosity, which allow the graft material to have extraordinary absorption properties. The inclusion of a polymer, such as the structural protein collagen, lends to improved handling and flexibility. The porosity and large pore distribution (1 μm-1000μm) of these bone grafts increases their ability to imbibe fluids such as bone marrow aspirate, blood, or saline and cell loaded solutions (e.g. fibroblasts, mesenchymal, stromal, marrow and stem cells) for use in vivo. Applications of this property include the ability to incorporate growth factors such as BMP into the graft to enhance healing. The flexibility of the bone graft allows the graft to be shaped into any basic shape, including cylinder, blocks, strips, sheets, and wedges. This graft may also serve as a coating on any orthopaedic appliance. Further, unlike traditional bone graft substitutes, this invention is highly compressible and therefore can be packed to insure maximum contact with adjacent bone for beneficial healing of a bony defect [16-18].

Porous Ceramic Composite Bone Grafts

This porous ceramic composite developed by Smith incorporates biodegradable polymers (polycaprolactone) for use as a bone substitute in the field of orthopedics and dentistry or as a scaffold for tissue engineering applications. The biodegradable polymer allows for the passage and/or delivery of a variety of agents throughout the porous ceramic matrix and improves mechanical properties of the implant in vivo. A disadvantage of current commercially available bone grafts is their poor mechanical properties, which limits the use of these implants to non-load bearing applications. Therefore, the main focus of this particular bone graft is to enhance the mechanical properties through the use of a porous ceramic composite without the risk of articulating debris. The bone graft is a porous bone substitute that can limit fragmentation, and migration of debris during standard orthopedic fixation practice [19,20].

The graft, composed of a porous osteoinductive ceramic matrix and a biodegradable polymer, possesses optimum pore size, pore size distribution, porosity, and pore connectivity to promote the rapid in-growth of bone tissue upon implantation. In comparison to prior ceramic bone grafts, this graft has advantageous mechanical properties as a result of repeatedly coating the organic substrate with a mixture of thickening agents (slurries) varying in solid loading. The coated structure is heated to burn away the flexible organic foam and then sintered, thereby providing a fused, ceramic foam having many interconnected voids. When used as a biodegradable polymer coating, it helps to improve functional (mechanical) properties of the implant in vivo. In summary, the porous ceramic graft presented by Smith has numerous advantages and uses in the field of orthopedics and dentistry both in vitro and in vivo. As an implant, the graft can be used in both non-load bearing and load bearing applications [21,22].

Bioactive Bone Graft Substitute – Collagen Enhancement

Clineff proposed a biocompatible bone graft composed of resorbable calcium phosphate, resorbable collagen, and bioactive glass. The invention is a composite of biocompatible, resorbable, substantially homogeneous blend of calcium phosphate having maco-, meso-, and microporosity. The graft replicates the natural osteoactivity of native bone by the addition of a bioactive glass. Bioactive glasses explored in the invention include glass-ceramics, crystalline phase materials, and a combination of acrylic polymerizable species. The purpose of the bioactive glass is to react as it comes in contact with physiologic fluids including, but not limited to, blood and serum. The reaction of the bioactive glass and the surrounding fluid will lead to bone formation by forming an apatite layer on the surface of the graft. The bioactive glass can have a glass ceramic composition comprised of heterogeneous particles with an irregular morphology and regions of crystallinity. Similar to other biocompatible synthetics bone grafts, collagen is included to enhance the ability of the graft to be shaped or cut using various instruments such as scalpel and scissors. Some basic shapes may be a disk, semi-sphere, semi-tube, or torus. Collagen and bioactive glass is combined with calcium phosphate by blending the mixture to form a homogeneous mixture and a composite matrix of various shapes and sizes [23,24].

The proposed graft materials may act as both a barrier to prevent migration of other implants or graft materials and serve as an osteoconductive resorbable bone graft capable of promoting bone formation. The bone graft will reabsorb following delivery to the surgical site. The inclusion of a bioactive glass as an osteoinductive component is believed to be novel bone technology application [25].

Growth Factor Encapsulation System for Enhancing Bone Formation

Lu developed a bone technology, which enhances bone formation by releasing various growth factors and/or platelet-rich plasma (PRP) from a solid material. PRP is known to contain a number of autologous thombocyte growth factors that may aid in the acceleration of bone regeneration. These growth factors include platelet-derived growth factor (PDGF) and transforming growth factors (TGF-1); both are produced by platelets and released during granulation. PDGF stimulates mitogenesis of osteoblastic precursors while TGF-1 stimulates proliferation and collagen synthesis by osteoblasts and osteoblast precursors. PRP gel has most recently been used as an adhesive with cancellous bone particles in oral and maxillofacial surgery bone grafting procedures. The invention is comprised of a capsule of protein-permeable material having growth factor therein, releasable calcium alginate porous beads with encapsulated growth factors, a PRP gel, and a bone regeneration facilitating material [26].

The bone regeneration facilitating material is a solid material or scaffold, which serves as facilitator for the formation of new bone by bone-forming cells. Such materials include collagen, BioOss (calcium phosphate-based bone graft substitute), Pepgen P-15 (synthetic P-15 peptide bound to natural form of hydroxylapatite) and AlloGraft (demineralized bone matrix, allograft-based bone graft substitute). The bone graft is designed so that the contained growth factors can be released and delivered to a desired location site when implanted. The alginate porous beads having autologous PRP contained therein allows the growth factors to be released from the PRP and then released from the bead for delivery to the defect location. The controlled release of this invention is crucial to the enhancement of bone regeneration because the growth factors can be released at varying stages throughout the natural healing process. Chitosan beads are also explored and mentioned in this patent as a possible containment for growth factors/PRP. This novel hydrogel delivery system permits prolonged and modulated release of growth factors relevant to bone regeneration [27].

Polymeric Bone Defect Filler

Deslauriers propose bone defect filler for implantation in a bone defect of patients. The bone filler includes a particulate polymer distributed within a polymeric binder. The particulate polymer includes a plurality of particles, which may have the same materials as the polymeric binder. The particles within the particulate polymer may take on a variety of shapes and/or sizes to provide the bone defect filler with improved pore interconnectivity, materials expansion, and contamination characteristics. The proposed bone defect filler also maintains sufficient mechanical strength and handling characteristics for bone repair applications. The presented polymeric bone defect filler is advantageous to current synthetic nondegradable bone defect fillers that maintain their chemical and mechanical properties, such as titanium. Synthetic bone fillers may have poor tensile and shear properties. They also have poor adhesion properties and therefore can be washed out of the defect area before the in growth of new bone. Conventional bone grafting technologies such as the use of PMMA, are problematic because, as permanent bone fillers, they are not resorbable and/or cannot be molded and shaped for in situ curing. A similar bone technology to the proposed innovation is the use of particulate polymer mixed with biological fluids, but the particulate polymer and fluid mixtures tend to adhere poorly to the surround bone and also exhibit low initial structural properties, e.g. tensile and compressive, after implantation [28].

DBM possesses most of the biological properties of native bone that are important for successful bone grafting. The present bone morphogenic proteins in DBM signal stem cells to differentiate into osteoprogenitor cells to product new bone; making DBM osteoinductive. DBM is also osteoconductive in that it supports neovascularization and invasion of osteoblasts. The DBM can be made from the same species as the recipients or from a different species, with similar genetic alterations as the ATM [29]. The inventors of this bone technology are able to create ATM and DBM in multiple forms including fibers, particles, or threads. The final product or bone graft can be composed of any combinations of forms of ATM and any form of DBM (e.g. fibers of ATM and particles of DBM) and freeze dried for prolonged storage (Table 5).

This particular bone graft, held in place by sutures, can be wrapped around a bone that is damaged or that contains a defect, placed on a surface of a bone that is damaged or defected, or placed at a non-bony site to induce bone formation [30,31].

Table 5: The types of DBM bone graft substitute which is commercially available [29]

tab 5

Conclusion

Bone graft and substitute materials which are either in the form of particulate or blocks are mostly used in dentistry to regenerate the missing hard tissue structures. There is a high and growing demand for new and more efficient dental grafting materials. Current bone graft and substitute materials primarily serve as a structural framework for osteo-regenerative processes that only satisfy the osteoconductivity criteria. r understanding of these materials and the growth factors at the molecular level is growing, which allows us to better control and modify their structure, understand their surface properties, and tune the interaction with other materials or physiological environment. This progress will eventually allow us to design and develop more effective dental bone substitutes. Despite the progress highlighted in this review article more work is needed to develop dental biomaterials that have a porous structure, mechanically stability, controlled degradation, and remodeling ability which is comparable with the rate of new bone formation.

References

  1. Fetner AE, Low SB, Wilson J, Hench LL (1987) Conducted a study to evaluate the particulate form of bioglass periodontal defects.
  2. Hegedus Z (1923) The rebuilding of the alveolar process by bone transplantation. Dent Cosmos 65: 736.
  3. Nabers CL, O’leary TJ (1965) Autogenous bone transplants in the treatment of osseous defects. J Periodontol 36: 5-14. [crossref]
  4. Melcher AH, Dent HD (1962) The use of heterogenous anorganic bone as an implant material in oral procedures. Oral Surg Oral Med Oral Pathol 15: 996-1000.
  5. Scopp IW, Morgan FH, Dooner JJ, Fredrics HJ, Heyman RA (1966) Bovine bone (boplant) implants for infrabony oral lesions. Periodontics 4: 169-176.
  6. Baldwin P, Li DJ, Austin DA, Mir HS, Yoon RS, et al. (2019) Autograft allograft bone graft substitutes. Clinical evidence and indication for use in the setting of orthopedic traumatic surgery. J Orthop Trauma. [crossref]
  7. Mellonig JT (1992) Autogenous and allogeneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med 3: 333-352.
  8. Borghetti A, Novakovitch G, Louise F, Simeone D, Fourel J (1993) Cryopreserved cancellous bone allograft in periodontal intraosseous defects. J Periodontol 64: 128-32. [crossref]
  9. Jangid MR, Rakhewar PS, Nayyar AS, Cholepatil A, Chhabra P (2016) Bone Grafts and bone graft substitutes in periodontal regeneration: A review. Int J Curr Res Med Sci 2: 1-7. [crossref]
  10. Piattelli M, Favero GA, Scarano A, Orsini G, Piattelli A (1999) Bone reactions to anorganic bovine bone (Bio-oss) used in sinus augmentation procedures: A histologic long-term report of 20 cases in humans. Int J Oral Maxillofac Implants 14: 835-40. [crosssref]
  11. Mahesh J, Mahesh R, John J (2012) Predictability of bone regeneration in periodontal surgery – A review. IOSR J Dent Med Sci 2: 46-50.
  12. Ashman A (1992) The use of synthetic bone materials in dentistry. Compendium 13: 1020.
  13. Gross JS (1997) Bone grafting materials for dental applications: A practical guide. Compend Contin Educ Dent 18: 1013-8, 1020-2. [crossref]
  14. Yagihashi K, Miyazawa K, Togari K, Goto S (2009) Demineralized dentin matrix acts as a scaffold for repair of articular cartilage defects. Calcif Tissue Int 84: 210-20. [crossref]
  15. Ritchie HH, Ritchie DG, Wang LH (1998) Six decades of dentinogenesis research. Historical and prospective views on phosphophoryn and dentin sialoprotein. Eur J Oral Sci 106: 211-20.
  16. Oonishi H, Kushitani S, Yasukawa E (1997) Particulate bioglass compared with hydroxyapatite as a bone graft substitute. Clin Orthop Relat Res 334: 316-25. [crossref]
  17. Ten Huisen KS, Brown PW (1998) Formation of calcium-deficient hydroxyapatite from alpha tricalcium phosphate. Biomaterials 19: 2209-17. [crossref]
  18. Eppley BL, Pietrzak WS, Blanton MW (2995) Allograft and alloplastic bone substitutes: A review of science and technology for the craniomaxillofacial surgeon. J Craniofac Surg 16: 981-989. [crossref]
  19. Harris RJ (2004) Clinical evaluation of a composite bone graft with a calcium sulfate barrier. J Periodontol 75: 685-692. [crossref]
  20. Hench LL (2006) The story of bioglass. J Mater Sci Mater Med 17: 967-978. [crossref]
  21. Stavropoulos A, Geenen C, Nyengaard JR, Karring T, Sculean A (2007) Oily calcium hydroxide suspension (Osteoinductal) used as an adjunct to guided bone regeneration: An experimental study in rats. Clin Oral Implants Res 18: 761-767.
  22. Giannoudis PV, Dinopoulos H, Tsiridis E (2005) Bone substitutes: An update. Injury 36: S20-7.
  23. Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA (2008) Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J Oral Maxillofac Surg 66: 235-45.
  24. Soga lA, Tofe AJ (1999) Risk assessment of bovine spongiform encephalopathy transmission through bone graft material derived from bovine bone used for dental applications. J Periodontol 70: 1053-63. [crossref]
  25. Brunel G, Brocard D, Duffort JF, Jacquet E, Justumus P, et al. (2001) Bioabsorbable materials for guided bone regeneration priorto implant placement and 7-year follow-up: report of 14 cases. J Periodontal. 72: 257-64. [crossref]
  26. Pieri F, Corinaldesi G, Fini M, Aldini NN, Giardino R, et al. (2008) Alveolar ridge augmentation with titanium mesh and a combination of autogenous bone and anorganic bovine bone: A 2-year prospective study. J Periodontol 79: 2093-103. [crossref]
  27. Trombelli L, Farina R, Marzola A, Itro A, Calura G (2008) GBR and autogenous cortical bone particulate by bone scraper for alveolar ridge augmentation: A 2-case report. Int J Oral Maxillofac Implants 23: 111-6. [crossref]
  28. Blanco J, Alonso A, Sanz M (2005) Long-term results and survival rate of implants treated with guided bone regeneration: A 5-year case series prospective study. Clin Oral Implants Res 16: 294-301. [crossref]
  29. Application of Bone Substitutes and Its Future Prospective in Regenerative MedicineUjjwal Ranjan Dahiya, Sarita Mishra and Subia BanoSubmitted: August 29th, 2018 Reviewed: February 11th, 2019.
  30. Rusin Z, Ruijia Y, Paul R, Cooper, Zohaib K, et al. (2021) Bone Grafts and Substitutes in Dentistry: A Review of Current Trends and Developments. Molecules 26: 3007. [crossref]
  31. Donimukkala BR, Chandrasekharan N, Meghana G (2018) Bone Substitutes used in Implant Dentistry.

Clinical Presentations of Acute Leukemia in Children’s Cancer Units at Al-Kuwait Hospital, Sana’a City: A Cross-Sectional Study

DOI: 10.31038/JCRM.2023613

Abstract

Background and aims: Leukemia is a heterogeneous group of blood disorders consisting of several diverse and biologically distinct subgroups. Leukemia is the eleventh and tenth most common cause of cancer morbidity and mortality worldwide, respectively. There are insufficient data on clinical symptoms of acute leukemia in Yemen, particularly in the study area. Therefore, this cross-sectional study aimed to determine the clinical form of acute leukemia among children with leukemia in pediatric cancer units of Kuwait Hospital, Sana’a City.

Patients and method: A cross-sectional study was conducted on children with leukemia who were selectively treated in pediatric leukemia units at Kuwait Hospital in Sana’a. The mass diagnosis and histopathological prognosis in line with the French, American and British classifications of pediatric leukemia were formed in pediatric leukemia units, over a period of 7 years from 1 January 2015 to 31 December 2021. Factors associated with leukemia such as age, sex, clinical symptoms and outcome were studied.

Results: The mean ± SD age of all cases was 7.96 ± 3.93 years. Most of the cases were in the age group 6-10 years (67.8%), followed by the age group 11-15 years (25.1%). As for gender, slightly more of the cases were males (53.3%), VS 46.7% in females (ratio=1.14-1). The cure rate was 40.56% while the death rate was 20 cases (6.19%). The relapse rate was 2.2%. The rest of the cases were in maintenance therapy (31.6%), induction therapy (15.2%), and consolidation (post-remission therapy) for 4.33% of cases. Most cases were ALL (83.3%) while AML was only 16.7%. The most common symptom was fever (78.3%), followed by pallor (34.4%), bleeding disorders (31.9%), and abdominal pain/distention (26.9%). Hepatomegaly was recorded in 5.6%, splenomegaly in 12.1%, lymphadenopathy in 10.8%, and 18.6% of the total patients had enlargement of all three organs.

Conclusion: ALL is the most common type of leukemia. The male-to-female ratio is roughly equal, and young children between the ages of 6-10 are most affected by leukemia. More comprehensive investigations of relevant factors and predictors using more recent diagnostic methods and investigation of association factors with valuation of the treatment protocols currently in use are needed.

Keywords

Childhood leukemia, Clinical presentation, Acute leukemia, Children, Sana’a City, Yemen

Introduction

Acute leukemia (ALs) are one of the most common types of cancer with approximately 20,000 cancers diagnosed and more than 10,000 deaths annually in the United States [1]. Acute leukemia represents tumors of hematopoietic cell precursors that manifest as clonal expansion of myeloid and lymphoid hematopoiesis [2]. Acute leukemia can be broadly categorized into acute lymphocytic leukemia and acute myeloid leukemia depending on the type of cell line affected. Hematopoietic tissue in the bone marrow is characterized by an overproduction of immature lymphocytes (a type of white blood cell). Acute lymphoblastic leukemia (ALL) occurs at all ages, from birth to puberty, but the incidence peaks between 2 and 6 years of age [3,4]. Acute Lymphocytic Leukemia (ALL) is clinically and morphologically heterogeneous.1 morphologically, it is classified according to FAB (French, American and British) criteria into L-1, L-2 and L-3 sub-types, which is clinically reproducible. Acute Myelogenous Leukemia (AML) refers to a group of hematological malignancies that arise within bone marrow precursors of myeloid, monocyte, erythroid and megakaryotic cell lineages. FAB classification system divides Acute Myelogenous Leukemia into M-0 to M-7 sub-types [5]. Improvements in treatment resulted in marked gains in survival, estimated at 79 percent at 5 years. The AML score was poorer than for ALL, with a 5-year survival rate of 41 percent [3,4]. The precise cause of leukemia is not up till now obvious. Nevertheless a lot of factors, mainly genetics, genetic mutations, epigenetic lesions, ionizing radiation, other chemical and occupational contacts, curative drugs, smoking and some viral agents, have been concerned in the development of leukemia [5-13]. In developing countries, the impact of leukemia is attributed to premature death of children, loss of parents, failure of productivity due to disability, and prohibitive medical costs affecting the social, economic and health well-being of the population [14-16]. While leukemia is treated very well in the developed world, there is little evidence for the current status of the disease in Yemen in general and in the study area in particular. On the other hand, in Yemen as in most Arab countries, there are few specialized epidemiological registries dedicated to this field, which is why it is important to encourage, update, build and continue to provide studies on pediatric leukemia. The goal is to have a greater impact on public health, with early diagnosis and appropriate treatment aimed at enhancing survival and minimizing potential consequences. According to the limited Yemeni cancer studies, the most common types of cancers among Yemeni children and adults are leukemia (33.1%), lymphoma (31.5%), central nervous system tumors (7.2%), and bone tumors (5.2%) [17-22], while there are new published reports indicating an increased interest in communicable and non-communicable diseases that are closely linked to war, poverty, and the collapse of health systems in Yemen [23-30]. But there is insufficient data on the clinical symptoms of acute leukemia in Yemen, especially in the study area, so this cross-sectional study aimed to determine the clinical form of acute leukemia among children.

Patients and Method

A cross-sectional study was conducted on children with leukemia who were selectively treated in pediatric leukemia units at Kuwait Hospital, Sana’a. The mass diagnosis and histopathological diagnosis was formed in line with the French, American and British classifications of pediatric leukemia, over a period of 7 years from 1 January 2015 to 31 December 2021. Incidence-related factors were studied including ages, sex, clinical symptoms and outcomes.

Statistical Analysis

By using EPI Info statistical program version 6 (CDC, Atlanta, USA) the analysis of data was performed. Expressing the quantitative data as mean values, standard deviation (SD), when the data was normally distributed. Expressing the qualitative data as percentages; Chi square test was used for comparison of two variables to determine the P value.

Ethical Approval

Ethical approval was obtained from the Medical Research & Ethics Committee of the Faculty of Medicine and Health Sciences, Sana’a University. All data, including patient identification were kept confidential.

Results

The mean ± SD age of all cases was 7.96 ± 3.93 years. Most of the cases were in the age group 6-10 years (67.8%), followed by the age group 11-15 years (25.1%), while only 7.1% of the cases were in the age group 1-5 years. As for gender, slightly more of the cases were males (53.3%), while the percentage of females was 46.7% (male to female ratio=1.14-1). Most of the patients were from rural areas counting 68.7% while only 31.3% were from urban areas (Table 1). The cure rate was 40.56% while the death rate was 20 cases (6.19%); the relapse rate was 2.2%. The rest of the cases were in maintenance therapy (31.6%), induction therapy (15.2%), and consolidation (post-remission therapy) for 4.33% of cases (Table 2). Table 3 shows the prevalence of leukemia type among children with childhood leukemia in Sana’a, Yemen, and most cases were ALL (83.3%) while AML was only 16.7%. Table 4 shows the prevalence of clinical symptoms at the first visit among 323 children suffering from childhood leukemia. The most common symptom was fever counting 78.3%, followed by pallor (34.4%), bleeding disorders (31.9%), and abdominal pain/distention (26.9%) while less than 20% occurring for weakness (12.7%) and weight loss (10.5%). Table 5 shows the results of the physical examination at the first visit. Hepatomegaly was recorded in 5.6%, splenomegaly in 12.1%, lymphadenopathy in 10.8%, and 18.6% of the total patients had enlargement of all three organs, while 9.6% had hepatosplenomegaly and 4.3% had lymphadenopathy + H or S as well as 39% of all patients had no hyperplasia in the 3 organs (Table 5).

Table 1: Age and gender distribution of children with childhood leukemia in Sana’a, Yemen

Sex

Total

No

%

Male 172 53.3
Female 151 46.7
Age groups
1-5 years 23 7.1
6-10 years 219 67.8
11-15 years 81 25.1
Total 323 100
Mean age 7.96 years
SD 3.93 years
Median 8 years
Mode 6 years
Min 1 year
Max 15 years
Residency
Urban 101 31.3
Rural 222 68.7

Table 2: Leukemia outcomes among children suffering from childhood leukemia in Sana’a, Yemen

Outcomes

Frequency

No

%

Induction therapy 49 15.2
Consolidation (post-remission therapy) 14 4.33
Maintenance therapy 102 31.6
Relapse 7 2.2
*Cure 131 40.56
Died 20 6.19
Total 323 100

*Cure = 5-year survival rate = percentage of children who live at least 5 years after a diagnosis of leukemia

Table 3: Age and gender wise distribution of various types of leukemia’s among children suffering from childhood leukemia in Sana’a, Yemen.

Characters

Diagnosis

ALL

AML

Total

No

%

No

%

No

%

Gender
Male 141 52.4 31 57.4 172 53.3
Female 128 47.6 23 42.6 151 46.7
Age groups
1-5 years 18 6.7 5 9.2 23 7.1
6-10 years 178 66.2 41 75.9 219 67.8
11-15 years 73 27.1 8 14.8 81 25.1
Total 269 83.3 54 16.7 323 100

Table 4: The prevalence of clinical symptoms at the first visit among 323 children suffering from childhood leukemia in Sana’a, Yemen.

Symptoms

Frequency

No

%

Fever 253 78.3
Pallor 111 34.4
Bleeding disorders 103 31.9
Generalized body aches 89 27.6
Abdominal pain / distention 87 26.9
Weakness 41 12.7
Weight loss 34 10.5

Table 5: Findings of physical examination at the first visit among 323 children suffering from childhood leukemia in Sana’a, Yemen.

Signs

Frequency

No

%

Hepatomegaly 18 5.6
Splenomegaly 39 12.1
Lymphadenopathy 35 10.8
All 3 enlarged 60 18.6
Hepatosplenomegaly 31 9.6
Lymphadenopathy + H or S 14 4.3
No enlargement 126 39
Total 323 100
Total hepatomegaly 116 35.9
Total splenomegaly 137 42.4
Total lymphadenopathy 109 33.7

Discussion

Information about the prevalence of leukemia in the population may provide pathogenic hypotheses for disease control and assist in the effective management of leukemia and other hematological malignancies. In developing countries, especially in Yemen, there is little information about the burden and patterns of hematological malignancies, especially leukemia. In the current study, in relation to gender, the number of cases was slightly more male (53.3%), while the percentage of female was 46.7% (male to female ratio=1.14-1). This result is similar to that reported in Africa where the male-to-female ratio is approximately equal, although slightly dominated by females (1:1.06) [31], but differs from that reported in the United States where the Cancer Society estimates American Leukemia in 2021, about 5690 new cases, 3000 in males and 2690 in females [32] and of those previously reported from Yemen where most cases were males (66.7%) while females were 33.3% (male to female ratio=2: 1) [33]. The present findings of different gender-specific leukemia prevalence rates contradict the facts that leukemia prevalence should vary by sex due to biological factors [13,34-36].

Leukemia may appear at all ages, from newborns to the elderly, but the distinctive forms have different age distributions [37]. In the current study, the mean age of ± SD for all cases was 7.96 ± 3.93 years and most of the cases were in the age group 6-10 years (67.8%) (Table 1). This is roughly similar to what has been reported elsewhere for pediatric leukemia where the mean age of pediatric leukemia cases was 6.0 years with a peak incidence at 6-10 years [4,38,39]. This differs from the leukemia hypothesis with age in which older children may develop leukemia more frequently than younger children due to advancing age, as many environmental exposures to carcinogens, irradiation, and malignant mutations due to clonal expansion occur more often [40,41]. However, most of the younger children in the current study can be explained by the fact that prenatal and early life exposures are thought to be important determinants of pediatric leukemia. Several mechanisms have been identified through which exogenous and intrinsic factors can influence the risk of childhood leukemia. Exposure to a carcinogen or toxin early in a female’s life may cause permanent damage. Since no new eggs are formed after birth and begin to mature during pregnancy, exposures that occur during this critical time can be of great importance. During pregnancy, exposure to factors such as ionizing radiation may act directly while others may act indirectly by transferring the placenta. On the other hand, offspring may be exposed after birth to environmental exposure, either directly or indirectly [42]. Since most of the children are from rural areas (68.7%) (Table 1), they may have been exposed to various environmental exposures during their stay with their parents who are farmers. Environmental factors, even though not well articulated, influence the chance of developing leukemia. In Yemen, rural residents’ lifestyle is based on agricultural activities such as farming and plantations agriculture; especially Gat, fruits and vegetables plantation are the major practice around the study area, thus this may lead to the repeated use of chemicals such as pesticides, herbicides, and fertilizers for agricultural activities which will result in genetic mutations conferring leukemia [43]. In this study, acute lymphocytic leukemia was the most common, accounting for 83.3% of the total, while acute myelogenous leukemia counted 16.7% (Table 3). This result was consistent with results from Ethiopia, Nepal, and Pakistan [33,44], while it was contradictory with a study from Albania [45].

The clinical presentation of acute leukemia is vague and variable which makes it difficult to diagnose [46]. In this study, fever (78.3%), pallor (34.4%), bleeding disorders (31.9%), and abdominal pain/flatulence (26.9%) were found to be the most common complaints presented to patients at the first visit (Table 4). These are consistent results with Perveen et al. and Kakibuto et al. studies [47,48]. Zaki et al. [49] Shahab and Raziq [50] mentioned that fever, bleeding and pallor are the main symptoms of complaints. These findings may be explained by the mechanism of leukemia as maturation block and/or suppression of erythrocytes and polymorph nuclear cells by increased production of blastocytes resulting in decreased/disordered production of normal leukocytes/neutrophils (leading to fever), and erythrocytes ( leading to anemia/pallor) and platelets (leading to bleeding) [50]. Hepatomegaly was seen in 35.9% of patients, splenomegaly in 42.4% of patients and lymphadenopathy in 33.7% of patients. Enlargement of all three organs occurred in 18.6% of the total patients. Yasmeen et al. [51] and Shahab and Raziq [50] reported elevated hepatomegaly (71%, 67%), splenomegaly (58%, 66%) and lymphadenopathy (75%, 71%). These results are consistent with the idea that patients in our area are in hospitals when the disease reaches an advanced stage [51]. This increase in the number of organ enlargements can be attributed to the fact that the study population was children and their organs can be easily observed if the slight increase in size is compared with the organs of adults.

Limitation of the Study

There were a number of limitations in this study. It was a retrospective, hospital-based study. There was selection bias because all cases were those that presented to the hospital. The hospital-based study also does not take into account the number of similar cases within the community, and therefore, estimates of the relative prevalence of specific diseases cannot be generalized. Data were taken from patient records that were filled in by different doctors, and were therefore not standardized.

Conclusion

ALL is the most common type of leukemia. The male-to-female ratio is roughly equal, and young children between the ages of 6-10 are most affected by leukemia. More comprehensive investigations of relevant factors and predictors using more recent diagnostic methods and investigation of association factors with valuation of the treatment protocols currently in use are needed.

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Review on Antimicrobial Susceptibility of Staphylococcus aureus from Raw Meat and Its Public Health Importance

DOI: 10.31038/MIP.2022334

Abstract

In the family Staphylococcaceae, Staphylococcus aureus is coagulase-positive, Gram-positive cocci. The bacteria are an opportunistic pathogen that frequently infects people without showing any symptoms. Although being mostly safe at these locations, it is possible for it to sometimes enter the body through skin breaches (such as abrasions, cuts, wounds, surgical incisions, or indwelling catheters) and injure both humans and animals. The ability of bacteria that cause foodborne poisoning to generate toxins after or during intoxication determines their pathogenesis. Staphylococcus aureus is one of the most common bacteria that cause these illnesses, and it is a major factor in gastroenteritis brought on by eating contaminated food. The ingestion of Staphylococcal enterotoxins produced in the food results in Staphylococcal food poisoning. The abrupt onset of nausea, vomiting, cramping in the abdomen and diarrhea are among its symptoms. Resistance to -lactam antibiotics and Vancomycin has mostly been attributed to plasmids and staphylococcal cassete chromosomes in particular. When bacteria are exposed to -lactam antibiotics, the extracellular enzyme -lactamase, which is encoded by blaZ, becomes active and confers penicillin resistance. The enzyme opens the -lactam ring by hydrolization to affect it. Globally as a result of the ongoing spread of bacterial strains that are resistant to antibiotics in the environment and the potential for food contamination, staphylococcal antimicrobial resistance is a serious issue for public health.

Keywords

Staphylococcus aureus, Antimicrobial susceptibility, Public health importance

Introduction

Staphylococcus aureus is a gram-positive, round (coccus) bacteria found in grape-like (staphylo) clusters; opportunistic colonies cause extreme harm. This bacterium is characterized by non-motile, non-spore forming and catalase positive which grow aerobically but which are capable to grow as facultative anaerobic [1]. Staphylococci are mostly occurs as harmless bacteria, that inhabiting the skin and soft tissue /nasal cavities of humans and animals. Among 31 species of staphylococci currently recognized, 15 are potentially pathogenic and It can causes a wide range of conditions in humans and animals, from mild skin infections to life-threatening bacteremia [2]. Staphylococcus aureus can also causes abscess in deep organs, by producing a toxin mediated diseases, self-limiting skin infections to life-threatening pneumonia, catheter-associated bacteremia, osteomyelitis, endocarditis, septicemia, Foodborne-illness and toxic shock syndrome (TSS) among other infections [3,4]. Meat is one of the animal product origins that contains high source of protein and vitamins for human being, again meat has high water content and rich in minerals and other nutrients which are suitable for the development of microorganisms. Due to its chemical composition and biological characteristics, meats are highly perishable foods providing a good source of nutrients for the growth of different microbial, that can leads infection in humans and also can lead to economic loss due to spoilage [5].

Staphylococcal food intoxication is happen due to the consumption of staphylococcal enterotoxins that preformed in the food. The main clinical manifestation of Staphylococcal food poisoning is vomiting, sudden onset of nausea, abdominal cramps and diarrhea. This condition is common in developing countries, because poor hygienic practices and low level of awareness. The staphylococcal enterotoxins are highly heat stable and are thought to be more heat resistant in food stuffs than in a laboratory culture medium. Due to this reason, even though we heating at normal cooking temperature, the bacteria may be killed but the toxins remain active. About half strains of staphylococcal strain are able to produce enterotoxins associated with food poisoning. Because of this condition enterotoxins producing Staphylococcus aureus are most dangerous and harmful for the human health [6]. Currently, Antimicrobial resistance is one of the most challenging situations to public health across the world. Even if different antimicrobial drugs are produced to treat S. aureus infections, the emergence and spread of antimicrobial resistant S. aureus can challenged for world to effectively treating and controlling of these. This is due to the high resistance percent could be traced to underuse or overuse of antibiotics due to poverty and ignorance, self-prescription, inappropriate prescription by physicians due to lack of effective antibiotic policies in our hospitals and other factors [7].

Staphylococci is one the most drug resistant bacteria, that develops resistance quickly and successfully to antimicrobial. This ways of defensive mechanism is due to consequence of the acquisition and transfer of antibiotic resistance plasmids and the possession of intrinsic resistance mechanisms [8] Currently, Methicillin-resistant Staphylococcus aureus (MRSA) strains are emerging wide spread to worldwide. Resistance to methicillin is mediated by different genes like, mec operon which is a part of the staphylococcal cassette chromosome mec (SCCmec). The mecA gene codes for an altered penicillin-binding protein, PBP2a, which has a minimum affinity for binding β-lactam antibiotics. The virulence of S. aureus was increased with existence of antibiotics resistance strains like Methicillin resistant S. aureus (MRSA) and Vancomycin resistance S. aureus [9].

Antibiotic resistance remains a major challenge in human and animal health. Resistance is increasingly being recognized in pathogens isolated from food. Food contamination with antibiotic-resistant bacteria can therefore be a major threat to public health, as the antibiotic resistance determinants can be transferred to other bacteria of human clinical significance. Furthermore, transfer of these resistant bacteria to humans has significant public health implications by increasing the number of food-borne illnesses and the potential for treatment failure. Food of animal origin could be contaminated from the farm, a situation which may be further compounded if the food is not properly handled during slaughtering and processing giving way for pathogens to multiply. Studies conducted in different countries to investigate the microbiological quality of food of animal origin reported the presence of potential human pathogens [10]. In general, S. aureus is one of the most common microbial, which causes diseases in both human and animals. Misuse of antibiotics in Livestock sector, Agriculture and in the treatment of human diseases, has contributed to the increase number of bacteria that are resistant to antimicrobial agents. Therefore, the main objective of this paper is to review the antimicrobial resistance in S. aureus from raw meat, virulence factors and focusing on the association between these characteristics and their implications for public and animal health.

Literature Review

Background of Staphylococcus aureus

Staphylococci family was first identified and isolated from the pus of surgical abscesses by the Scottish surgeon Sir Alexander Ogston in 1880 and he observed grape-like structure with circular in shape and he describe it staphylococcus. In 1881, Ogston found out that non-virulent staphylococci are also present on skin surfaces. Most staphylococcal strains from pyogenic lesions can produce golden yellow colonies, and the strains from normal skin, white colonies on solid media. In 1884, Friedrich Rosenbach name them Staphylococcus aureus (S. aureus) and S. albus respectively. Based on their characteristics and categorized them based on the production colonies color or pigments either golden or yellowish colonies. Later S. albus was renamed as S. epidermidis which were coagulase negative, mannitol non-fermenting and usually nonpathogenic strains.

The presence of Mobile genetic elements like bacteriophages, pathogenicity islands, plasmids, transposons, and staphylococcal cassette chromosomes enabled S. aureus to continually evolve and gain new traits. The genetic variation within the S. aureus species is approximately 22% of the S. aureus genome is non-coding and differ bacterium to bacterium, this is due to its reliance on heterogeneous infections. The different strains can secrete different enzymes/bring different antibiotic resistances to the group, increasing its pathogenic ability (https://en.wikipedia.org, 2021a).

Microbial Nomenclature

Staphylococcus aureus is a Gram-positive bacterium, which affects soft tissue and skin of host cell. The most common species of this pathogen that affects animal and human include S. aureus, S. intermedius, S. delphini, S. hyicus, S. schleiferi subsp. coagulans, S. pseudintermedius, S. equorum, S. xylosus, S. carnosus, S. simulans, S. saprophyticus, S. succinus, S. warneri, S. vitulinus, S. pasteuri, S. epidermidis, and S. lentus. One of these different species is S. aureus; so-named because of the color of the pigmented colonies (“aureus” means golden in Latin). Generally, S. aureus are opportunistic pathogens or commensals on host skin. However, they may act as pathogens if they gain entry into the host tissue through a trauma to the cutaneous barrier, inoculation by needles, the implantation of medical devices, or in cases in which the microbial community is disturbed or in immune compromised individuals [11,12].

Morphological and Biochemical Characteristics of Staphylococcus aureus

Morphologically, Staphylococcus aureus are characterized by spherical in shapes and after applying gram staining techniques, when examined under light electron microscope this bacteria can appeared as clusters resembling bunch of grapes with large round, golden-yellow colonies, often with hemolysis on blood agar Medias [13]. Additionally, S. aureus can produce an enzyme called coagulase. This enzyme reacts in the blood and produces a chemical called staphylothrombin. Staphylothrombin might make S. aureus even more difficult to kill by adding a layer of clotted protein to the bacterium membrane. Furthermore the S. aureus has a peptidoglycan membrane layer that would make it very hard for a bactericide drug to enter the cell and destroy it [14]. Biochemical test was one of the techniques that used to identify and differentiate S. aureus from other gram positive cocci microorganisms. Based on biochemical test, S. aureus is characterized by catalase-positive, which can be used to differentiate it from catalase-negative streptococci species and oxidase-negative. Staphylococci species can also be classified biochemically, S. aureus, which is coagulase-positive, produces a coagulase enzyme that agglutinates/clots blood or plasma while other medically important species of staphylococci, such as S. epidermidis and S. saprophyticus, are coagulase-negative. S. aureus can be distinguished from S. saprophyticus by novambicin susceptibility, while S. saprophyticus is novambicin-resistant.

Epidemiology of the Staphylococcus aureus

Staphylococcus aureus infections are found on the skin and mucous membranes. Human are the main reservoir for these organisms. Mostly, the S. aureus colonization up to 80% is common in health care workers, diabetics’ patient and intravenous drug users, hospitalized patients, and immunocompromised individuals [15]. The epidemiology of MRSA in particular has increased and distributed over the entire world. In general there are types of MRSA, this include community-associated MRSA, hospital-associated (HA-MRSA) and livestock-associated MRSA. Hospital-associated MRSA, the rise of novel strains of MRSA in the 1990s outside of the nosocomial environment will makes this pathogen to the recognition of “community-associated MRSA” (CA-MRSA), when compared to ancient hospital-associated (HA-MRSA) strains. In the mid-2000s, a third genre of MRSA was recognized, as colonization and infection of livestock and livestock workers and nominates it as livestock-associated MRSA (LA-MRSA) [16].

Distribution of S. aureus in Humans, Animals and Food of Animal Origin

Staphylococcus aureus is bacteria that normally reside in or on humans and does not usually cause infection. In 2019, Minnesota Department of health report on Staphylococcus aureus infectious disease, it stated that over 20% of their population almost always be colonized with S. aureus, while 60% of the population will be colonized with S. aureus either affected or not and the rest 20% are almost never colonized with S. aureus [17].

Meat is important food stuff and one of the main sources of protein, fats, minerals and vitamins. Meat contains high amount of water content and due to this reason most microorganism can growth easily, which leads to the food spoilage and foodborne infections to humans [18,19]. There are different mechanisms or factors that can initiate the growth of microorganism in meat. This factor includes; intrinsic factor and extrinsic (environmental factors), but the most common and efficient factors that contributes microbial to growth on meat are includes: – The temperatures in which meat can be storage, humidity and oxygen are the most important factors for microbial growth. Additionally, meat can be contaminated by these bacteria from the skin of animal during slaughtering at the abattoir and from different materials or equipment that are used for operation [20]. Currently, one of the most challenging problems in the world content is antibiotics resistance strains of S. aureus which pose a great risk in the food stuff. Of this meat of animal origin is one the most common sites at which drug residues can accumulate for a long period of time. Human being can gate this infection by eating contaminated meat [21-23]. Poor hygienic condition can cause meat to be contaminated by Staphylococcus aureus. When meat can contaminate by S. aureus; it can produce a toxin that activates disease. Even though, cooking destroys this pathogen, it will not destroy the toxin that produced by this pathogen, this is due to S. aureus can produce heat stable toxin [24]. Normally, S. aureus does not compete sufficiently with common microbial in raw foods; the contamination of food stuff with this pathogen is mostly associated with improper handling of foods, keeping of the food at which favorable for the growth of microorganism, which leads to multiplication of S. aureus and production of the enterotoxin [25].

Reservoirs and Sources of Infections

The primary ecological reservoir of Staphylococcus aureus causing infection in humans is the human nose, but a normal micro flora of the skin, hair, and mucous membranes may also be colonized. This pathogen can cause dermal infection if the cutaneous barrier is damaged. Any individuals that have been colonised by the bacteria are susceptible to any secondary infections, especially immune compromised people due to disease like HIV, type 1 diabetes and intravenous drug users, and patients undergoing hemodialysis, surgical patients are the most susceptible group for secondary infection. Additionally multiple sites in the body like, perineum, axillae, vagina, and gastrointestinal tract also were found to harbor this bacterium. Staphylococcus aureus in general have a commensal relationship with its host. The pathogen can causes disease in host tissue, when the skin of the host tissue can be damaged, inoculation by syringes, or by direct implantation with medical devices and leads infection in the host tissue. The main reservoirs of Staphylococcus aureus are infected mammary glands, ducts, and papillary lesions [26]. The primary reservoirs of S. aureus in affected countries are those animals in intensive systems like pigs, veal calves and broilers [27]. Normally S. aureus can be found in healthy cows, as carriers on the teat skin, nasal cavity, and rectum. But, the main reservoirs in a dairy cow are infected udders and teat skin [28]. From animal Pork is the main source of S. aureus reservoir host and human can gate this pathogen through consuming of the meat and causes foodborne illnesses. Staphylococcal foodborne infection is food poisoning disease that can occurs when human consume contaminated meat and the pathogen can induce staphylococcal enterotoxins expressed by enterotoxigenic strains of Staphylococcus species [29] S. aureus is an opportunistic pathogen that has capable to colonize a wide variety of host species, including birds and fish [30].

Modes of Transmission

Staphylococcus is the most common bacteria that cause mastitis in ruminants. The pathogen spread from one teat to another through the lining of the tea cups, milker’s hands, towels and fruit flies [31]. Staphylococcus including MRSA can be transmitted from animals to humans through direct contact especially from meat and also humans act as a reservoir for the transmission of S. aureus to vertebrate animals. Infections that can be present in both humans and animals and transmitted in both directions, such as S. aureus infections called as “amphixenoses. Different researcher can reported animal-to-human transmission of S. aureus in dairy sheep. S. aureus is usually transmitted by direct contact with colonised skin. Generally, Staphylococci can be transmitting from one species to another species or within the same species through direct or indirect contact with a patient who has a clinical infection of the respiratory or urinary tract and who is colonised with the bacterium. Contaminated surfaces and medical equipment are also used as a vehicle for transmission of MRSA (www.health.vic.gov.au).

Pathogenicity of Staphylococcus aureus

Virulence Factors

S. aureus possess different potential virulence factors that causes tissue damage: surface proteins that promote colonization of host tissues; invasions that promote bacterial spread in tissues (leukocidin, kinases, hyaluronidase); surface factors that inhibit phagocytic engulfment (capsule, Protein A); immunological disguises (Protein A, coagulase); membrane-damaging toxins that lyse eucaryotic cell membranes (hemolysins, leukotoxin, leukocidin and exotoxins that damage host tissues and leads disease [32]. S. aureus exotoxins, alpha-toxin, beta-toxin, delta-toxin and phenol soluble modulins are the cellular by products that activates the lysis of leukocytes (white blood cell), although α-toxin and phenol soluble modulins (PSMs) can also induces the formation of biofilms. Another surface-associated virulence factors like, protein A, fibronectin-binding antigen, and envelope associated proteins used to attaches and entrance of S. aureus to epithelial cells and initiates infection in the host cells [33]. S. aureus bacterial structures such as capsules, adhesins, extracellular products (enzymes) and toxins such as toxin α toxin β toxin leucocidin, enterotoxin, exfoliative toxin, and toxic shock syndrome toxin, contribute to different stages of infection [34]. Alpha toxin (α) is one of the vital virulence factors of S. aureus, that contains beta sheets which is water-soluble monomer targeting the red blood cells [35].

The formation of biofilms makes the pathogen to enter or live from the host cell, increasing their population within the host cell and protects the pathogen from environmental attack within the host cell. Enterotoxin is one of the dangerous toxins that mostly detect in the meat of animal origin due to S. aureus contamination and leads to gastroenteritis. S. aureus enterotoxin intoxication on consumers occurs through the establishment of contamination on food consumed. This enterotoxin is resistant to heat (heat stable), acid-resistant, and resistant to the effects of proteolytic enzymes like pepsin and trypsin [36]. Additionally biofilm formation is used the pathogen to attach to a living or non-living surface area which is used for grow and secrete several small molecules that attaches the microbial cells together [37]. Biofilms can cause antibiotics resistance, chronic disease and makes the host immune weak, because of it allows the pathogen to evade multiple clearance mechanisms [38]. S. aureus have capability to regulate the expression of virulence factors because of they have accessory regulatory gene (Agr) and the sigma factor (σB) and also this pathogen have ability adapt different microenvironments with environmental conditions, due to they generate the acquisition of genes like, bacteriophage, the staphylokinase gene and Panton-Valentine [39].

Mechanism of Disease Development

Although S. aureus is a normal flora of the skin and mucous membranes, any break in the skin or colonization of individuals with compromised immune systems can give an opportunity for this bacterium to invade and cause infection. The disease process can be mediated via two possible mechanisms; the production of toxins and the colonization that causes tissue invasion and destruction [40]. The pathogenicity of S. aureus is depends on the virulence factors that promote adhesion and evasion of the host immunologic responses. This organism can produce some toxins, that are causes diseases and a high mortality rate, of them toxic shock syndrome toxin (TSST) and Panton–Valentine leukocidin toxin, which causes necrotizing pneumonia and inducing leukocytosis and tissue necrosis [41]. Staphylococcus aureus can produce different kinds of virulence, which make to decrease in host’s immune system and causes diseases. Among S. aureus these virulence cytotoxins, nucleases, proteases, lipases, hyaluronidase, catalase, coagulase, collagenase, leucocidin, Toxic Shock syndrome (TSST-1), enterotoxins and exfoliative toxins are the most common virulence factors that S. aureus can produce in order to affect the host tissues. Other virulence factors are: – peptidoglycan, protein A, adhesion factors, teichoic acids, capsular polysaccharides and biofilms are the structural components that produce different toxin in the host cell (Figure 1) [42,43].

fig 1

Figure 1: The mechanism of Staphylococcus aureus infection cells (Zhou et al., 2018)

The mechanism of Staphylococcus aureus disease development has five stages; this includes colonization, localization, dissemination and metastatic infections. The colonization proceeds to infection under certain predisposing factors such as prolonged hospitalization, immune suppression, surgeries, use of invasive medical devices and chronic metabolic diseases. Localized skin abscess develop when the organism is inoculated into the skin from a site of carriage. This can further spread and results in various clinical manifestations of localized infections such as carbuncle, cellulitis, and wound infection. The organism can enter into blood and spread systemically to different organs causing sepsis [44].

Disease Caused by Staphylococcus aureus

S. aureus was a bacterial infection that affects humans and all warm blooded animals. These organisms are the causative agents of different human and animal diseases, like bacteremia, endocarditis, impetigo, folliculitis, furuncles, carbuncles, cellulitis, scalded skin syndrome, osteomyelitis, septic arthritis, prosthetic device infections, pulmonary infections, and gastroenteritis, meningitis, toxic shock syndrome, and urinary tract infections.

Disease in Humans

Staphylococcus aureus causes a different form of disease in humans. Human staphylococcal infections are frequent, but usually remain localized at the portal of entry by the normal host defenses and leads to superficial lesions such as inflammation (characterized by an elevated temperature at the site, swelling, the accumulation of pus, and necrosis of tissue). Around the inflamed area, the fibrin will clot and the bacteria will form abscess. Additional this pathogen can causes Localized infection of the bone, which is called osteomyelitis and at serious stages it will causes septicemia and bacteremia, when the bacteria invade the blood stream. Moreover, S. aureus can causes more serious infections like pneumonia, mastitis, phlebitis, meningitis, and urinary tract infections; osteomyelitis and endocarditis. S. aureus is a major cause of hospital acquired (nosocomial) infection of surgical wounds and infections associated with indwelling medical devices. S. aureus causes food poisoning by releasing enterotoxins into food, and toxic shock syndrome [45].

Staphylococcus aureus is the leading cause of bacterial disease that harboring the health of human being and it causes gastrointestinal, respiratory, skin and soft tissue, and blood stream infections. In human S. aureus can causes different diseases ranging from ranges from mild stage to life threatening issues and hence most common is the skin infections which are often caused by abscesses. The most common disease of S. aureus on human are includes: purulent skin infections such as boils, abscesses, impetigo and scalded skin syndrome, systemic infections such as bloodstream infections, pneumonia, osteomyelitis, endocarditis and deep abscesses, hospital-acquired (nosocomial) infection of surgical wounds or treatment lines, infections of prosthetic devices such as pacemakers, heart valves, joint replacements and other foreign bodies, including central venous catheters and peritoneal dialysis catheters and food poisoning by releasing toxins into food toxic shock syndrome by releasing toxins into the bloodstream. Occasionally, staphylococcal infections can cause disease condition such as Bloodstream infections, Endocarditis, Osteomyelitis and Lung Infection.

Disease in Animals

S. aureus infections in animals are the most common reported as a cause of abscesses, mastitis, pneumonia and meningitis. Additionally, this pathogen can cause Abortion and stillbirth in sheep and goat [46]. In dairy cow, S. aureus causes mastitis. S. aureus can cause both acute and chronic form of mastitis. Acute form of mastitis caused by S. aureus is characterized by severe clinical infection with visible changes to milk color. The second typical sign of S. aureus in dairy cow is chronic form of mastitis, which is characterized by subclinical and under this condition there is no any change of milk color [47]. Staphylococcus aureus is the leading pathogen causing the most dangerous mastitis in cattle and the most difficult dairy product in most countries. Staphylococcus aureus has emerged as superbug of dairy udder, compromising animal health and economy. Its virulence is due to its ability of producing wide array of virulence factors that enhances its attachment, colonization, longer persistence and escaping the immune response. S. aureus can causes different disease conditions in pigs with starts from skin infections to severe condition. The most common infection caused by S. aureus in pig includes, septicemia, mastitis, vaginitis, metritis, osteomyelitis, and endocarditi. In small ruminants, S. aureus is a major cause of mastitis and septicemia. In goats, staphylococcal infection can allows the secondary infection because of the host immunity was decreased due to S. aureus infection and among the secondary infection that affects shoat due to this pathogen was Para poxvirus infection, which causes chorioptic mange or contagious pustular dermatitis. Staphylococcus aureus was also affect pet animal like dog and it causes different types of disease condition including pyoderma, otitis media, and wound infections [48].

Prevalence of Staphylococcus aureus from Meat

Globally, the prevalence of S. aureus ranges from 23.3% to 73 and the prevalence rate of S. aureus in raw meat in African countries are 16.0% in Tunisia, 57.8% in Ethiopia and 52.0% in Egypt were reported (Table 1) [49].

Table 1: Prevalence of Staphylococcus aureus from meat in the world

Countries Prevalence Reference
Iran 26.31% Dehkordi et al., 2017
United state 27.8% Carrel et al., 2017
Colombia 6% Gutierrez et al., 2017
China 20.5% Li et al., 2019
Africa 24.5%, Thwala et al., 2021
Chile 47.6% Valeria et al., 2019
Indonesia 58.3% Wardhana et al., 2021

Prevalence of Staphylococcus aureus from Meat in the World

The prevalence of S. aureus in raw meat from different countries is varies, this is due to different reason like: – techniques of sample collection, season of the study, microbiologically examination methods, and meat handling methods [50]. In European countries, prevalence of Livestock Associated -MRSA ranging from 0 to 16% in broiler chickens, while the prevalence of chicken retail meat products ranges from 0 to 37% have been recorded. In general, the prevalence of Livestock Associated -MRSA in different countries are as follow: – In Hong-Kong, 6.8% of 455 chicken meat, from Quebec, Canada, and to characterize LA-MRSA isolates total of 309 retail chicken, MRSA was found in 4 samples out of the 309 retail chicken meat samples for an estimated prevalence of 1.3% (Table 2) [51].

Table 2: Prevalence of Staphylococcus aureus from meat in the Africa

Countries

Prevalence

Reference

Algeria 29.4% Chaalal et al., 2018
Ethiopia 34.3% Hassan et al., 2018
Morocco 40.38% Ed-Dra et al., 2018
Ghana 45% Effah et al., 2018
Egypt 15% Osman et al., 2015

Prevalence of Staphylococcus aureus from Meat in the Africa

The contamination of meat by S. aureus across the food chain is a complicated process. The contamination may originate from animals, as well as from humans. Improper hygiene at that level should be avoided to reduce the odds of meat contamination and food poisoning. The main factors that influence the level of contamination are the length at which animals are transported and the methods which are used to move animals from one place to another, holding conditions, geographic location, as well as climate changes (Table 3).

Table 3: Prevalence of Staphylococcus aureus from meat in the Ethiopia

City

Prevalence

Reference

Bahirdar 54.45% Bizuneh et al., 2020
Addis Ababa 29.17% Kibrom, 2017
Jigjig 32.22% Ayalew et al.,  2015
Mekelle 40% Gurmu et al., 2013
Debre-Zeit 36.5% Senait and Moorty, 2016

Prevalence of Staphylococcus aureus from Meat in the Ethiopia

In the above table there is difference between prevalence in the different years and cities, this may be due to the degree of meat contamination at food handling, level of environmental hygiene and the degree of awareness related to microbial contamination. The highest incidence of disease usually occurs in people with poor personal hygiene, people subject to overcrowding and children. The European Union estimated that the additional costs of MRSA infections are €380 million annually. In United States different research reported that increase in costs for treating a patient with a MRSA infection compared to a methicillin susceptible Staphylococcus aureus (MSSA) infection range from $3836 – $13,901 per patient per incident. Mortality rates for MRSA and MSSA disease are also increased [52].

Antimicrobial Resistance in Staphylococcus aureus from Meat

Staphylococcus aureus can develops antimicrobial resistance through mutation and horizontal transfer of resistance genes. The most mechanisms which are used to resist the action of antimicrobials include, the production of enzymes that inactivate or destroy the antimicrobial; a reduction of the bacterial cell wall permeability limiting the antimicrobial access into the cell; the development of alternative metabolic pathways to those inhibited by the antimicrobial; and active elimination of the antimicrobial from the bacterial cell or the target site. The new mec gene called which called mecD can confers resistance to all β-lactams antimicrobials, including anti-MRSA cephalosporins, ceftobiprole, and ceftaroline. The mecD gene was in an island of resistance associated with a site-specific integrase, which implies a risk of transmission by horizontal gene transfer to other species [53].

Mechanism of Antimicrobial Drug Resistance

Penicillin Resistance

Penicillin G was discovered in 1928 by Alexander Fleming and the drug was used in human as chemotherapeutic agent in 1941. This antimicrobial was the most common used to treat fatal Gram positive pathogens including Staphylococcal infections. Penicillin resistance of S. aureus is highly prevalent with up to 86% of clinical S. aureus isolates being resistant to the antibiotic in the US. Similar finding was made in Australia and recorded 80% of S. aureus isolates were resistant to penicillin. Staphylococci can produce penicillin resistance by inducing enzyme penicillinase or beta-lactamase encoded by the blaZ gene. This enzyme have ability breakdown the beta-lactam ring of penicillin which lead to inactivation of the antibiotic [54].

Methicillin Resistance

Methicillin Resistance which is also called penicillin’s-stable in S. aureus is characterized as resistance to all β-lactam antibiotics. Because of the presence of resistance gene (mecA) that can stops β-lactam antibiotics from inactivating enzymes. The mecA is a biomarker gene that is responsible for resistance to methicillin and other β-lactam antibiotics by expression of foreign antigens (PBP and PBP2a) that can bind to penicillin. The PBP and PBP2a are resistant to the action of methicillin. Synthesis of PBP2a is controlled and kept at low level, but the level of synthesis can be enhanced if mutations occur in the regulatory genes (https://en.wikipedia.org, 2021b). Additionally, MRSA has a mobile genetic element which called staphylococcal cassette chromosome (SCCmec). The SCCmec carries the mecA gene to encode altered PBP (PBP2a) these binding proteins decrease the ability of β-lactam antibiotics and the MRSA strains can survive in the presence of β-lactam antibiotics [55,56].

Vancomycin Resistance

Vancomycin-resistant S. aureus is a strain of S. aureus that has become resistant to the glycopeptides. This drug was primary observed from a microbial source which is called Streptomyces Orientalis in 1952 and approved for use in 1958. This drug is the first line drug of choice for MRSA infections. The first, reduced vancomycin susceptibility in S. aureus was reported in 1997 in Japan. This resistance mechanism can be occurred by inhibiting the transpeptidation of the peptidoglycan layer in the bacterial cell wall by binding to the C-terminal D-ala-D-ala of the peptidoglycan stem pentapeptide, which prevents the interaction between the penicillin binding proteins and their substrate [57]. The binding between Vancomycin and bacterial cell wall with D-alanyl-D-alanine can inhibits the elongation and cross-linking of bacterial cell wall peptidoglycans, although repressing cell wall synthesis and proceeds to bacterial death. Today, different researchers can divide vancomycin-resistant Staphylococcus aureus into three types: Vancomycin-resistant Staphylococcus aureus, vancomycin-intermediate Staphylococcus aureus and heterologous vancomycin resistant Staphylococcus aureus [58].

Macrolide Resistance

The mechanism of antibiotic resistance development in S. aureus to macrolide, lincosamides can happen when there is the occurrence of methylation at the receptor binding site on the ribosomes. However, this methylation can be catalyzed by a methylases enzyme that is encoded by ribosome methylationmthrough erythromycin methylases enzymes erm and mediated by an efux pump system encoded by mrsA.

Quinolone Resistance

Predominantly the mechanism of action of quinolones was act on DNA gyrase, which is an enzyme that relieves DNA supercoiling and topoisomerase. These antimicrobials can develop resistance due to marked by a gradual acquisition of chromosomal mutations. This action can take place at gyrase and ParC (GrlA in S. aureus) of topoisomerase [59].

Diagnosis and Treatment of S. aureus

The diagnosis of S. aureus pathogen was based on laboratory examination techniques, isolation and identification method. Among the bacteriological examination techniques, the common used for isolation and identification of this pathogen are includes: – Serological and biochemical tests such as catalase, DNase and coagulase tests are used to identify the strain of S. aureus. The most common samples or specimens collected for laboratory examination for this pathogen include: – Blood, sputum, tracheal aspirate, pus, and surface swab. During examined under microscope after employing Gram staining techniques, the organism presence with Gram-positive grape-like cocci in clusters, or pairs. Biochemical test is also the techniques that uses for isolation and identification of this pathogen. Mannitol salt agar is a selective medium that used to isolate S. aureus and S. aureus produces different types of haemolysis including beta-haemolysis, alpha haemolysis and gamma haemolysis on blood agar media (https://microbiologyclass.com/).

The treatment of the Staphylococcus aureus was based on the strain of the infection whether it is resistant to methicillin antibiotic (MRSA) or sensitive to methicillin antibiotics (MSSA). S. aureus infections must be treated with antibiotics, especially in elderly, young, and immune-compromised patients. Skin infections can be treated topically with antibiotic creams. Antibiotic that used for treatment of MRSA includes vancomycin, clindamycin and a combination of antimicrobials that are resistant for bacterial strains. Penicillin is used for non-resistant S. aureus infections (https://biologydictionary.net, 2020). Before treating the affected person as well as humans the physicians must be doing the antibiotic sensitivity test. The most common used antibiotics against this bacteria/pathogen are penicillin, tetracycline, streptomycin, novobiocin, sulfonamides, lincomycin, and spectinomycin. But currently most bacteria are resistant to penicillin and other variety of antibiotics. However, at this time Vancomycin most effective drug of choice against this pathogen.

Anti-virulence or anti–toxin compound is the best option used to treat S. aureus strain pathogen, especially those produce toxin because of this compound does not affect bacterial viability or growth. This anti virulence compound can inhibit bacterial virulence genes, and leads decreasing the ability of pathogen to colonize the host and inversely allow the host innate immunity/biomarkers to eradicate the attenuated pathogen [60]. According to the report from Cordeiro et al. Lysostaphin drug was the most effective than mupirocin in rat models, but there is no any trials are applied for human. Additionally, both thymol and carvacrol are the phenolic terpenoids that are effective antimicrobial activity against S. aureus [61]. Again Daptomycin, a cyclic lipopeptide molecule, is a novel antibiotic that used for vancomycin-unresponsive S. aureus disease. This drug can damages the cytoplasmic membrane of bacteria and leads the protein synthesization [62]. The pathogenic S. aureus is resistant to different antibiotics that previously used to treat this pathogen like; cephalosporins, vancomycin, methicillin, oxacillin and penicillins. Drainage of the fluids or pus in abscess caused by S. aureus can be employed in the management of pus-infections mediated by the pathogen. Treating food poisoning Staphylococcus aureus by fluid and electrolyte were used to boost the immune system of the patient (https://microbiologyclass.com).

Mupirocin is also another antibiotic that used to treat impetigo and nasal decolonization infection of S. aureus. Mupirocin can inhibit the protein synthesis. Fusidic acid is an antibiotic that binds to bacterial elongation factor G and leads to impaired translocation process and inhibition of protein synthesis. This antibiotic has potent activity against S. aureus and clinically used in treatment of mild to moderately severe skin and soft-tissue infections, for example, impetigo, folicullitis, erythrasma, furunculosis, abscesses and infected traumatic wounds. For treating S. aureus strain that develops the biofilm formation, not only antibiotic treatment is effective, in addition to antibiotics using alternative treatment like postsurgical antibiotics was effective. Novel treatments for S. aureus biofilm involving nano silver particles, bacteriophages, and plant derived antibiotic agents effects against S. aureus embedded in biofilms (https://en.wikipedia.org).

Prevention and Control

The control and prevention methods of staphylococcus aureus disease was based on the practice of proper hygienic and individual protection at abattoir and hospital areas. Currently, there is no vaccine available to prevent staphylococcal diseases or infections, due to this reason individuals and hospital institutions must be implement the individual and environmental hygienic practices like hand washing and proper disinfection. Teaching the societies regarding to the protection method of the pathogen such as contaminated foods should be avoided; and food handlers should always observe proper hygiene in the handling, processing, preparation and distribution of food in order to avoid the outbreak of food poisoning due to Staphylococcus aureus (https://microbiologyclass.com). Educate hospital staff based on how hand hygiene can be important in order to protect this bacterium. Narrow-spectrum antibiotics, is used to control decolonization in patients planned for high-risk surgical procedures. Affected group might be recommended antibiotics to eliminate the bacteria, like mupirocin (www.health.vic.gov.au).

Public Health Importance

S. aureus is a major pathogen of public health concern throughout the world, this is due the pathogen can produce Staphylococcal food poisoning. Meat and meat products of animal origin are one of the main sources of staphylococcal food poisoning. Symptoms of Staphylococcus poisoning which include diarrhea, abdominal cramps, vomiting, and nausea occur after consuming toxin-contaminated food. The emergence of antimicrobial resistance, especially the multidrug resistance strain of S. aureus becomes an emerging zoonotic issue for worldwide. Because the resistant organisms fail to respond to first-line treatment, hence, leading to high cost of treatment, prolonged illness and high risk of death with its concomitant financial burden and loss in man-hour to families and societies [63]. Multi Drug resistant staphylococci can affect the health care system by causing prolonged hospitalization, increases the costs of treatments and patient mortality.

Zoonotic bacteria or pathogen can transmit to human through direct contact with animals or indirectly through the food of animal origin. The most common population at risk with zoonotic pathogen are farmers, veterinarians, farm laborers and abattoir workers is greater risk of being colonized or even infected with zoonotic pathogen. Humans may represent an important source of new bacterial strains, which can cause disease in livestock and, as such, pose a potential threat to food security. According to the recent research, the epidemic S. aureus clones in human and animal hosts, Both LA-MRSA ST398 and S. aureus ST5 clone, can causes lameness in poultry, have been shown to originate from humans but have now adapted and diversified to spread in animal hosts [64]. According to different researcher the organisms can be transferred to animals, and re-transmitted from this source to humans (reverse transmission) [65]. Different researcher reports the presence of Methicillin-resistant S. aureus in chicken meats, because of contamination and is considered a source of human infections caused by consuming contaminated meat of animal origin [66] Administering of under dose drugs to food animals can leads the pathogen to carry antimicrobial resistance genes or plasmids, which makes the multiplication and transmission of those genes among strains. This means using low dosage of antibiotics can initiates the transmission of resistance between different hosts including humans, animals and the environment [67]. The incidence rate of S. aureus disease was highest among the people with poor personal hygiene, overcrowding and children. But, staphylococcal disease may affect all people and animals. Healthcare employees, football players, prison inmates, people in day-care centers, people in military quarters, homeless people, intravenous drug users and men who have sex with men are also among the most people at risk (www.health.vic.gov.au).

Economic Impact of S. aureus

In Europe, Asia and North America, there is an increasing level of MRSA due to epidemics of highly transmissible. Due to the increasing incidence rate of MSSA and MRSA diseases and it increase in load of bacteremia and costs for treatment. This will causes economic problems, especially for developing countries there is scarcity of effective drugs and failure of treatment due to inappropriate antimicrobials or lack of efficacy of anti-MRSA drugs, excess toxicity of will causes to increase the morbidity and mortality. Drug-resistant infections also affect patients’ social and economic status by increasing healthcare costs, mortality and morbidity, and decreasing productivity. Among countries where use has been successfully reduced, significant investments were necessary to improve biosafety and biosecurity on farms in order to enable intensive production systems without the use of antimicrobials. Similar measures could be implemented in newer facilities in LMICs but may be too expensive for small livestock operations that lack the necessary technical and financial resources. Regardless, the benefits of reducing national resistance rates are predicted to outweigh the costs of introducing such bans. One study predicted that a worldwide ban on antimicrobial growth promoters would lead to a decrease of 1% to 3% in global meat production and a loss in meat production value of US$ 13.5 to US$ 44.1 billion, compared to an estimated loss of US$ 35 billion per year in the United States alone due to healthcare costs and losses to productivity from AMR [68-85].

Conclusion and Recommendation

Staphylococcus aureus is a Gram-positive, facultative anaerobic bacterium which grows individually, in pairs, short chains or grape-like clusters. The bacterium is catalase and coagulase positive, oxidase-negative, non-motile microorganism that does not form spores. Staphylococcus aureus can causes different diseases such as abscess in deep organs, toxin mediated diseases, self-limiting skin infections to life-threatening pneumonia, osteomyelitis, endocarditis, septicemia, Foodborne-illness and toxic shock syndrome (TSS). Foods contaminated with S. aureus are a potential vehicle for the transmission of enterotoxigenic S. aureus to humans. Staphylococcus aureus is a foodborne pathogen which is responsible for contamination of different food products and results food spoilage, reduction of food safety and shelf life and cause foodborne poisoning via production of deadly enterotoxins. S. aureus is a very versatile human pathogen that readily adapts to changing environments and acquires antibiotic resistance genes through a number of different mechanisms. Antimicrobial resistance is a serious threat to public health across the globe. A wide variety of antimicrobial drugs are employed to treat S. aureus infections. However, emergence and spread of antimicrobial resistant S. aureus isolates constitute a global challenge for the effective treatment and control of these infections.

Therefore, based on the above conclusion, the following recommendations are forwarded:-In the future the researcher:

  • Should focus on developing a safe vaccine that contains secreted as well as cell wall-associated antigens that evoke a sustained protective response over a significant period of time.
  • Should utilize information on the variation, distribution and function of surface protein antigens amongst aureus lineages to ensure that cocktails of gene variants are included in the vaccine.
  • Should focus on the unraveling of the cellular immune responses directed against aureus.
  • proper handling of raw meat, adequate cleaning of hands, surfaces, equipment’s, disinfection of slaughter houses, vehicles and good personal hygiene can reduce spreading of Staphylococcus through meat.
  • The occurrence of multidrug resistance Staphylococcus particularly aureus should be under consideration during selection of antimicrobials for the treatment.
  • Multiple drug resistant Staphylococcus aureus have a wide distribution in different meat of animal origin and therefore care should be taken in to account during processing to destroy the micro-organisms to avoid the risk of human infection.

Acknowledgment

I would like to start by extending gratitude and praise to Almighty Allah, the kindest and most merciful, for keeping us well and bestowing upon us the unwavering resolve, bravery, strength, and endurance needed to complete this difficult endeavor. The person who controls the course of advancement is Dr. Daniel Shiferaw (DVM, MSC, Assist Prof), who is my advisor. Words can’t quite explain how grateful I am for his constant constructive criticism, diligent scientific advice, and untold hours spent editing this work. Last but not least, we would want to express how grateful we are to Haramaya University Faculty of Veterinary Medicine for providing the necessary facilities.

Abbreviations

Agr: Accessory Regulatory Gene; AMR: Antimicrobial Resistant; CA-MRSA: Community-Associated Multi Drug Resistant Staphylococcus aureus; DNA: Deoxy Nucleic Acid; HA-MRSA: Hospital-Associated Multi Drug Resistant Staphylococcus aureus; HIV: Human Immunodeficiency Virus; LA-MRSA: Livestock-Associated Multi Drug Resistant Staphylococcus aureus; MRSA: Multi Drug Resistant Staphylococcus aureus; PBP: Penicillin-Binding Protein; PSM: Phenol Soluble Moduli’s; SCCmec: Staphylococcal Cassette Chromosome mec; SCV: Small Colony Variant; TSS: Toxic Shock Syndrome; σB: Sigma Factor.

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A Case Study and Review of the Literature Regarding Extradural Spinal Arachnoid Cyst

DOI: 10.31038/JNNC.2023611

Abstract

Arachnoid cysts are spaces containing cerebrospinal fluid partitioned into an arachnoid-formed sheath and are a rare cause of symptomatic spinal cord compression. This case study examined a patient with spastic paraparesis who underwent surgery to remove the cystic lesion and push back the marrow. Post-op control spinal MRI showed total excision of the cyst, and the patient has progressed well and has fully recovered from his deficit.

Nabors divides extradural arachnoid cysts into three types: type 1, type 2, and type 3. Type 1 is essentially thoracic, extending over several vertebrae with a peak of greater frequency around the eighth dorsal vertebra. Symptoms are generally slowly progressive, but rapid revelation or decompensation are possible. Treatment options include marsupialization, wide resection, and total excision. For symptomatic cases, total excision is the reference treatment. For painful cases, complete excision, tied off the intradural communication pedicle, and reshaping the dura is the primary surgical goal.

Keywords

Arachnoid cyst, Spastic paraparesis, Decompensation

Introduction

Arachnoid cysts are commonly defined as spaces containing cerebrospinal fluid partitioned into an arachnoid-formed sheath. Described for the first time by Magendie in 1843 [1]. However, they represent a rare cause of symptomatic spinal cord compression [2]. Their development would require the presence of a communication pathway with the subarachnoid spaces by means of a small opening. This opening could remain open, form an anti-reflux valve, or close completely and then give rise to true cysts. Communicating cysts are also called “arachnoid diverticula” [3]. We report the case of a symptomatic spinal arachnoid cyst that was operated on in our department.

Definition

Arachnoid cysts are arachnoid formations with arachnoid walls that don’t look different from the arachnoid tissue around them. They can develop wherever there is arachnoid tissue, with a tendency to localize in the cisterns, but spinal localization remains rare. These cysts contain CSF of the same composition as the neighboring CSF and communicate with the contiguous arachnoid lakes, allowing regular exchange of intracystic fluid.

Materials and Methods

We have collected a case of symptomatic extradural intraspinal arachnoid cysts that required complete excision with ligation of the intradural communication pedicle and dural plasty.

Case Study

A young 36-year-old patient who has had spastic paraparesis for a few months, whose radiological exploration with a sagittal (a) and axial (b) T2 MRI showed a cystic lesion at the height of D10 D11 with the same signal as the lateralized extradural CSF on the left and driving back the spinal cord on the right.

The patient underwent surgery where a laminectomy was performed, removing this voluminous arachnoid cyst (black arrow) and pushing back the marrow on the right (white arrow). d: reduction of the cystic volume by puncture and coagulation of the cystic wall, which is made of a thick arachnoid. After complete excision of this cyst, we find good release of the marrow (white arrow) and the nerve roots (black arrows). A post-op control spinal MRI shows total excision of the arachnoid cyst; the patient has progressed well and has fully recovered from his deficit (Figure 1).

FIG 1

Figure 1: Radiological images sagittal (a) and axial (b) T2 MRI showed a cystic lesion (c), (d) reduction of the cystic volume by puncture and coagulation of the cystic wall. After cyst removal (e) good release of the marrow (white arrow) and the nerve roots (black arrows), (f) post-op control spinal MRI.

Discussion

The term “arachnoid cyst” is used to describe most types of cysts that involve the arachnoid. Nabors [4] has put them into groups based on where they are in relation to the nervous system in:

Type 1: An extradural cyst not comprising a nervous structure;

Type 2: Extradural cyst comprising nervous structures (Tarlov cyst);

Type 3: Intradural cyst.

Its topography is essentially thoracic, extending over several vertebrae with a peak of greater frequency around the eighth dorsal vertebra; our case sits at the level of D10 D11. Cervical or lumbosacral localization is very rare [5]. Dorsal locations are particularly frequent in the second decade of life given the narrowness of the canal at this level, and lumbosacral locations are observed later, between 30 and 50 years of age [6,7]. It is almost exclusively posterior, more rarely anterior or anterolateral [8,9].

In our case, the seat is posterolateral:

There is no sex ratio; the age of discovery can vary from 4 to 80 years, according to the cases listed in the literature [8]. Our patient was 36 years old; the symptoms are generally slowly progressive, but rapid revelation or decompensation is possible [10]; There is no relationship between the severity of the signs and their date of appearance. For thoracic cysts, the duration of the development of symptoms is shorter than for lumbar cysts due to the difference in the diameter of the spinal canal [11];

There are some particularities in terms of their clinical expression: The spinal syndrome and the radicular syndrome are very often in the foreground, frequently increased by the standing position (which may correspond to a tensioning of the cyst or its stretching) [12,13]; spinal deformities are the prerogative of old cysts; the sublesional syndrome, linked to the position of the cyst, is dominated by posterior cord involvement; sphincter disorders are more rare and moderate.

The etiopathogenesis remains hypothetical, and several theories have been presented. Extradural arachnoid cysts likely have a congenital origin, and they are the result of congenital dural diverticula or herniation of the arachnoid through congenital dural aplasia [14]. The nerve or the junction of the dural root and sheath are the most common sites of these defects, although less often the dorsal midline of the dural sac is also involved. The defect of the dura mater would be due to a structural anomaly of congenital origin, the consequence of a failure of the tightness of the collagen fibers. This failure leads to elongation and ectasia of the dura mater. Cases of spinal arachnoid cysts that do not clearly have a congenital origin have also been reported. The association of spinal arachnoid cysts with arachnoiditis   potential source of arachnoid septations), spinal surgery, and spinal cord trauma has prompted some authors to suggest that these cysts may result from acquired dural lesions [15]. Several surgical methods can be proposed, including marsupialization of the cyst which consists in opening the cyst and making its contents widely communicated with the spaces under perimedullary arachnoids, however, wide resection of the cyst is the method of choice. Since the goal is to stop the pressure difference between the cyst and the space under arachnoid.

For asymptomatic patients, it is recommended to observe conservative treatment with monitoring of the evolution of clinical symptoms and radiological controls regular.  Regarding symptomatic epidural arachnoid cysts, all authors agree on the indication for surgery. It is then recommended to carry out the complete excision of the cyst, and then the pedicle connecting the cyst to the subarachnoid space and the cyst is tied off. repair of the dural defect. This is the technique of choice to prevent the CSF reaccumulation and cyst recurrence. For our patient with a painful extradural arachnoid cyst, we removed the whole cyst, tied off the intradural communication pedicle, and reshaped the dura.

Conclusion

Extradural spinal arachnoid cysts are rare lesions, and treatment options should be considered carefully. In symptomatic cases, total excision of the cyst should be considered the reference treatment. We believe that closure of the dural defect should be the primary surgical goal to prevent recurrence. We offer laminoplasty for the treatment of extradural arachnoid cysts involving multiple segments to prevent postoperative kyphosis.

References

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  2. Lesoin F, L Eys D, Rousseaux M, Cama A, Jomin M, Petit H (1985) Spinal intradural arachnoid cysts. Acta Neurchir 76 : 125-128.
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  5. AJNSAfrican Journal of Neurological Sciences | » KYSTE ARACHNOÏDIEN EXTRADURAL RACHIDIEN AJNS 2009. 28(1).
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  7. Rimmelin A, Clouet PL, Salatino S, Kehrli P, Maitrot D, et al. (1997) Imaging of thoracic and lumbar spinal extradural arachnoid cysts: report of two cases. Neuroradiology 39(3): 203-206. [crossref]
  8. LVISI C, ERISOLI M, IULIONI M, UERRA L (1987) Long term results of surgically treated congenital intradural spinal arachnoid cysts. J Neurosurg 67 : 333-335. [crossref]
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  10. Rousseaux M, Combelles G, Destée A (1983) Diverticules et kystes arachnoïdiens rachidiens intraduraux: 6 observations. Neurochirurgie 29: 279-284.
  11. Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, et al. (1988) Updated assessment and current classification of spinal meningeal cysts. J Neurosurg 68(3): 366-377. [crossref]
  12. YS, RS, MS (1991) Spinal intradural arachnoid cysts. Neurochirurgia (Stuttg) 1 Juill. 34(4): 127-130. [crossref]
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  14. Neo M, Koyama T, Sakamoto T, Fujibayashi S, Nakamura T (2004) Detection of a dural defect by cinematic magnetic resonance imaging and its selective closure as a treatment for a spinal extradural arachnoid cyst. Spine 29(19): E426-430. [crossref]
  15. Saqui AE, Aggouri M, Benzagmout M, Chakour K, Chaoui ME (2017) Une cause rare de compression médullaire: kyste arachnoïdien épidural rachidien (à propos de 03 cas). The Pan African Medical Journal. [crossref]

Health Beauty Regimens, Inner Beauty, and Homo emotionalis versus Homo economicus

DOI: 10.31038/PSYJ.2023542

Abstract

Female respondents each evaluated sets of 48 unique vignettes, comprising messages about new regimens for ‘beauty from within’. The messages were sales and information messages that might likely appear in an advertisement. Respondents rated believability in the messages presented by the vignette, and from a set of different prices selected the price they would pay for the product described by each vignette. Deconstructing the rating assigned to a vignette into the contribution of the messages revealed three strong minds when the criterion was ‘believability; MSB1 – Make your inner self come alive and real; MSB2 – Appeal to authority and tradition; MSB3 – Reinforce the power for beauty within by hypnosis. Deconstructing the price rating revealed two strong mind-sets; MSP1 – Appeal to secret ‘formula’; MSP2 – Ease and convenience; and one weak mind-set. All six mind-sets show similar patterns of price would pay versus belief, even though each mind-set differed in the patterns of what it believed, or in the patterns of what it would pay. The approach, using Mind Genomics, shows how topics of everyday experience can become inputs for a science of ordinary human behavior.

Introduction

The pursuit of beauty is and has been a long-term affair in the history of humankind. Beauty, however defined, is always sought after. What makes the topic so interesting is that the search for beauty seems to be almost universal. People want to look good for themselves and to others. The exact methods by which this goal is accomplished depend on the historical eras, the available technology, the particular conception of what is beauty, and finally the ‘zeitgeist,’ and the ever-changing technology of the time.

One can scarcely open any media and successfully elude the barrage of stories and advertisements, all talking in an increasing babble about one or another aspect of ‘beauty.’ What was a simple world a century ago after World War I have morphed into a cacophony. Beauty is no longer ‘skin deep’ but has migrated to all parts of the body and the brain. One need only look at the stories in the paid advertisements to realize that beauty has migrated to the world of Estee Lauder three quarters of a century ago to the world of good living, meditation, hypnotism, and so forth. All are things, behaviors, ways of thinking to which beauty is attached, and which can enhance beauty.

In the 1980’s and 1990’s the author wrote two books on cosmetics and personal products [1,2]. The research in those books was based upon the emergent science of psychophysics, the study of the relation between physical stimulus and subjective responses. During the formative years of the author’s scientific career, 1969-1985, a great deal of the work with done with product developers, interested in the laboratory-level improvement of cosmetics, toiletries, and fragrances. Colleagues and clients such as Morton Pader would encourage this effort

During the later years of the 1980’s, the author began to work with the marketing departments of companies, with the focus on how to communicate the benefits of beauty. The intense competition among the major cosmetic companies, as well as those large companies marketing the world of products known as ‘personal care’ drove interest into studying the mind of the consumer. The focus moved from how to formulate to achieve optimal acceptance and support of a positioning through just what to say. It became increasingly clear that there were no real databases about the mind of the consumer, despite the seemingly massive amounts of corporate data residing in the corporate files. The information available was one-off, focused, often being the ‘verbatims’ reported from focus groups and depth interviews, but almost no quantitative data. Even companies like Procter & Gamble, Inc., in Cincinnati, bastion of standardized methods, could not or would not produce books about messaging, although they were able to produce books about standard research methods.

It was in the early to mid-1990’s that the approach used here, Mind Genomics, would emerge to create the necessary structured database about the mind. Mind Genomics is a science which studies through experiments the perception of the person’s everyday world [3,4]. It is the application of Mind Genomics to the new world of ‘beauty from within’ which will be the subject of this paper.

Method

Through a disciplined approach using statistical experimental design, Mind Genomics combines elements describing daily experience (messages), creating vignettes. The vignettes comprise simple combinations of these elements, one element atop the other in an easy-to-read format, viz., without connectives. The respondent scans the vignette, viz., this combination of elements, and assigns a rating on the scale(s) provided. The analysis deconstructs the response to the combinations, revealing the part-worth contribution of each element.

This seeming ‘round-about’ way to understand the strength of each element has several built-in positives.

Ecological Validity

In our normal lives we don’t evaluate one stimulus at a time in splendid isolation, even though that approach is taught as the epitome of good science. People experience the stimuli in combinations, ideas fighting each other for attention. Mind Genomics attempts to reproduce a world of ‘bustling confusion.,’ and within that world suffused with noise estimate how each element performs.

Reduction of Bias

Often respondents attempt to ‘guess’ what the researcher wants, and assign the desired answer, rather than the answer which truly reflects the way the individual respondent feels. All one has to do is ask people to describe their food shopping behaviors and their food pantries to end up with a description of what seems to be a healthy diet filled with the foods that are highly recommended. Closer inspection of the houses of such individuals often reveals a lot of junk food. Similarly, people who vote and then participate in an exit poll or a qualitative interview often do not give an honest answer when asked for whom they voted. The effort to appear politically correct may undercount some candidates who held publicly unpopular yet meaningful and attractive points of view about social situation. Former President Donald Trump provides an example. Votes for Trump were undercounted because the participants in the poll were often subtly positive but felt that the interviewer would feel negatively about them were they to state their positive feeling.

Ability at the Level of Each Individual to Understand How the Elements ‘Drive’ the Ratings

The Mind Genomics method works by creating experimental designs (combinations of elements into vignettes), and with the property that each individual respondent evaluates the precisely correct combination of elements in the 48 vignettes so that one can use statistical methods such as OLS (ordinary eat-squares) regression to relate the presence/absence of the 36 elements to the rating, or to a specified transformation of the rating [5]. In behavioral science the ability to do all of the analyses at the level of the individual (within-subjects design) means that the respondent ends up providing all of the relevant information. There is no immediate need to work with data beyond one person to understand the pattern of results generated by that one person.

Evaluation of More of the Design Space

Every respondent evaluates a unique set of combinations, allowing the research to explore a great deal of the so-called design space, the space of possible combinations. This set of individual sets of combinations means that in our study of 100 respondents, each of whom evaluated 48 different combinations, the study actually covered 4800 different combinations. The benefit of covering a lot of the design space is that the research becomes an exploration, a cartography of new to the world topic, rather than requiring the researcher to evaluate the most likely test combinations to prove or disprove a hypothesis. Mind Genomics becomes an exploratory tool for new knowledge, a tool which helps one understand the topic at a macro level. [6]

Explicating the Process with the Study on Hypnosis and Inner Beauty

With the foregoing in mind, we now proceed to the study of a new way of thinking about beauty, beauty from within. The actual study came from a discussion with Wendy Packer of Westchester, New York, around 2013. The issue was whether Mind Genomics could provide a way to quantify what was believable in some of the topics and claims, and for what was something for which respondent would pay. The author immediately offered to ‘try out’ the different messages, in a simple exploratory study, to see what would emerge. The paper is the result of that effort. What is important to keep in mind is that the templated version of Mind Genomics allows the researcher to setup the study, get the respondents, run the study, and receive the data almost automatically in an hour or two [7]

Step 1: Create the Raw Materials, Comprising Questions (Aspects) and Answers (Elements, Test Messages)

This first section is the hardest. Once the study is named, a step requiring the researcher to summarize the study in a word or two, the task becomes harder. The researcher has to develop a ‘story,’ within that story ask six questions which flow in reasonable order, and then for each question provide six answers. Table 1 shows the final set of six questions, and each question having six answers.

Table 1: ‘The final set of six questions and six answers (elements) for each question

tab 1

This initial exercise may seem easy to the reader, but the task is often daunting, mostly for beginning researchers, but occasionally for experienced researchers as well. The researcher must create a set of questions or topic statements which tell a story. The story need not have a plot. Rather the story will end up being a set of questions which seem plausible when stated. In turn each question requires six answers.

The above-mentioned task often drives the researcher to abort the study as it is being developed. Our education system is reasonably strong in teaching us how to answer questions. It is critical thinking necessary to formulate the questions in a way which becomes hard. We are accustomed to one at a time questions, the questions not being part of a story. Making the researcher produce a story can be frustrating for the researcher.

The act of developing the ‘proper’ questions and the array of possible answers (elements) for these questions often becomes the most important part of the learning process. One might think that the experiment itself with real respondents does most of the teaching. Three decades of working with Mind Genomics and its antecedent, IdeaMap® have continued to show them that much of the learning occurs in the up-front preparation, and that in effect the benefits of IdeaMap end up being the co-creation of insight by the research during the up-front set-up along with information gleaned from the respondent in the actual experiment.

Step 2: Create the Instructions and the Rating Questions

In this earlier version of Mind Genomics, the study ended up focusing on two aspects of the topic, believability, and value, respectively. The practical aspects of the topic led naturally to study these two issues as the core of what was needed for the practitioner to discover. The first issue was ‘would anyone believe this statement,’ which answer would emerge after the deconstruction of the rating of believability assigned to a vignette into the part-worth estimates of believability of the component elements. To the practitioner, having a statement which is believable is of paramount importance.

The second topic aspect was the expected price that the element could command. From the practitioner’s viewpoint it is always important to offer something which respondents are willing to purchase, rather than offering something for which they are not willing to open their pocketbook, expecting it to be free.

Table 2 shows the orientation scale, and the two rating questions. Each rating question was transformed into a format mor easily used by the computer in regression analysis. For the first rating question, believability, ratings 8-9 were transformed into the top part of a two-part scale, believable. For the same first rating scale, the ratings of 1-7 were transformed into the bottom of the two-part scale, not believableFor price; the selected price became the rating of value.

Table 2 also presents a set of self-profiling questions, completed by the respondent. The self-profiling questions enable the researcher to understand more about WHO the respondent is, what the respondent DOES, and what the respondent BELIEVES. This information can come only from the respondent or from a deep analysis of data available for sales, data that has to be combed through to create a partial profile of the respondent. It is far easier to ask the respondent to profile herself.

Table 2: Belief scale, price scale

tab 2

Step 3: Execute the Mind Genomics Experiment on the Internet

The standard approach is to recruit respondents who are pre-qualified, usually individuals who are members of an online panel. It is tempting to save money by recruiting individuals who one knows, and who can be persuaded to ‘volunteer.’ Although the use of unpaid respondents may seem to be a cost saving, rarely does it ever turn out to be so. The study may take at least 20-50 times longer to complete, as the researcher hunts for willing, qualified respondents. In light of this, the Mind Genomics system works with panel providers, companies which specialize in providing qualified respondents, doing so in a matter of hours, not weeks.

The respondents were recruited with the panel provider. Today’s studies are done with Luc.id Inc., a panel provider with the ability to source respondents from around the world. The study was done in 2012, a decade ago with an entirely different company. The study was completed in a matter of our hours, from launch to completion. The Mind Genomics system sends out the test elements and constructs them on the site. The respondent reads the introduction, is presented with each screen (48 screens altogether, each with 3-4 elements, according to the vignette), rates the vignette on the two questions, and then immediately proceeds to the next vignette

Step 4: Acquire the Data Format the Data for Analysis

Each respondent generates 48 rows, one row for each of 48 different vignettes that a respondent evaluates. The database comprises three sets of columns. The first set of columns defines the respondent, and the information provided by the respondent about herself from the self-profiling questionnaire. This first set of columns remains the same for all 48 rows, since it refers to the respondent, and not the vignette. The second set of columns contains one column showing the test order (1-48), and then 36 succeeding columns, one column assigned to each of the 36 elements in the design. For a specific column (the element) and a specific row (the vignette), the cell will either have a ‘0’ when the element is absent from that vignette, or a ‘1’ when the element is present in that vignette. This is called ‘dummy variable coding’ because the variable has almost no information except absent or present. The third set of columns shows the rating assigned to the vignette, the dollar value selected, and then two additional columns which are transformed values. The second to the final column is 100 when the rating was 9 or 8, denoting extremely or very believable, and 0 when the rating was 7 or lower, denoting modestly believable, or degrees of unbelief. The final column shows the actual dollar and cents value corresponding to the rating selected for the second question.

As preparation for the additional analysis, a vanishing small umber (<10-5) was added to every transformer rating for both belief (R98) or price. The vanishingly small number ensures that no matter what rating the respondent chooses, there is always variability associated with the rating, a requirement for regression analysis.

Step 5: Create a ‘Sneak Preview’ of the Data to Get a Sense of ‘How Well’ the Vignettes Performed

Even before we look at the strength of the individual elements, we can quickly assess how well we did. Figure 1 shows the distribution of ratings of believability (left panel) and the distribution of selected prices (right panel).

By itself, Figure 1 tells us little about the mind of the respondent. We could look more deeply into the data by a variety of different analyses, simply on the responses to the vignettes alone. Another analysis might be to look at the ratings at the beginning of the evaluation versus at the end of the analysis (viz., ratings assigned for test orders 1-3 vs ratings assigned for test orders 46-48). Do they differ, and if so, then how do they differ? Figure 2 shows this comparison. Figure 2 suggests a slight decrease in belief in the validity of what the vignette communicates, as well as a slight decrease in the price one would pay. What Figures 1 and 2 fail to do, however, is exploit the cognitive richness of the vignette embedded in the meaning of the elements, and then draw conclusions about the effect of order.

fig 1

Figure 1: Distribution of the ratings of believability and price for the full set of vignettes

fig 2

Figure 2: Distribution of the ratings of believability and price for the first four vignettes (order 1-4) versus the final four vignettes (order 45-48).

Step 6: Create an Equation Relating the Presence/Absence of the 36 Elements to the Transformed Rating

The equation is estimated by standard statistical techniques. The equation shows how each of the 36 elements ‘drives’ the transformed rating. The equation is developed for each respondent, respectively, as well as for groups. This ability to fit the equation, even at the level of the individual respondent, occurs because of the previously discussed process known as experimental design. The experimental design that we use in Mind Genomics is set up so that each individual respondent evaluates the precisely correct vignettes for a regression model.

The equation is expressed as: DV (dependent variable+ = k1A1 + k2A2…k36F6

The dependent variable is either the variable R98 denoting believable, or Price (the actual price chosen by the respondent).

We create this pair of equations for every subgroup of interest. The computer program (Systat, 2013) allows the researcher to input the variables (dependent, independents), to then select or not select the additive constant (we do not select), after which in less than 1-2 seconds, the statistical program has estimated and stored the parameters of the equation.

The key benefit of the analysis by OLS regression is that we now understand the data more deeply. Rather than treating each of our ratings as simply a ‘point’ and focusing on the general pattern created by those set of points, we can understand the ‘meaning’ of each point from knowing the text of each element. With that type of information, our questions about the data become more pointed, more realistic, and ultimately far more informative.

Table 3 shows the coefficients for the 36 elements. The left pairs of data columns show the elements sorted in descending order of believability, with the believability coefficient on the left, and the price coefficient to its right. The right pairs of data columns show the same elements, this time sorted by price, with price coefficient on the left, and the believability coefficient to its right.

Table 3: Self profiling questions and number of respondents choosing each answer

tab 3

Table 3 presents a great deal of data. To enable the pattern to emerge we show all elements of coefficient of 6 or higher for R98 or price would pay (for the element) of $5.00 or higher. Noteworthy in Table 3 is the low coefficients for R98 (viz., low belief in the validity of the messages), and the low price that would be paid. Figure 3 shows the approximately linear relation between the degree of believability and the price that would be paid, both coefficients from the regression models presented in Table 3. We conclude from Figure 3 that respondents feel willing to pay more for elements whose validity they believe, although the relation is ‘noisy.’ Despite the noisiness, the linear relation gives one confidence that the data are internally consistent.

fig 3

Figure 3: Scatterplot showing the relation between the coefficient for believability (abscissa) and the coefficient for dollars would pay (ordinate).

Step 7: Uncover Mind-sets Based Upon Coefficients for Believe, and Again Mid-sets Based on Coefficients for Price

A hallmark of Mind Genomics is the search for groups of like-minded respondents, the term ‘like-minded’ applied to similar patterns of responses to a granular topic. The world of consumer research is awash with different ways of dividing people, the most common being differences in who the people ARE [8], how the people THINK [9], and how the people BEHAVE [10]. The effort to create these different groups is significant so that the division of people into these groups, the process called segmentation, is reserved for the most important topics in the area, and becomes a seminal work generally not repeated because of effort and expense. The result is the macro-level segmentation of big topics and the efforts needed in turn to apply this macro-level segmentation to the world of the everyday, where it is most needed, and where ‘real life’ occurs.

The Mind Genomics approach works at the level of the granular, looking at simple-to-understand patterns of differences in responses to messages about a specific topic. Rather than working at the macro-level and trying to apply the general rules to the particular instance, Mind Genomics uses the pattern of responses to the specific topic to create the different groups, the segments, or in the language of Mind Genomics, the so-called ‘mind-sets.’

The segmentation into mind-set for our study proceeds in a simple manner [11].

  • Create 101 individual-level models or equation, of the same form that we created above. Do this creation twice, once for the equation relating the element to R98 (believable), and then for the equation relating the elements to price.
  • Beginning with the 101 individual level equations for believable, compute the ‘distance’ between each pair of the 101 respondents, using the formula Distance = (1-Pearson R). This distance will be 0 when the Pearson R (correlation) is 1.00, viz., the case where two respondents are perfectly aligned in their pattern of 36 coefficients. In contrast, this distance will be 2.0 when the Pearson correlation is -1, viz., when the two respondents are perfectly aligned in opposite directions.
  • Cluster the respondents into two, and then three groups, such that the distances between the people in a cluster are small, whereas the distances between pairs of centroids of different clusters are large. This strategy ends up assigning people to clusters or mind-sets in a purely quantitative fashion. There is no conscious effort for the clusters to make sense.
  • Invoke two rules, parsimony (fewer clusters are better than more clusters), and interpretability (the strong performing elements within a cluster should tell a coherent story).
  • For this project three clusters made more sense than two clusters, even though the two-cluster solution was more parsimonious.

Table 4 shows the three mind-sets emerging from clustering on the basis of belief in the validity of the information. Table 5 shows a different group of three mind-sets, emerging from the clustering the basis of price.

Table 4: Coefficients of the 36 elements for the Total Panel, across the two dependent variables (believable via R98; price would pay in actual dollars).

tab 4

Table 5: Coefficients for Mind-Sets based upon belief in validity (DV = 98). Only positive coefficients 4 or higher are shown.

tab 5

The segments are different. When we extract three mind-sets for each dependent variable, we find that the mind-sets emerging from the emotion reaction (R98; believe in validity) seem to the author be authentic and compelling. In contrast, the mind-sets based upon price seem to be more conventional. Furthermore, although we pull out three mind-sets for price, the reality is that there are probably two mind-sets, not three. The third mind-set (self-fulfillment) really only has one strong performing element.

Mind-Sets Based Upon Believe in Validity (R98)

MSB1 – Make your inner self come alive and real (N=47)

MSB2 – Appeal to authority and tradition (N=34)

MSB3 – Reinforce the power for beauty within by hypnosis (N=20)

Mind-Sets Based Upon Price

MSP1 – Appeal to secret ‘formula’ (N = 40)

MSP2 – Ease and convenience (N = 26)

MSP3 – Self Fulfillment (N=35)

Figure 3 shows a linear relation between coefficient of price (ordinate) and coefficient of believability (abscissa). Figure 4 shows the same plot, this time for the three mind-sets created by clustering coefficients for believability (MSB1, MSB2, MSB3), and for the three mind-sets created by clustering coefficients for price (MSP1, MSP2, MSP3). Surprisingly, the lines fit to the scatterplots are parallel to each other.

fig 4

Figure 4: Scatterplot for the six mind-sets extracted from the data. MSB1-MSB3 were extracted from the coefficients for believability. MSP1-MSP3 were extracted from the coefficients for price.

Discussion and Conclusions

The study presented in this paper was done around 2012, a decade ago, and resurrected after a discussion about alternative forms of beauty that are available. During the course of the conversation the author recalled the study, returned to it, looked at the topics, and ‘worked up’ the data for publication. The realization then once again dawned. Here was a way to do science, motivated by a simple problem (quest for beauty), a world view (holistic), and a set of techniques (hypnotism and auto-suggestion).

A search through the scientific literature using Google Scholar® revealed little published information about hypnosis combined with beauty, and virtually nothing dealing with the appropriate messaging about the topic. There were papers and books dealing with the general benefits of hypnosis for better living, including enhanced beauty [12]. It is as if the idea of hypnosis and beauty was left to the popular press, and not invited to be studied by serious researchers.

At this point, almost 11 years after the study was done, remains the realization of the value of the process. On the one hand, it was easy to do in 2011-2012. One simply needed to collaborate with a person involved in beauty and with another person working in the world of hypnosis and psychodynamics (e.g., psychotherapy). The was no need for expertise, but simply a set of questions, and then answers each question, as well as two additional scales (believe, price, respectively) The rest proceeded virtually automatically, creating what might be called a ‘database of the mind’ in this exceptionally circumscribed topic of beauty emerging from hypnosis. The other key observation is the value of data about messaging in a specific, circumscribed topic, value which lasts decade, and no doubt longer.

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The Ionic Liquid-Assisted Synthesis of a Novel Polyaniline/Graphitic Carbon Nitride/Zinc Tungstate (PANI/g-C3N4/ZnWO4) Ternary Nanocomposite: The Usage of Easy Double Electron Transfer Photocatalyst for Glyphosate Photocatalytic Degradation Process

DOI: 10.31038/NAMS.2023622

Abstract

In this study, a novel polyaniline/graphitic carbon nitride/zinc tungstate (PANI/g-C3N4/ZnWO4) (PGZ) ternary nanocomposites (NCs) as a heterostructure photocatalys was examined during photocatalytic degradation process in the efficient removal of glyphosate herbicide from a aqueous solution. Different pH values (3.0, 5.0, 7.0, 9.0 and 11.0), increasing glyphosate concentrations (5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l), increasing PANI/g-C3N4/ZnWO4 ternary NCs concentrations (5 mg/l, 15 mg/l, 30 mg/l and 45 mg/l) and increasing recycle times (1., 2., 3., 4., 5., 6. and 7.) was operated during photocatalytic degradation process in the efficient removal of glyphosate in a aqueous solution. The characteristics of the synthesized nanoparticles (NPs) were assessed using X-Ray Difraction (XRD), Field Emission Scanning Electron Microscopy (FESEM), Energy-Dispersive X-Ray (EDX), Fourier Transform Infrared Spectroscopy (FTIR), Transmission Electron Microscopy (TEM), Diffuse reflectance UV-Vis spectra (DRS) and X-Ray Photoelectron Spectroscopy (XPS) analyses, respectively. The cyctotoxicity test was operated to the standard TBE (trypan blue dye exclusion) assay technique with Drosophila melanogaster (fruit fly). ANOVA statistical analysis was used for all experimental samples. The maximum 99% glyphosate removal efficiency was obtained during photocatalytic degradation process in aqueous solution, at 15 mg/l gylphosate, at 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs, at pH=11.0, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time and at 25°C, respectively. The maximum 99% cyctotoxicity removal was observed at untreated glyphosate samples, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively. The maximum 99% cyctotoxicity removal was observed at 5 mg/l PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst concentrations, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively. The study revealed the excellent minimization of cytotoxicity of glyphosate after photocatalytic degradation process with the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst. As a result, the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst is found to be non-cytotoxic irrespective of its quantity used. Finally, the combination of a simple, easy operation preparation process, excellent performance and cost effective, makes this a novel PANI/g-C3N4/CoMoO4 ternary NCs heterostructure photocatalyst a promising option during photocatalytic degradation process in agricultural industry wastewater treatment.

Keywords

ANOVA statistical analysis, Cytotoxicity test, Diffuse reflectance UV-Vis spectra (DRS), Drosophila melanogaster (fruit fly), Electrochemical filtration process, Energy-dispersive X-ray (EDX), Field emission scanning electron microscopy (FESEM), Fourier transform infrared spectroscopy (FTIR), Gylphosate, Herbicites, Ionic liquid-assisted synthesis, Novel polyaniline/graphitic carbon nitride/zinc tungstate (PANI/g-C3N4/ZnWO4) ternary nanocomposites, Pesticides, Photocatalytic degradation, Transmission electron microscopy (TEM), X-ray difraction (XRD), X-ray photoelectron spectroscopy (XPS)

Introductıon

The intense populational growth and industrial expansion in the most diverse segments of society have led to a substantial increase in the demand for drinking water supply and large-scale food production [1]. Thus, to increase productivity at an economically profitable level, the employment of agrochemicals has been widely used to combat pests and weeds [2]. With the enhanced use of a new variety of anthropogenic compounds towards industrialization, water pollution has increased substantially [3]. Anthropogenic compounds like synthetic pesticides and herbicides are often used in agricultural fields to protect crops. However, pesticides are characterized by low biodegradability, high bioaccumulative capacity arising from their physicochemical properties, and a long half-life, of 5-15 years, increasing their toxicity to the environment and humans [4,5]. Thus, pesticide persistence in soil, wastewater, ground, and surface water has proved to be a considerable environmental problem, and may be compounded along the food chain, reaching concentrations toxic to human health [6]. Due to their high stability, these compounds can contaminate areas distant from pulverization through water volatilization and soil absorption. Studies have associated exposure to compounds with hormonal changes in the immune, neurological and cardiac systems, as well as with the development of neoplasms [7,8].

For this purpose, diverse techniques, such as adsorption and advanced oxidative processes (AOPs), which include Fenton, photo-fenton, heterogeneous photocatalysis and ozonation systems, have been explored for removing and degrading biopersistent organic compounds [9-11]. AOPs are based on the generation of free radicals, e.g., hydroxyl (OH) and superoxide (O2– ●) radicals, which have high oxidizing power in an aqueous solution and are able to degrade pollutants into lower molecular weight intermediates and inorganic precursors [12,13]. Heterogeneous photocatalysis is an advanced oxidative process that occurs through the photoactivation (by sunlight or artificial light) of a semiconductor, which uses water molecules and dissolved oxygen as reagents of oxi-reduction reactions [14]. This technique is very efficient and promising for the degradation of organic pollutants, including dyes, drugs and pesticides [15,16]. Among the materials used, metallic nanooxides (zinc oxide, ZnO and titanium dioxide, TiO2) have been largely employed due to their excellent properties, such as low toxicity, good availability, chemical stability, large surface area/porosity, and photocorrosion [17,18]. However, these conventional nanocatalysts are characterized by their high bandgap energy, which is the energy required to start photocatalytic reactions. Additionally, due to their high surface energy, they tend to agglomerate during the photocatalytic process. Therefore, the association of these nanocatalysts with a second, less active material (called catalytic support or matrix) can solve these drawbacks, even when the active material is dispersed in low concentrations (ca. 0.5-5 wt%) on the support [19]. Thus, combining the two materials results in a new material called NCs, in which the active substance is in the above-mentioned concentration range and this is named the reinforcement phase [20].

NCs are multiphase materials formed by a continuous and dispersed phase and have at least one dimension in the nanoscale [21]. The continuous phase (matrix) consists of a compound of polymeric, ceramic or metallic origin, while the dispersed phase (reinforcement) is commonly derived from fibrous materials [22-24]. NCs materials are synthesized to combine individual properties and reduce limitations, such as physicochemical and thermal instability, expanding the scope of applications. In parallel, at the nanoscale, the materials exhibit distinct behaviors to those found at the micrometer scale, such as volume/area relationship and increased reactivity [25]. Another technique widely used for pesticide removal from wastewater consists of adsorption, especially when using nanomaterials (adsorbents), due to its simplicity of operation, relatively low cost, and low energy requirements [26]. In addition, nanoadsorbents are characterized by their high specific surface area, chemical/thermal stability, and affinity for organic pollutants [27]. Although the efficiency of nanoadsorbents in the removal of organic compounds is remarkable, there are still limitations to conventional materials’ use, such as separation from the aqueous medium and the reuse of nanoadsorbents and nanocatalysts [28]. Recently, the development of nanocomposites as nanoadsorbents has been the subject of diverse research due to their increased surface area and physicochemical stability. Moreover, magnetic NCs have been used as a good alternative to improve the stability, textural properties, and reuse of nanoadsorbents [29]. The facilities separate material from the aqueous medium and considerably increase their reuse, resulting in high adsorptive capacity [30]. Additionally, the same behavior is observed for magnetic NCs as nanocatalysts. Using magnetic nanocatalysts allows the reuse of the material, increasing the cost-effectiveness and avoiding subsequent steps such as filtration and centrifugation [31].

Glyphosate {N-phosphomethyl[glycine] or (C3H8NO5P)}, is an organophosphorus compound with herbicide properties discovered in 1970. It is a competitive inhibitor of the 5-enolpyruvylshikimate-3-phosphate synthase, an enzyme involved in aromatic amino acid biosynthesis in plants and microorganisms [32]. Glyphosate is now the most used herbicide globally, and its usage keeps increasing with the emergence of weed resistance, from 16 million kg spread in the world in 1994 to 79 million kg spread in 2014, including 15% in the United States alone [33]. Once in the environment, glyphosate is metabolized by microorganisms into aminomethylphosphonic acid (AMPA; known as its most active metabolite) and methylphosphonic acid (MPA) (Figure 1) [34]. Glyphosate and its metabolite AMPA can be found in soils, water, plants, food, and animals [35-37]. Glyphosate is detected in human urine, blood, and maternal milk, with urinary levels of 0.26-73.5 μg/l in exposed workers and 0.16-7.6 μg/l in the general population [38,39]. Glyphosate most likely enters the body via the dermal, oral and pulmonary routes [40]. Even if the dermal route allows a poor absorption (≈2%), it is the main reported route of entry in exposed farmers [41]. Glyphosate then seems to accumulate principally in the kidneys, liver, colon, and small intestine and is eliminated in the feces (90%) and urine within 48 h. Because of this omnipresence, its safety is of grave concern. Glyphosate has long been regarded as harmless allegedly because it targets an enzyme inexistent in animals, is supposedly degraded into CO2, and its formulation contains misleadingly-called “inert” ingredients. Nevertheless, there is growing literature that describes the risks for glyphosate and glyphosate-based herbicides on human health [42]. After more than 40 years of global use, glyphosate has been classified as “probably carcinogenic” in humans by the International Agency for Research on Cancer (IARC). In March 2015, the World Health Organization’s IARC classified three organophosphates (glyphosate, malathion, and diazinon) as “probably carcinogenic for humans” (Category 2A) [43]. In contrast, in November 2015 the European Food Safety Agency determined glyphosate was “unlikely to pose a cancer risk for man” [44]. In 2018 the European Chemicals Agency, Risk Assessment Committee concluded that “the scientific evidence so far available does not satisfy the criteria for classifying glyphosate as carcinogenic, mutagenic or toxic for reproduction” [45]. In 2019, US federal health agency, the Agency for Toxic Substances and Disease Registry (ATSDR) [46], part of the Centers for Disease Control and Prevention [47], determined that both cancer and non-cancer hazards derive from exposure to glyphosate and glyphosate-based herbicides.

fig 1

Figure 1: Glyphosate and main glyphosate by-products; aminomethylphosphonic acid (AMPA), methylphosphonic acid (MPA) and glyoxylate, respectively.

In modern agriculture, especially in most intensive and large-scale crops, herbicides are used to eliminate weeds. Glyphosate is a non-selective, highly effective, broad-spectrum, and low toxicity herbicide, whose usage increases exponentially for the effective in eliminating weeds indiscriminately [48]. In recent years, the long half-life of glyphosate and its main metabolite AMPA causes the existence in the environment. The potential impact of glyphosate in the environment is an increasing concern around the world. In the recent past, a significant increase in the use of the glyphosate herbicide has been noticed which further increased after the introduction of glyphosate-tolerant crops [49,50]. According to a report, The United States saw a 14 times increase in glyphosate use between 1992 and 2015, where the majority was applied to soybean and corn crops [51]. Being a nonselective, mutagenic, and carcinogenic herbicide, their presence in atmosphere can cause severe health and environmental issues [52]. As a result, it poses a high environmental risk and requires prompt studies towards its elimination.

In recent years, photocatalytic studies have explored the fabrication of ternary heterojunctions as a preferred scientific and practical method to improve the migration of photogenerated charge carriers [53]. Towards this end, ternary type II heterojunctions have shown significant success with accelerated charge carrier production [54]. However, the repulsion between the photogenerated electrons and the formation of weaker redox potentials limit its photocatalytic activity [55]. Therefore, another promising photosystem known as a Z-scheme heterojunction was developed to overcome the aforementioned issues [56]. In the case of Z-scheme photosystems, the conduction band electrons with a lower energy of one semiconductor migrate towards the valence band holes with a higher energy of other semiconductors. This combination leads to the formation of highly reductive electrons as well as highly oxidative holes [57]. Additionally, Z-scheme photo-systems not only enhance the charge separation efficiency of semiconductor photocatalysts but also possess electrons and holes with strong redox potential for superior photocatalytic applications. Moreover, ternary heterojunctions with a double electron transfer Z-scheme have photogenerated charge carriers with a prolonged lifetime compared to binary systems which improves the scope of light-harvesting [58]. Some recent ternary heterojunctions with double electron transfer Z-scheme channelization are g-C3N4/ZnO/ZnWO4, polyaniline-BiOBr-GO, g-C3N4/Zn2SnO4N/ZnO [59-61].

The fabrication of NCs in ionic liquid (IL) media can provide a better scaling up approach for microscopic dispersion of particles and close interface contact between the individual components [62]. ILs as synthetic media provide unique advantages like negligible vapor pressure, thermal stability, and better conductivity than NCs. Additionally, the effect of “cation-π” and “π-π” interactions due to the presence of ionic liquids improve the nanoparticles (NPs) dispersion and stabilization which boosts the surface to volume ratio of NCs [63]. Recently, ionic liquids have been also employed for extensive polymerization and catalysis applications. Pahonik et al. [64] verified the oxidative polymerization of aniline with ammonium persulphate and the IL 1-butyl-3-methylimidazolium chloride (BMIMCl) under acidic conditions. More interestingly, IL-assisted NCs synthesis processes are relatively rapid, facile, greener, and more efficient without the requirement of any foreign stabilizer and surfactants [65]. The development of nanostructures and NCs with a simplified and greener IL-assisted in situ oxidative polymerization method is highly preferable method for photocatalytic degradation process of environmental pollutants.

Polyaniline (PANI) is a conducting polymer and organic semiconductor of the semi-flexible rod polymer family. PANI is one of the most studied conducting polymers [66,67]. To fabricate a ternary heterojunction, PANI can serve as the third active component of the photosystem. PANI has high demand as a low-cost and environment-friendly conjugated semiconductor for the fabrication of visible light harvesting photocatalysts [68]. It is a conducting polymer with an extensive conjugated π-system and high absorption coefficient towards visible light mediated charge carrier production. Furthermore, advantages like simple processing and high conductivity make it an emerging material for the synthesis of heterojunction materials. Recently, many efforts have been made to maximize the photo-harvesting efficiency of PANI-based composite materials. Researchers explored many positive hybrid effects arising from such systems due to the close contact of the interfaces of individual components leading to high separation efficiency of photogenerated electron-hole pairs [69].

The two-dimensional (2D) g-C3N4 semiconductor has a wide range of applications in the environmental and energy fields because of its visible-light activity, unique physicochemical properties, excellent chemical stability and low-cost [70,71]. Some important limitations of the photocatalytic activity of g-C3N4 are its low specific surface area, fast recombination of electrons and holes and poor visible light absorption [72-74]. To improve the above problems, the construction of a heterojunction with a suitable band gap semiconductor (co-catalyst) has been shown to be a good strategy to improve the photocatalytic performance of g-C3N4, such as g-C3N4-based conventional type II heterostructures, g-C3N4-based Z-scheme heterostructures, and g-C3N4-based p-n heterostructures, etc. The unique “Z” shape as the transport pathway of photogenerated charge carriers in Z-scheme photocatalytic systems is the most similar system to mimic natural photosynthesis in the many g-C3N4-based heterojunction photocatalysts. The construction of Z-scheme photocatalytic systems can promote visible light utilization and carrier separation, and maintain the strong reducibility and oxidizability of semiconductors [75-78]. There are many studies on g-C3N4-based Z-scheme heterojunction photocatalysts, such as ZnO/g-C3N4 [79-82], WO3/g-C3N4 [83], g-C3N4/ZnS, g-C3N4/NiFe2O4 [84], g-C3N4/graphene/NiFe2O4 [85], NiCo/ZnO/g-C3N4 [86] and Bi2Zr2O7/g-C3N4/Ag3PO4 [87], respectively. g-C3N4-based Z-scheme heterojunction photocatalysts have been made to improve the photocatalytic activity by combining with other semiconductor materials. Therefore, there are some problems with the single photocatalytic method, such as low adsorption ability, limited active sites and low removal efficiency. The integration of the adsorption and photocatalytic degradation of various organic pollutants is considered as a suitable and promising technology. On the other hand, it is still essential to fabricate photocatalysts with superior adsorption and degradation efficiencies.

g-C3N4 has been gaining great attention as a potential photocatalyst due to its stability and safety characteristics, as well as the fact that it can be facilely synthesized from low-cost raw materials. The low bandgap (~2.7 eV) can drive photo-oxidation reactions even under visible light [88-90]. However, the pure g-C3N4 has some drawbacks such as its low redox potential and high rate of recombination between photo-induced electrons and holes, which dramatically limits its photocatalytic efficiency. Several strategies have been investigated, including modification of the material’s size and structure [91], nonmetal and metal doping [92,93], and coupling with other photocatalysts [94-97]. For example, Liu et al. improved bulk g-C3N4’s performance in terms of Rhodamine B degradation from 30% to 100% by synthesizing mesoporous g-C3N4 nanorods through the nano-confined thermal condensation method. Dai et al. doped g-C3N4 with Cu through a thermal polymerization route and acquired a degradation rate of 90.5% with norfloxacin antibiotic. Nithya and Ayyappan, synthesized hybridized g-C3N4/ZnBi2O4 for reduction of 4-nitrophenol and reached an optimal removal efficiency of 79%. Among all, the construction of heterostructure photocatalysts by coupling g-C3N4 with other semiconductors seems to be an effective strategy to prevent electron and hole recombination, hence improving photocatalytic efficiency for contaminant treatment.

Zinc tungsten oxide or zinc tungstate (ZnWO4) has received wide attention owing to its high ultraviolet (UV) light response, tunable band edges, optical transparency, easy availability, chemical stability, and adequate strength [98]. The band edge tunning of ZnWO4-centered nanostructures can be organized through appropriate changes such as heterostructure construction, doped/combining with transition metal ions, and noble metals [99,100]. The alteration of electronic environment in ZnWO4 nanomaterials through such engineered modifications can lead to interesting catalytic properties. The relationship between their structures and properties should therefore be considered to progress extremely proficient solar light conserving photocatalysts for the removal of toxic contaminants [101]. In the case of heterogeneous photocatalysis such as ZnWO4, solid catalysts/semiconductors are utilized to remove organic pollutants under light irradiation due to redox reactions in photogenerated charge carriers. The mechanism is divided into three significant steps, generation of charge carrier pairs under irradiation, photogenerated charge carriers migrating on the surface of the catalyst, and initiation of the redox reaction by oxidative (OH) and superoxide (O2– ●) radicals [102]. For instance, Alshehri et al. [103] investigated that ZnWO4 was used as a photocatalyst to degrade MB dye, and they reported the formation of OH and O2– ● free radicals oxidized the dye molecules to form inorganic minerals. The organic molecules by the photogenerated electron holes can also occur while hydroperoxyl radicals (OOH) and H2O2 are produced by the subsequent reactions, which occur between O2– ● and H+. This heterogeneous photocatalytic process induces the mineralization of organic pollutants (CO2 and H2O). Depending on the process’s efficiency, the pollutant’s composition, and its structure, additional products such as acids and salts can be formed. Exploration into photocatalysis has shown how UV-light, visible light, and solar irradiation can be utilized effectively to reduce environmental pollution [104,105]. Electron-hole pairs are produced when photon energy more prominent than the band gap of the semiconductor used to illuminate the semiconductor; this then leads to the formation of electron-hole pairs. OH when the generated electrons and holes react with H2O and molecular oxygen on the surface of the crystal. With oxygen ions deposited around the tungsten, ZnWO4 forms an insulated [WO6] octahedron coordination with an asymmetric shape showing its local atomic structures with a monoclinic wolframite-type structure with the space group P2/c [106]. This is an essential inorganic ternary oxide material as it has been known to crystallize as a scheelite structure depending on the ionic radius [107]. However, W clusters form a network because they are more stable, which leads to forming the covalent nature of W-O bonds. In forming electron-hole pairs associated with a charge separation process and dipoles, the WO6 clusters act as electron receptors. Thus, the oxygen vacancies in the Zn/W clusters can transfer electrons to the tungsten cluster and thus form permanent dipoles [108]. The Zn and W vacancies act as hole traps because they are negatively charged [109]. During the UV irradiation of ZnWO4, the conduction band electrons generated are transferred to Ag nanocrystallite due to the Schottky barrier at Ag/ZnWO4, which aid the charge carrier separation [110,111]. Different researchers have provided detailed and in-depth information, including improving ZnWO4 as the next-generation catalysts for wastewater treatment. For instance, Gouveia et al. demonstrated that the overall performance of ZnWO4 NPs was linked to the exposed surfaces of materials, their functional properties, and morphological structures; however, the authors failed to explain the concept of binary and multiple doping effects of ZnWO4. According to the first-principle approach, the photocatalytic activity of ZnWO4 depends on the intrinsic atomic properties and the electronic structure of the incomplete surface clusters of the exposed surfaces of the morphology. The authors found that the surface clusters in the morphology controlled the intrinsic atomic properties of the metal oxide in question. Furthermore, Geetha et al. [112] prepared ZnWO4 nanoparticles via the co-precipitation method for the photocatalytic degradation of methylene blue (MB). The highest dye removal (81%) was observed for ZnWO4 NPs prepared with 30 cm3 distilled water. Also, the performance of ZnWO4 depended on the volume of the solvent (30-90 ml) and band gap energy (3.19 eV-3.16 eV), which was evidence of reduced interaction between metal and oxygen orbital. The members of the tungstate family have, over the years, been used for the mineralization of organic pollutants under UV [113] and sunlight [114] irradiation. However, the photocatalytic strength of ZnWO4 stand-alone is not strong enough (Rahmani and Sedaghat, 2019). The enhancement of the photocatalytic activity of semiconductor ZnWO4 for practical applications has deeply been considered for the degradation of contaminants. This has been the goal of many industries and scientists interested in environmental pollution control. However, a couple of approaches have been reported to further increase the properties of ZnWO4 NPs for wastewater treatment.

In this study, a novel PANI/g-C3N4/ZnWO4 ternary NCs as a heterostructure photocatalys was examined during photocatalytic degradation process in the efficient removal of glyphosate herbicide from a aqueous solution. Different pH values (3.0, 5.0, 7.0, 9.0 and 11.0), increasing glyphosate concentrations (5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l), increasing PANI/g-C3N4/ZnWO4 ternary NCs concentrations (5 mg/l, 15 mg/l, 30 mg/l and 45 mg/l) and increasing recycle times (1., 2., 3., 4., 5., 6. and 7.) was operated during photocatalytic degradation process in the efficient removal of glyphosate in a aqueous solution. The characteristics of the synthesized NPs were assessed using XRD, FESEM, EDX, FTIR, TEM, DRS and XPS analyses, respectively. The cyctotoxicity test was operated to the standard TBE (trypan blue dye exclusion) assay technique with Drosophila melanogaster (fruit fly). ANOVA statistical analysis was used for all experimental samples.

Materıals and Methods

Preparation of Graphitic Carbon Nitride (g-C3N4) Nanoparticles

g-C3N4 nanoparticles (NPs) was prepared by calcination of melamine (C3H6N6) in a crucible with a lid at 550°C for 4 h. The obtained yellow powder was ground in an agate mortar after being cooled down to 25°C room temperature.

Preparation of Zinc Tungstate (ZnWO4) Nanoparticles

ZnWO4 NPs was prepared to sol-gel methods. Sol-gel method also called chemical solution deposition; it entails hydrolysis and polycondensation, gelation, aging, drying, densification, and crystallization. It is a highly effective method for synthesizing ZnWO4 NPs with modified surfaces. Grossin [115] describe this method as involving the hydrolysis of the precursor in acidic or basic mediums and the polycondensation of the hydrolyzed. Rahmani and Sedaghat studied the nature of the ZnWO4 NPs obtained from this study. The ZnWO4 NPs were synthesized by adding 30 ml ethanol and 3 ml HCl into a mixture of zinc acetate dropwise, while sodium tungstate in deionized water was added to 20 ml of ethanol in a dropwise form. Both solutions were mixed vigorously, after which urea was added to the zinc acetate and sodium tungstate mixture. The ZnWO4 NPs synthesized were characterized as well, where it was observed that the band gap energy was 3.20 eV. The ZnWO4 NPs synthesized had an average diameter of between 26-78 nm.

Preparation of A Novel PANI/g-C3N4/ZnWO4) (PGZ) Ternary Nanocomposites (NCs)

The novel PANI/g-C3N4/ZnWO4) (PGZ) ternary NCs was synthesized by adopting an ionic liquid-assisted in situ oxidative polymerization process. The process includes the 1-butyl-3-methylimidazolium chloride-assisted polymerization of aniline using (NH4)2S2O8 as an oxidant. Firstly, 0.5 ml, 1.0 ml and 2.0 ml of aniline was added to an aqueous solution of 1-butyl-3-methylimidazolium chloride to make three different PANI solutions. Afterward, to each PANI mixture, an appropriate amount of (NH4)2S2O8 was added in a (NH4)2S2O8 /aniline=1/1 molar ratio. In two other round bottom flasks, 0.20 g g-C3N4 and 0.20 g ZnWO4 were dispersed in 30 ml of 0.10 M HCl solution under ultra-sonication for 30 min. Subsequently, the particle mixtures were poured into the previously prepared PANI mixtures. The polymerization process was maintained for 12 h under mechanical stirring at 25°C room temperature. The products were separated by centrifugation and washed multiple times with ethanol to remove the residual IL media. The three composite mixtures obtained were dried in a vacuum oven at 70°C. The prepared samples are marked as xPGZ (0.5-PGZ, 1-PGZ, and 2-PGZ), where x denotes the amount of aniline added. For simplicity, sample 1-PGZ is referred to as PGZ throughout this study.

Photocatalytic Degradation Reactor

A 2 liter cylinder quartz glass reactor was used for the photodegradation experiments in the glyphosate aqueous solution at different operational conditions. 1000 ml glyphosate aqueous solution was filled for experimental studies and the photocatalyst were added to the cylinder quartz glass reactors. The UV-A lamps were placed to the outside of the photo-reactor with a distance of 3 mm. The photocatalytic reactor was operated with constant stirring (1.5 rpm) during the photocatalytic degradation process. 10 ml of the reacting solution were sampled and centrifugated (at 10000 rpm) at different time intervals. The UV irradiation treatments were created using one or three UV-A lamp emitting in the 350-400 nm range (λmax=368 nm; FWHM=17 nm; Actinic BL TL-D 18W, Philips). Three 50 W UV-A lamps (Total: 150 W UV-A lamps) were used during experimental conditions for this study.

Glyphosate Photocatalytic Degradation Experiments

The photocatalytic degradation efficiencies of PANI, g-C3N4 NCs, ZnWO4 NCs and PANI/g-C3N4/ZnWO4 ternary NCs were investigated with a cylinder quartz glass photocatalytic reactor under UV-vis light irradiation. The series of glyphosate degradation studies were performed in an aqueous solution. The temperature of the photocatalytic system was maintained using continuously circulating aqueous solution. Typically, 25 mg/l catalysts were used for the batch degradation study with 100 ml of 10 mg/l glyphosate under continuous magnetic stirring. The pH=7.0 ± 0.1 of the pollutant solutions was maintained throughout the degradation process by adding H2SO4 and NaOH solutions as necessary. Initially, the reaction mixtures were kept in dark to check the adsorption properties of glyphosate and to attain adsorption-desorption equilibrium. Next, the whole setup was exposed to UV-vis light for the photocatalytic degradation study. In 20 min time gap, a 4 ml aliquot of the pollutant solution was withdrawn and centrifuged to separate the NCs. The initial and final concentration supernatants were analyzed using a UV-vis spectrometer for detection of the intermediates and degradation products formed during the photocatalytic degradation process. The percentage degradation was calculated by the following Equation (1):

for 1

Determination of Glyphosate and Photodegradation by-Products

The quantification of glyphosate and glyphosate major photodegradation products was determined to a Gas Chromatography-Mass Spectrometry (GC-MS). These samples were performed with a gas chromatographya gas chromatographically (Agilent 6890N GC) equipped with a mass selective detector (Agilent 5973 inert MSD) (GC-MS) (Hewlett-Packard 6980/HP5973MSD). A capillary column (HP5-MS, 30 m, 0.25 mm, 0.25 m) was used. The initial oven temperature was kept at 50°C for 1 min, then raised to 200°C at 25°C/min and from 200°C to 300°C at 8°C/min, and then maintained for 5.5 min. High purity He(g) was used as the carrier gas at constant flow mode (1.5 ml/min, 45 cm/s linear velocity). The method involves the addition of 5% borate buffer to the aqueous sample to adjust the pH=9.0 and then mixing with 9-fluorenylmethyl chloroformate (FMOC) in acetonitrile prior to analysis. The derivatization process was continued for 16 h at 25°C and the process was stopped by drop-wise addition of 6 M HCl solution where the resulting pH was measured to be pH=1.5. Chromatographic separation was performed with a C18 column where the mobile phase was 5 mM HAc/NH4Ac (pH=4.8) acetonitrile. The acetonitrile percentage was changed from 75% (0-42 min) to 100% (42.1-45 min) to 5% (45.1-50 min). For each sample separation process was completed in 50 min. The degradation products were detected at 210 nm with a PDA detector. The same method was also applied for derivatization and analysis of glyphosate and glyphosate by-products; acetate, aminomethylphosphonic acid (AMPA), phosphate, sarcosine and glycine as standards.

Quantification of Major Oxygen Species

To quantify the reactive oxygen species (OH and O2– ●) production under light illumination, 1.2 g/l benzoic acid and 5×10−5 mol/l nitro blue tetrazolium dichloride (NBT) solutions were considered as molecular probes, respectively. 100 mg of PANI/g-C3N4/ZnWO4 ternary NCs was dispersed in 100 ml of the molecular probe solutions to evaluate the radical production efficiency. For every 10 min, 3 ml of sample was pipetted out for further analysis. The NBT sample was analyzed with a UV spectrometer (Shimadzu 2450) at 258 nm. The quantification of O2– ● was done by the NBT degradation method. The quantity of OH was measured by analyzing the amount of p-hydroxybenzoic acid in the sample with the same GC-MS method mentioned above. In this case, the mobile phase was acetonitrile/water (30/70) with a 1 ml/min flow rate.

Characterization

X-Ray Diffraction Analysis

Powder XRD patterns were recorded on a Shimadzu XRD-7000, Japan diffractometer using Cu Kα radiation (λ=1.5418 Å, 40 kV, 40 mA) at a scanning speed of 1°/min in the 10-80° 2θ range. Raman spectrum was collected with a Horiba Jobin Yvon-Labram HR UV-Visible NIR (200-1600 nm) Raman microscope spectrometer, using a laser with the wavelength of 512 nm. The spectrum was collected from 10 scans at a resolution of 2 /cm. The zeta potential was measured with a SurPASS Electrokinetic Analyzer (Austria) with a clamping cell at 300 mbar.

Field Emission Scanning Electron Microscopy (FESEM) and Energy Dispersive X-Ray (EDX) Spectroscopy Analysis

The morphological features and structure of the synthesized catalyst were investigated by FESEM (FESEM, Hitachi S-4700), equipped with an EDX spectrometry device (TESCAN Co., Model III MIRA) to investigate the composition of the elements present in the synthesized catalyst.

Fourier Transform Infrared Spectroscopy (FTIR) Analysis

The FTIR spectra of samples was recorded using the FT-NIR spectroscope (RAYLEIGH, WQF-510).

Transmission Electron Microscopy (TEM) Analysis

The structure of the samples were analysed TEM analysis. TEM analysis was recorded in a JEOL JEM 2100F, Japan under 200 kV accelerating voltage. Samples were prepared by applying one drop of the suspended material in ethanol onto a carbon-coated copper TEM grid, and allowing them to dry at 25°C room temperature.

Diffuse Reflectance UV-Vis Spectra (DRS) Analysis

DRS Analysis in the range of 200-800 nm were recorded on a Cary 5000 UV-Vis Spectrophotometer from Varian. DRS was used to monitor the glyphosate concentration in experimental samples.

X-Ray Photoelectron Spectroscopy (XPS) Analysis

The valence state of the biogenic palladium nanoparticles was investigated and was analyzed using XPS (ESCALAB 250Xi, England). XPS used an Al Ka source and surface chemical composition and reduction state analyses was done, with the core levels recorded using a pass energy of 30 eV (resolution ≈0.10 eV). The peak fitting of the individual core-levels was done using XPS-peak 41 software, achieving better fitting and component identification. All binding energies were calibrated to the C 1s peak originating from C-H or C-C groups at 284.6 eV.

Cytotoxicity Test

The standard TBE (trypan blue dye exclusion) assay technique was followed for to check the cytotoxicity of the photo-treated glyphosate solution and photocatalyst. Drosophila melanogaster (fruit fly) was considered as a model organism since 75% of its disease genome sequence is functionally homologous to that of humans [116]. Similar studies were also reported where Drosophila melanogaster was employed as a model research organism to study the toxic effects of various chemicals, drugs, medicines and NPs. The TBE assay has been studied for differentiating live and dead cells in the Drosophila melanogaster larval gut. Before the cytotoxicity study, glyphosate samples (untreated, 5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l) were prepared. And, to analyze the cytotoxic effects of both the initial glyphosate solution and phototreated products, the TBE assay was implemented. Firstly, third instar larvae were taken and washed with 1× PBS to remove food particles that remained in the larval body. Then, the larvae were transferred to a Petri plate with 2% solidified agar to keep them hungry. After that, 10 3rd instar larvae were transferred to 1.5 ml eppendorf tubes each containing 500 μl of the glyphosate solutions, respectively. These larvae were kept for 30 min to feed on the chemical orally. After the incubation, the larvae were washed once with 1× PBS. Then, the larvae were transferred into a container with 0.5% TBE solution and kept for 45 min in a dark atmosphere at 25°C room temperature. After incubation, again the excess strain was washed twice with 1× PBS for 10 min each [117]. Then, further analysis was done with a USB stereomicroscope and digital images were taken to check any abnormality in the gut. A similar procedure was followed for different amounts of the PANI/g-C3N4/ZnWO4 ternary NCs samples (5 mg, 15 mg, 30 mg and 45 mg). Finally, the percentage of the defective Drosophila melanogaster larva is calculated as following Equation (2):

for 2

Statistical Analysis

ANOVA analysis of variance between experimental data was performed to detect F and P values. The ANOVA test was used to test the differences between dependent and independent groups [118]. Comparison between the actual variation of the experimental data averages and standard deviation is expressed in terms of F ratio. F is equal (found variation of the date averages/expected variation of the date averages). P reports the significance level, and d.f indicates the number of degrees of freedom. Regression analysis was applied to the experimental data in order to determine the regression coefficient R2 [119]. The aforementioned test was performed using Microsoft Excel Program.

All experiments were carried out three times and the results are given as the means of triplicate samplings. The data relevant to the individual pollutant parameters are given as the mean with standard deviation (SD) values.

Results and Discussions

A Novel PANI/g-C3N4/ZnWO4 Ternary NCs Characteristics

The Results of X-Ray Diffraction (XRD) Analysis

The results of XRD analysis was observed to pure g-C3N4 NPs, pure ZnWO4 NPs, pure PANI and PANI/g-C3N4/ZnWO4 ternary NCs, respectively, in aqueos solution with photocatalytic degradation process for glyphosate removal (Figure 2). The characterization peaks were observed at 2θ values of 12.71° and 28.84°, respectively, corresponding to the (100) and (002) planes of implying pure g-C3N4 NPs in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 2a). The characterization peaks were obtained at 2θ values of 17.10°, 19.52°, 14.70°, 15.01°, 30.17°, 37.28°, 39.11°, 42.34°, 44.41°, 46.53°, 49.20°, 50.65°, 53.42°, 54.41°, 61.36°, 65.22°, and 68.74°, respectively, corresponding to the (010), (100), (011), (110), (111), (021), (200), (121), (112), (211), (002), (220), (130), (202), (032), (311) and (041), respectively, implying pure ZnWO4 NPs in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 2b). The characterization peaks were found at 2θ values of 18.27°, 24.32°, 26.11°, 28.44°, 30.10°, 37.22°, 41.34°, 53.28°, 61.34° and 64.42°, respectively, corresponding to (100), (011), (110), (002), (111), (021), (200), (121), (202), (032) and (311), respectively, implying PANI in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 2c). The characterization peaks were observed at 2θ values of 28.39°, 30.17°, 37.63°, 41.20°, 54.33°, 61.20° and 64.60°, respectively, corresponding to (002), (111), (021), (121), (202), (033) and (312), respectively, implying PANI in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 2d).

fig 2

Figure 2: The XRD patterns of (a) pure g-C3N4 NPs, (b) pure ZnWO4 NPs, (c) PANI and (d) PANI/g-C3N4/ZnWO4 ternary NCs, respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of Field Emission Scanning Electron Microscopy (FESEM) Analysis

The morphological features of pure g-C3N4 NPs, pure ZnWO4 NPs, PANI and PANI/g-C3N4/ZnWO4 ternary NCs were characterized through FE-SEM images (Figure 3). The FESEM images of pure g-C3N4 NPs were obtained in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 3a). The FESEM images of pure ZnWO4 NPs were observed in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 3b). The FESEM images of PANI were viewed in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 3c). The FESEM images of PANI/g-C3N4/ZnWO4 ternary NCs were characterized in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 3d).

fig 3

Figure 3: FESEM images of (a) pure g-C3N4 NPs, (b) pure ZnWO4 NPs, (c) PANI and (d) PANI/g-C3N4/ZnWO4 NCs, respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of Energy Dispersive X-Ray (EDX) Spectroscopy Analysis

The EDX analysis was also performed to investigate the composition of pure g-C3N4 NPs (Figure 4a), pure ZnWO4 NPs (Figure 4b), PANI (Figure 4c) and PANI/g-C3N4/ZnWO4 NCs (Figure 4d), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

fig 4

Figure 4: EDX images of (a) pure g-C3N4 NPs, (b) pure ZnWO4 NPs, (c) PANI and (d) PANI/g-C3N4/ZnWO4 ternary NCs, respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of Fourier Transform Infrared Spectroscopy (FTIR) Analysis

The FTIR spectrum of pure g-C3N4 NPs, pure ZnWO4 NPs, PANI and PANI/g-C3N4/ZnWO4 ternary NCs, respectively, were determined in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 5). The main peaks of FTIR spectrum for pure ZnWO4 NPs (black spectrum) was observed at 3421 1/cm, 1326 1/cm, 1015 1/cm and 678 1/cm wavenumber, respectively (Figure 5a). The main peaks of FTIR spectrum for pure g-C3N4 NPs (green spectrum) was obtained at 3348 1/cm, 1645 1/cm, 1410 1/cm, 1234 1/cm and 807 1/cm wavenumber, respectively (Figure 5b). The main peaks of FTIR spectrum for PANI (blue spectrum) was determined at 3151 1/cm, 1544 1/cm, 1408 1/cm, 1239 1/cm, 900 1/cm and 815 1/cm wavenumber, respectively (Figure 5c). The main peaks of FTIR spectrum for PANI/g-C3N4/ZnWO4 ternary NCs (red spectrum) was obtained at 3416 1/cm, 1638 1/cm, 1074 1/cm and 549 1/cm wavenumber, respectively (Figure 5d).

fig 5

Figure 5: FTIR spectrum of (a) pure ZnWO4 (black spectrum), (b) g-C3N4 NPs (green spectrum), (c) PANI (blue spectrum) and (d) PANI/g-C3N4/ZnWO4 ternary NCs (red spectrum), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of Transmission Electron Microscopy (TEM) Analysis

The TEM images of PANI/g-C3N4/ZnWO4 ternary NCs was observed in micromorphological structure level in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 6).

fig 6

Figure 6: TEM images of PANI/g-C3N4/ZnWO4 ternary NCs in micromorphological structure level in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of Diffuse reflectance UV-Vis Spectra (DRS) Analysis

The absorption spectra of glyphosate was observed in DRS Analysis (Figure 7). First, the absorption spectra of glyphosate were obtained at a maximum concentration of 15 mg/l in the wavelength range from 300 nm to 800 nm using diffuse reflectance UV-Vis spectra (Figure 7). Absorption peaks were observed at wavelengths of 375 nm for pure g-C3N4 NPs (red pattern) (Figure 7a), 390 nm for pure ZnWO4 NPs (blue pattern) (Figure 7b), 370 nm for PANI (green patern) (Figure 7c) and 430 nm for PANI/g-C3N4/ZnWO4 NCs (black pattern) (Figure 7d), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

fig 7

Figure 7: The DRS patterns of (a) pure g-C3N4 NPs (red pattern) (b) pure ZnWO4 NPs (blue pattern), (c) PANI (green pattern) and (d) PANI/g-C3N4/ZnWO4 NCs (black pattern), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Results of X-Ray Photoelectron Spectroscopy (XPS) Analysis

The XPS analysis of pure g-C3N4 NPs, pure ZnWO4 NPs, PANI and PANI/g-C3N4/ZnWO4 ternary NCs, respectively, were perforned to investigate in aqueous solution with photocatalytic degradation process for glyphosate removal (Figure 8). Absorption peaks were observed at binding energy of 401.51 eV for pure g-C3N4 NPs (blue pattern) (Figure 8a), 399.63 eV for pure ZnWO4 NPs (green pattern) (Figure 8b), 398.12 eV for PANI (red patern) (Figure 8c) and 398.36 eV for PANI/g-C3N4/ZnWO4 NCs (black pattern) (Figure 8d), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

fig 8

Figure 8: The XPS spectra of (a) pure g-C3N4 NPs (blue pattern) (b) pure ZnWO4 NPs (green pattern), (c) PANI (red pattern) and (d) PANI/g-C3N4/ZnWO4 NCs (black pattern), respectively, in aqueous solution with photocatalytic degradation process for glyphosate removal.

The Reaction Kinetics of Glyphosate Herbicide

The reaction kinetics glyphosate were investigated using the Langmuir-Hinshelwood first-order kinetic model, expressed by Eddy et al. [119], as following Equation (3):

for 3

where; ro: denotes the initial photocatalytic degradation reaction rate (mg/l.min), and k: denotes the rate constant of a first-order reaction. At the beginning of the reaction, t=0, Ct=C0, the equation can be obtained after integration as following Equation (4):

for 4

where; C0 and C: are the initial and final concentration (mg/l) of glyphosate; the solution at t (min) and k (1/min) are the rate constant.

The pollutants photocatalytic degradation rate was found using a pseudo first-order reaction kinetic equation (Equation 5):

for 5

where; Kapp: is the apparent rate constant, C0: is the pollutant concentration before illumination and Ct: is the final concentration of the pollutant at time t.

The correlation coefficients had R2 values greater than 0.9, as a result, the first-order kinetic model fit the experimental data well. The first-order rate constants (k) were determined from the slope of the linear plots.

Photocatalytic Degradation Mechanisms

The possible photocatalytic reactions for glyphosate degradation over the PANI/g-C3N4/ZnWO4 ternary heterojunction (PGZ) can be expressed as following Equation (6), Equation (7), Equation (8), Equation (9), Equation (10), Equation (11), Equation (12) and Equation (13):

for 6-13

The photocatalytic degradation mechanism can be better understood when it is correlated to the kinetics of the degradation reaction. The rate constants were determined from the equation ln(Ct/C0)=Kappt, where Kapp is the apparent rate constant for the reaction, and C0 and Ct represent the initial and final (after time t) concentrations of glyphosate. The apparent rate constants were calculated from the experimental data. Linear fitting between the experimental data and pseudo-first order kinetic model suggested that the degradation process of glyphosate follows the pseudo-first-order kinetic model. The optimized results indicate the highest photo-degradation ability and kinetics for the PANI/g-C3N4/ZnWO4 ternary NCs, which may be due to its suitable composition and enhanced surface active sites as suggested by BET (Brunner-Emmett-Teller) analysis.

Effect of Increasing pH values for Glyphosate Removal in Aqueous Solution during Photocatalytic Degradation Process

Increasing pH values (pH=3.0, pH=5.0, pH=7.0, pH=9.0 and pH=11.0, respectively) was examined during photocatalytic degradation process in aqueous solution for glyphosate removal (Figure 9). 42%, 58%, 71% and 89% glyphosate removal efficiencies was measured at pH=3.0, pH=5.0, pH=7.0 and pH=9.0, respectively, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at 25°C (Figure 9). The maximum 99% glyphosate removal efficiency was obtained during photocatalytic degradation process in aqueous solution, at pH=11.0, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time and at 25°C, respectively (Figure 9).

fig 9

Figure 9: Effect of increasing pH values for glyphosate removal in aqueous solution during photocatalytic degradation process, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time and at 25°C, respectively.

Effect of Increasing Glyphosate Concentrations for Glyphosate Removal in Aqueous Solution during Photocatalytic Degradation Process

Increasing glyphosate concentrations (5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l) were operated at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0, at 25°C, respectively (Figure 10). 60%, 85% and 73% glyphosate removal efficiencies were obtained to 5 mg/l, 10 mg/l and 20 mg/l glyphosate concentrations, respectively, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C (Figure 10). The maximum 99% glyphosate removal efficieny was found with photocatalytic degradation process in aqueous solution, at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively (Figure 10).

fig 10

Figure 10: Effect of increasing glyphosate concentrations for glyphosate removal in aqueous solution during photocatalytic degradation process, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively.

Effect of Increasing PANI/g-C3N4/ZnWO4 Ternary NCs Concentrations for Glyphosate Removals in Aqueous Solution during Photocatalytic Degradation Process

Increasing PANI/g-C3N4/ZnWO4 ternary NCs concentrations (5 mg/l, 15 mg/l, 30 mg/l and 45 mg/l) were operated at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0, at 25°C, respectively (Figure 11). 51%, 75% and 82% glyphosate removal efficiencies were obtained to 5 mg/l, 15 mg/l and 45 mg/l PANI/g-C3N4/ZnWO4 ternary NCs concentrations, respectively, at 15 mg/l glyphossate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0, at 25°C, respectively (Figure 11). The maximum 99% glyphosate removal efficieny was measured to 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs with photocatalytic degradation process in aqueous solution, at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively (Figure 11).

fig 11

Figure 11: Effect of increasing PANI/g-C3N4/ZnWO4 ternary NCs concentrations for glyphosate removal in aqueous solution during photocatalytic degradation process, at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively.

The Results of Cytotoxicity Test

The cytotoxicity of PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst and the glyphosate solutions were tested with the TBE assay analytical protocol and by considering with Drosophila melanogaster larvae before and after photocatalytic degradation process. Cytotoxicity test was performed with untreated glyphosate solution and after photodegradation process sample of different glyphosate concentrations (5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l) and different PANI/g-C3N4/ZnWO4 ternary NCs concentrations (5 mg/l, 15 mg/l, 30 mg/l and 45 mg/l), at 25°C, at pH=7.0, respectively (Table 1).

98%, 95%, 90% and 80% cyctotoxicity removal efficiencies were obtained to 5 mg/l, 10 mg/l, 15 mg/l and 20 mg/l glyphosate concentrations, respectively, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively (Table 1). The maximum 99% cyctotoxicity removal was observed at untreated glyphosate samples, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively (Table 1).

96%, 82% and 74% cyctotoxicity removal efficiencies were measured to 15 mg/l, 30 mg/l and 45 mg/l PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst concentrations, respectively, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively (Table 1). The maximum 99% cyctotoxicity removal was observed at 5 mg/l PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst concentrations, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively (Table 1). The study revealed the excellent minimization of cytotoxicity of glyphosate after photocatalytic degradation process with the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst. Also, the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst is found to be non-cytotoxic irrespective of its quantity used.

Table 1: Effect of increasing glyphosate and PANI/g-C3N4/ZnWO4 ternary NCs concentrations on cyctotoxicity test in aqueous solution after photocatalytic degradation process, at 25°C, at pH=7.0, respectively.

tab 1

Effect of Different Recycle Times for Glyphosate Removals in Aqueous Solution during Photocatalytic Degradation Process

Different recycle times (1., 2., 3., 4., 5., 6. and 7.) were operated for glyphosate removals in aqueous solution during photocatalytic degradation process, at 15 mg/l glyphosate, 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively (Figure 12). 92%, 87%, 84%, 80%, 76% and 73% glyphosate removal efficiencies were measured after 2. recycle time, 3. recycle time, 4. recycle time, 5. recycle time, 6. recycle time and 7. recycle time, respectively, at 15 mg/l glyphosate, 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively (Figure 12). The maximum 99% glyphosate removal efficiency was measured in aqueous solution during photocatalytic degradation process, after 1. recycle time, at 15 mg/l glyphosate, 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively (Figure 12).

fig 12

Figure 12: Effect of recycle times for glyphosate removal in aqueous solution during photocatalytic degradation process, at 15 mg/l glyphosate, 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively.

Conclusıons

The maximum 99% glyphosate removal efficiency was obtained during photocatalytic degradation process in aqueous solution, at pH=11.0, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time and at 25°C, respectively.The maximum 99% glyphosate removal efficieny was found with photocatalytic degradation process in aqueous solution, at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively.The maximum 99% glyphosate removal efficieny was measured to 30 mg/l PANI/g-C3N4/ZnWO4 ternary NCs with photocatalytic degradation process in aqueous solution, at 15 mg/l glyphosate, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=11.0 and at 25°C, respectively.The maximum 99% cyctotoxicity removal was observed at untreated glyphosate samples, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively. The maximum 99% cyctotoxicity removal was observed at 5 mg/l PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst concentrations, after 180 min photocatalytic degradation time, at 150 W UV-vis light irradiation power, at pH=7.0 and at 25°C, respectively. The study revealed the excellent minimization of cytotoxicity of glyphosate after photocatalytic degradation process with the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst. Also, the PANI/g-C3N4/ZnWO4 ternary NCs photocatalyst is found to be non-cytotoxic irrespective of its quantity used.

As a result, the a novel PANI/g-C3N4/CoMoO4 ternary NCs photocatalyst during photocatalytic degradation process in aqueous solution for glyphosate removal was stable in harsh environments such as acidic, alkaline, saline, and then was still effective process. When the amount of contaminant was increased, the a novel PANI/g-C3N4/CoMoO4 ternary NCs photocatalyst during photocatalytic degradation process performance was still considerable. The synthesis and optimization of a novel PANI/g-C3N4/CoMoO4 ternary NCs heterostructure photocatalyst provides insights into the effects of preparation conditions on the material’s characteristics and performance, as well as the application of the effectively designed photocatalyst in the removal of gylphosate herbicites, which can potentially be deployed for purifying wastewater, especially agricultural industry wastewater treatment. Finally, the combination of a simple, easy operation preparation process, excellent performance and cost effective, makes this a novel PANI/g-C3N4/CoMoO4 ternary NCs heterostructure photocatalyst a promising option during photocatalytic degradation process in agricultural industry wastewater treatment.

Acknowledgement

This research study was undertaken in the Environmental Microbiology Laboratories at Dokuz Eylül University Engineering Faculty Environmental Engineering Department, Izmir, Turkey. The authors would like to thank this body for providing financial support.

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Accelerating and Widening Knowledge of the Everyday: Reducing Churn for a Financial Service What a Thousand Dollars Can Do that a Million Dollars Cannot

DOI: 10.31038/PSYJ.2023541

Abstract

This paper responds to a Linked In post by Matt Lerner, regarding efforts by PayPal, Inc. to segment the market, identify personas, and move towards more actionable marketing efforts. The reported disappointing results came after thousands of interviews, a period of one year to design the research, collect the data, and analyze the results, with an expenditure of 1mm dollars. Using the same challenge, to provide a company such as PayPal with powerful, actionable information, the study of 100 people using artificial intelligence embedded in Mind Genomics, generated results and insights presented here, doing so in approximately two hours from start to finish, at an out-of-pocket cost slightly above $400. The results are presented as an exemplar of easy-to-create databases of the human mind on topics that range from profound to quotidian events, the everyday situations that escape notice but could contribute to a deeper knowledge of people and society.

Introduction

In early March 2023, the following post appeared in Linked In, a social media site specializing in business connections. The tonality of the post coupled with the specific information provides an implicit challenge to today’s methods to build systematic knowledge databases. Lerner moved from the standard methods of developing personas in segmentation [1] to the important approach called JTDB (jobs to be done), a contribution by the late Harvard business professor, Clayton Christensen [2]. Figure 1 presents a screen shot of the first part of the Linked In post, leaving out the details about the JTDB.

fig 1

Figure 1: Screen shot of post by Matt Lerner regarding PayPal

The post by Lerner immediately generated a cluster of strong reactions, as perhaps it was meant to do. The most important reaction was the sense that here was an opportunity to demonstrate what could be done in an hour or two to solve the same problem, albeit with a different worldview (experimentation rather than hypothesis generation). We chose the road ‘less trodden,’ viz., describe and attempt to provide direct business solutions using a combination of simple thinking, direct experimentation, artificial intelligence, focusing almost on the basis of the business issue for PayPal, namely solving a problem (reducing impediments to customer usage and customer retention).

We offer this paper as an example of what can be done today (2023) in about 1-3 hours, at a cost of a few hundred dollars. This alternative approach involves thinking, reduces the cycle time for learning, demands far lower investments for the knowledge, and produces databases of knowledge, local, generally, in the moment, or over time to provide time-based, geography-based knowledge. Rather than providing a different approach to the specific problem, the authors present a general re-thinking of the issue as one of the ‘production of useful information’. The paper is not a solution as much as a stimulant for discussion. We present our approach to tackling the PayPal issue, this time using Mind Genomics. Mind Genomics is an experimenting science of decision making and behavior, tracing its origins to experimental psychology (psychophysics), statistics (experimental design), and public opinion and consumer research.

Psychophysics, the oldest branch of psychology, is the study of the relation between physical stimuli and subjective reactions to those stimuli. The objective is to measure the perception of the stimulus, viz, a subjective measurement, and then relate that measure to the nature and magnitude of the physical stimulus. Harvard Professor of Psychophysics, S.S Stevens, called this discipline the ‘outer psychophysics’. Mind Genomics focuses on what Stevens called the ‘inner psychophysics,’ the structure and measurement of relations between ideas [3].

Statistics provides a way of dealing with the world, analyzing the measures, finding relations, defining order of magnitude and the evidence of effects of one variable on another. Statistics also allow us to find ‘order’ in nature, and in some cases help us interpret the order. The discipline of experimental design allows us to create test combinations of stimuli, those stimuli being combinations of phrases or ingredient [4], or even combinations of other variables, such as combinations of pictures to study responses to a package [5]. Experimental design lets us understand relations between variables in a clear fashion, moving the world of ‘insights’ out from disciplined description to quasi-engineering. Finally, consumer research and opinion polling focus on the nature of what is being measured. Rather than looking for general principles of behavior, deep behaviors, often needing artificial situations in which these deep principles can be illustrated, consumer research works with the quotidian, the everyday, the granular in which life is lived and experienced [6]. The consumer researcher is interested in the reactions to the world of the everyday, as the world is constituted, rather than concentrating on unusual combination, structured in an unusual fashion to illustrate an effect. Our stated goal for the project was to see how quickly and how inexpensively we could ‘solve’ the problem, or at least contribute materially to the solution. The ‘real’ goal, however, was to create a series of templated steps to solve the problem and offer those steps to the world community as an ‘algorithm’ to approach the creation of new knowledge about decision making, assuming the effort to start with absolutely no knowledge at all. Rather than theorizing about the best steps, opining about what should be done and why, we began with the belief that the best approach would be simply ‘do it’, and see what happens. In this spirit, we offer the reader our templated approach, with results, and with the delight that the effort lasted about two hours, cost about $400 (but could have been less), and that that effort produced clear, understandable, testable results. The final delight is that had the initial effort been less successful there was another two-hour slot immediately afterwards to build on the partially successful first effort.

How Mind Genomics Works

Mind Genomics differs from the traditional questionnaire. In the traditional approach, the researcher presents the respondent with a phrase or other test stimulus and instructs the respondent to rate that single stimulus. The pattern of responses to many such stimuli provides the raw materials. Such a system might at first seem to be the very soul of good research, because the stimulus is isolated, and rated one at a time. In some cases that might be the case, but when we deal with real people we are faced with the ongoing desire for the respondent to ‘game’ the system, to provide what is believed to be the ‘right answer’, perhaps an answer that the respondent feels to be one that the researcher will more readily accept. The published literature recognizes these types of response biases, and has done for at least 60 years, and more like 80 years [7,8].

Mind Genomics operates differently. Mind Genomics works by combining phrases, presenting combinations of these phrases to respondents, obtaining a rating of the combination, and then deconstructing the response to the combination in order to understand how each phrase drives the response. In a Mind Genomics study the respondent evaluates different combinations, generally 24 different combinations of phrases. Each combination or ‘vignette’ in turn comprises 2-4 phrases (elements), with these elements appearing five times in the 24 vignettes evaluated by each respondent and absent 19 times in the 24 vignettes.

Often researchers who look at the Mind Genomics studies complain that it seems to be almost impossible to ‘do this study correctly.’ The inability to ‘guess’ the right answer because of the apparently random combinations of elements irritates many professionals, who feel that the respondent has to cope with a ‘blooming, buzzing confusion,’ the term that psychologist William James used to describe the perceptual world of the newborn child [9]. The reality, however, is that most respondents who think they are guessing actually do quite well, as they negotiate through the 24 vignettes. They pay attention to what is important to them. The result is a clear pattern, often a pattern which might surprise them by its correctness and clarity in the light of their experience with these combinations of messages that seemed so random.

The Mind Genomics Steps – from Chaos to Tentative Structure

We present the Steps in Mind Genomics, assuming that we start with virtually no knowledge at all about the issues involved with PayPal, other than possible customer issues which may or may not end up in ‘churn.’ The reality of the process is far deeper than one might imagine. Virtually all research conducted by author Moskowitz since first starting a career in 1969 has revealed that most researchers in the business community do not really profoundly understand how to solve specific problems, although with a bit of study many learn to discern the relevant aspects of a problem, and eventually move towards a solution, whether that solution be optimal or not. Thus, the need for an algorithmic approach to problem design and problem solution, a solution which can be implemented even by a young person (e.g., age 10 or so).

The authors of this paper are all reasonably senior or beyond. In order to keep to the vision of an algorithmic solution doable quickly and easily by anyone, we have limited all of the effort to working with artificial intelligence as a provider of substantive materials for questions and answers pertaining to PayPal and its issues.

Step 1: Choose a Name (Figure 2, Top Left Panel)

Naming requires that the researcher focus on what is to be studied. Choosing a name is generally simple, but not always. Even in this study there was a bit of hesitation about what to call the study. Such hesitation is revealing. It means that the researcher may have a general idea about the topic but must focus. That focus can be a bit discomforting at first, because it means deliberately limited the effort, almost hypothesizing at the start of the project about what is the real ‘goals’ Figure 2 (top left panel) shows the screen where the respondent names the study.

fig 2

Figure 2: Set-up screen shots. Top Row Left Panel = select a name for the study, Top Row Right panel = Idea Coach input to provide questions. Bottom Row Left panel = 7 of 30 questions generated by Idea Coach, Bottom Row Right Panel = The four questions finally chosen (screen shot shows partial text).

Step 2: Choose Four Questions Which ‘Tell a Story’

The objective here is to lay the groundwork for a set of test elements or messages that will be shown to the respondent in systematically varied combinations. Rather than simply drawing these test elements out of the ‘ether’ and having respondents rate each one, Mind Genomics instructs the research to create a story, beginning with questions flowing in a logical sequence. Those questions will be used to generate answers. A recurrent problem faced by researchers using Mind Genomics is that the ordinary, unskilled professional often gets lost at this early stage. It is daunting to think of questions. Answers are easy; we are accustomed to answering questions from our early and later education. It is the questions which are difficult. We are not accustomed to thinking of good questions, except when we debate in a competitive way, and have to hone down our answers, or perhaps when we begin higher education after college. Before then, college and earlier, our expertise is answering, not asking. It is no wonder that many would-be researchers attempting to follow the steps of Mind Genomics simply throw up their hands at this step.

Our ‘demo study’ on PayPal is a perfect example. We know the problem. But what are four relevant questions that we should ask? We are not accustomed to thinking about questions, and so we need an extra ‘hand’ to pass through this Step 2. The approach we use employs AI, artificial intelligence, embedded in the Idea Coach. The researcher describes the problem (Figure 2, top right panel), lets Idea Coach use the description to produce sets of 30 questions (Figure 2, bottom left), and across several uses of Idea Coach. The research will end up with four questions (Figure 2 bottom right).

The important thing to keep in mind is that the researcher can interact with the AI driven Idea Coach. The briefing given to Idea Coach (Figure 2 top right panel) can be run several times, each time with different questions emerging, along with repeat questions. The briefing can be changed, and the Idea Coach is re-run, again producing different sets of 30 questions. Finally, the questions which emerge from Idea Coach can themselves be changed by the user. Table 1 shows the four questions in their final text form, along with the four answers to each question.

Table 1: The four final questions, and the four answers to each question. Questions and answers emerged from Idea Coach, powered by AI.

tab 1

Step 3: Select Four Answers to Each Question

Once the researcher selects the questions, the BimiLeap program presents each question 2, with a request to provide four answers. Figure 3 shows this third step. The top left panel in Figure 3 shows the layout, presenting the first question for the researcher, and requesting four answers. Often researchers find this step easy. For those who want to use Idea Coach, the question is already selected, but can be edited, and then Idea Coach invoked (Figure 3, Top Row, Right screen). Each request to Idea Coach uses the question as Idea Coach currently finds it. As the researcher learns more about the topic from Idea Coach, the researcher can run many requests to get the four answers, or change the question, and rerun the Idea Coach. The Bottom Row (left panel) shows 7 of the 15 answers.

fig 3

Figure 3: Creating four answers for a single question, showing the contribution of Idea Coach

The Bottom Row (right panel) shows the four answers selected or written in. Once again, the answers can be used as Idea Coach provides them, or edited, or even some answers can be provided by the researcher without using Idea Coach. As the researcher becomes more familiar with the Mind Genomics templated process it becomes easier to skip the Idea Coach steps, at least when providing answers.

Step 4: Create an Orientation Page and a Rating Scale

Respondents in the Mind Genomics study will be presented with vignettes, viz., with combinations of messages. The respondent has to be instructed what to do. In most studies it suffices to instruct the respondent to read the vignette. Figure 4 (Top Left Panel) shows the orientation page, presented at the start of the study. Right below (Figure 4, Bottom Left Panel,) appear the instructions accompanying each test stimulus (vignette, described below), along with the set-up page to define the scale. The five-point scale used here is a simple Likert scale, with the middle scale point reserved for ‘don’t know.’ Respondents find this scale easy to use.

fig 4

Figure 4: Left panels show the orientation to the respondent (Left Panel, Top Row), and the rating scale to be used for each vignette (Left Panel, Bottom Row). Right panel Top Row shows the instructions for the open-end question regarding feelings about PayPal. Right Panel Bottom Row shows the instructions regarding the acquisition of respondents.

There is little guidance given to the respondent, the reason being that it is the elements which must convey the information, not the instruction. Only in situations where it is necessary for the respondent to understand the background facts more deeply, e.g., law cases, does the respondent orientation move beyond the basics of ‘read and rate.

Step 5: Launch the Study

Once the study is created, a process requiring about 30-40 minutes, the final task is to launch the study. In the interests of efficiency, the BimiLeap program provides the researchers with four builds in options, as shown in Figure 4 (Bottom Row, Right Panel). The standard approach is to use a built-in link to the panel provider (Luc.id), for easy-to-find respondents of specific gender, age, income, education, country, etc. This standard approach is made easy. All the research need do it select the top bar in the screen shot. The researcher ends up paying about $4.00/respondent for respondents in most geographies. Below are other options, such as a custom sample of respondents, a third-party provider of respondents (e.g., not Luc.id, Inc.), and finally the ability to source one’s own respondents at the fee of $2.00/respondent processed. In all cases but the first, with BimiLeap providing the respondent, it is the researcher who must assume the responsibility of finding respondents. For this study, the request was for n=100 respondents, males and females, ages 18-54.

The Mind Genomics process works best with respondents who are part of a panel. The panel comprises many hundreds of thousands, perhaps millions of individuals, whose qualifications are known, and who have agreed to participate in these types of studies. The field service (Luc.id Inc., for this study) sends out invitations to respondents who fit the criteria requested by the researcher. The entire mechanism is automated. In the interests of cost and efficiency, it is almost always better to work with standard respondents provided by BimiLeap. The time between launch and completion of Mind Genomics sessions, one per respondent, is generally 50-60 minutes for the respondents specified here.

In the end, Steps 1-5 required about a little less than two hours from start of the study with ‘no knowledge’. The results are returned by email, the detailed analysis along with summarization through AI contained in an Excel report.

Step 6: The Respondent Experience

The respondents receive an email invitation. Those who click on the embedded invitation link are led to the study. The first screens introduce the topic, obtain information about the respondent. The standard information is gender and age. The third self-profiling question was the respondent’s experience-with/opinion-of PayPal.

The actual experience comprises a set of 27 screens.

  1. Welcome.
  2. Self-profiling classification (gender, age, attitude/experience regarding PayPal. The self-profiling classification has room for a total of 10 questions, each question with 10 possible answers.
  3. Introduction to the issue.
  4. Presentation of 24 screens, each screen comprising 2-4 rows of elements, and the rating scale below.

The noteworthy thing to keep in mind about the experience is that each respondent evaluates a set of vignettes which comprise seemingly unconnected elements, as Figure 2 shows. To many respondents and to virtually all professionals who inspect the 24 vignettes, the array of 2-4 elements in vignette after vignette speaks of a ‘blooming, buzzing confusion’ in the words of the revered Harvard psychologist, William James, writing at the end of the 19th century. Nothing, however, could be further from the truth. The 24 vignettes are set up in an specific array, called an experimental design,, with the property that the 16 elements are presented an equal number of times, that they are statistically independent of each other, that the data emerging from any single set of 24 vignettes from one respondent can be analyzed by OLS (ordinary least squares) regression, and finally the coefficients have ratio scale properties. The design is called a permuted design.

Figure 5 shows the content of the three vignettes recorded after the evaluation, and just before deconstruction in to the record-by-record database used in the statistical analysis. The figure shows the respondent number, the order of the vignettes, the text of the vignette as presented to the respondent, followed by the rating scale and the response time. The rating scale is taken from Figure 4 (bottom left panel).

fig 5

Figure 5: Content of three vignettes, as recorded by the BimiLeap program, showing the respondent (participant), the text of the vignette, the rating, and the response time in thousands of a second.

The respondents are oriented with what ends up being very little information, but after the first evaluation the respondent find the evaluation easy to do. Figure 6 shows the average response time by each position of the 24 positions. By the time the third or really fourth vignette is evaluated, the respondent feels comfortable with the process, and settles down to a about 2-2.5 seconds per vignette. One of the unexpected implications of these results is that the initial set of responses may be unstable, at least in terms of the externally measured variable of response time. It may be that the decreasing response time is due to the time taken to develop an automatic point of view, one which may not change during the last 20 or so vignettes. If this is the case, then we might not want to look at the data from the first part of the study simply because the processing of the information has not reached ‘steady’ state.’ The implications call for a rethink of just how to measure attitudes when the ratings for the first few questions are labile as a point of view emerges and solidifies, unbeknownst to the respondent and to the researcher alike. This is an interesting finding, and reinforces the good research practice of randomizing the different test stimuli.

fig 6

Figure 6: How average response time to the vignettes varies with test order

Table 2 presents the final information recorded for the study, including name, number of respondents, etc. This table is presented for archival purposes in every report of the study returned to the researcher.

Table 2: Final specifics of the study, based upon the input for the researcher

tab 2

Step 7: Create the Database in Preparation for Statistical Analysis

All of the set up and research steps become preparations for a database that can be accessed by statistical analysis. The database is ‘flat,’ with all of the relevant information in one file. Thus, beyond the automatic analysis of the data to be done by the BimiLeap program, the raw data are available for further custom analysis by the researcher.

The database comprises one record or row for each vignette. Thus, 100 respondents, each of whom evaluate 24 different vignettes, generate a database of 100 x 24 or 2400 rows. The entries in the database are usually numbers ready for immediately statistical analyses, or easily converted to new variables for additional analysis.

First set of columns – correspond to the study name and the information about the respondent, including a respondent identification number unique for the Mind Genomics system, as well as a sequence number for the particular study. The data in this first set of columns correspond to information which remains the same across all 24 vignettes.

Second set of numbers – change according to the vignette. The first number is the order number, from 01 (first vignette in the set of 24) to 24 (the 24th vignette in the 24). The ‘actual first vignette’ is used as training, data not recorded. The actual first vignette is repeated to become the 24th of 24 vignettes whose data are recorded. The next set of 16 elements, 2nd to 17th, correspond to the 16 elements. For a specific row or vignette, the elements which appear in that vignette are coded ‘1’, the elements absent from that vignette are coded ‘0.

Third set of numbers – vary according to the 5-point rating assigned by the respondent, and then the response time in thousandths of a second elapsing between the time that the vignette appeared on the screen and the time that the respondent assigned a rating using the 5-point scale.

The fourth set of numbers is created by the program or by the researcher working with the raw data. This fourth set of numbers is called the binary transformed data. The objective of the binary transformation is to move from a scale to a yes/no measurement. The reason for doing so is pragmatic, based on the history of consumer research and public opinion polling. Those who use the scales, such as managers in companies find it difficult to understand how to interpret the average value of a scale, such as our 5-point scale. For example, just what does a 4.2 mean on the scale? Or a 2.1? And so forth. The question is not whether two scale values ‘differ’ from each other in a statistical sense, but rather just what does this mean tell the manager? Is it a good score? A bad score? How does on interpret the scale value, the average rating, and communicate its real meaning to others?

The consumer researcher and public opinion pollsters have realized that the ordinary person can easily deal with concepts such as ‘a lot of people were positive’ or the message convinced some of the people to change their attitude from mildly positive to deeply negative. To simplify the interpretation, these researchers and pollsters have transformed the 5-point scale (or other scales like in) into discrete scale, such as ‘positive to an idea’ versus ‘negative to an idea’. The typical transformation on a 5-point scale (5 = agree, 1 = disagree) is that the ratings of 4 and 5 are ‘agree with / positive to an idea, whereas the ratings of 1.2, and 3 agree ‘not agree with / positive to an idea’. Following this train of thought, the binary transformation would be ratings of 5 and 4 are transformed to 100, whereas ratings of 3,2 and 1 are transformed to 0 This transformation produces 100’s and 0’s. The transformation is called, not surprisingly, ‘TOP2’. In other studies, there might be several transformations, such as BOT2 (Ratings 1,2 → 100, Ratings 3,4,5 → 0). A vanishingly small random number (<10-5) is added to each transformed number, to ensure that the binary transformed variables exhibit some variation, a variation that will be necessary for analysis by OLS (ordinary least-squares) regression.

Step 8: Relate the Presence/Absence of Elements to the Binary Transformed Variable, TOP2

The underlying objective of Mind Genomics is to relate subjective feelings (responses) to the underlying messages. The entire thinking, preparation and field execution is devoted to the proper empirical steps needed to discover how the different ideas embodied in the elements drive the response.

The TOP2 variable is the positive response to PayPal selected after reading the vignette (Definitely/Probably use PayPal). How does each of our 16 elements ‘drive’ that feeling. And, what it the pattern across the different genders, ages and PayPal-related attitudes and self-described behaviors?

The analysis uses OLS (ordinary least-squares) regression analysis, colloquially known as curve fitting, although the model here is strictly linear, with no curvature [10]. We express the dependent variable, Binary Transformed Variable, TOP2 as a weight sum of the elements, or more correctly, the weights of ‘positive feeling’ (ratings 4 and 5) contributed by each of the 16 elements. Each element is going to contribute to the positive feeling when that element is present in the vignette, or perhaps take away from the positive feeling.. The real question is ‘how much weight or how big is the contribution’.

OLS uses the regression model to create the simple equation: TOP2 = k0 + k1(A1) + k2(A2)…k16(D4).

We interpret the model as follows:

Additive constant (k0) is the estimated percent of ratings of 5 and 4 (TOP2) in the absence of elements. Of course, the experimental design ensures that each respondent will evaluate vignettes with a minimum of two elements and a maximum of four elements. There is never a vignette actually experienced with no elements. Yet, the OLS regression estimates that value. The additive constant ends up being a ‘baseline’ value, the underlying likelihood of a TOP2 rating. The additive constant is high when most of the vignettes are rated 4 or 5, not 1 or 2 or 3. The additive constant is low when most of the vignettes are rated 1 or 2 or 3.

The coefficients k1-k16 show us the estimated percent of positive ratings (TOP2) when the element is incorporated into the vignette. Statisticians use inferential statistics to study the statistical significance of the coefficients. Typical standard errors of the coefficients are around 4-5 for base sizes of 100 respondents.

Mind Genomics returns with a great deal of data, almost a wall of numbers, such as that shown in Table 3. To allow the patterns to emerge we blank out all coefficients of +1 or lower and highlight through shading coefficients of +7 or higher.

Table 3 shows us high additive constants for all respondents except those who define themselves as having used PayPal once or twice. The 8 respondents generate an additive constant of 21, quite different from the high additive constants for the regular users.

Table 3 further shows a great number of positive coefficients, as well as very strong performing elements. Our goal here is not to describe the underlying rationales of what might be occurring, but rather in the spirit of an applied effort with limit budget and short time frames identify ‘what to do.’ The science exists and can be developed at one’s leisure.

Table 3: Parameters of the models for Total Panel and for panelist who identify themselves by gender, age, and experience/attitude regard PayPal.

tab 3

Step 9: Create Individual Level Models and Use Clustering to Discover Mind-sets

A hallmark analysis of Mind Genomics is to cluster the respondents on the basis of the pattern of their 16 element coefficients, in order to discover new to the world mind-sets, viz., patterns of reactions to the different elements. Underlying this strategy of clustering is the worldview of Mind-Genomics that it is the pattern of responses to the activities of the everyday which teach us a great deal.

A word of explanation is in order here. Researchers accept the fact that people differ from each other, and that the nature of these differences is important to understand, for either basic science of human behavior., or for applications. The conventional methods of dividing people fall into at least three different classes, namely WHO the person is, what the person THINKS/BELIEVES, and finally what the person DOES, viz., how the person behaves. These divisions are not considered to be hard and fast, but rather simple heuristics to divide people into meaningful groups. The studies leading to these groups in, these clusters, are generally large, expensive, and work at the higher level of abstraction. That is, the focus is on how people think in general about a topic. The topic of these ways of understanding people has been written about many times, in popular books, but also in scientific tomes [11-13].

A key problem of conventional division of people into the large groups is how to apply this group information to the world of the specific, granular, every day. Faced with a real-world problem, such as our PayPal issues, can we use these large-scale studies to illuminate the issue with what to do with PayPal. In other words, what are these issues when the topic is the whole world, but rather the quotidian, daily efforts of people in the world of ‘PayPal.

The Mind Genomics approach to the problem of individual differences is to work at the level of the granular, finding groups of respondents who show different patterns of responses to the same test stimuli, with these patterns of responses being both parsimonious (the fewer the better) and interpretable (the patterns must make sense). Generally, as the researcher extracts more groups of smaller size from the population the groups are increasingly interpretable, but at the same time the effort ends up with many groups, often too many to use in any application.

The approach used by Mind Genomics ends up being very simple, but often such simplicity generates powerful, actionable results. The researcher follows these steps:

  • Generate a model, viz., equation, for each individual respondent, following the same form as the equation for the total panel and each subgroup. It will be straightforward to create this model for each respondent because the vignettes, test combinations evaluated by the respondent, were created to follow an experimental deign at the level of the individual respondent. Furthermore, even when the respondent rates every one of the 24 vignettes similarly (e.g.,, ll rated 5 or 4, transformed to 100 for TOP2), the vanishingly small random number added to eh transformed value of TOP2 ends up ensuring sufficient variation I the dependent variable, in turn preventing the regression program from crashing.
  • The regression generates 100 models or equation one for each respondent, with 17 parameters (additive constant, 16 coefficients)
  • Using only the 16 coefficients, compute a correlate coefficient between each pair of respondents. The correlation coefficient measures how ‘linearly related’ are two individuals, based upon the measures of the 16 correlations. This is called the Pearson R, which varies from a high of +1 when the 16 pairs of coefficients line up perfectly, to a low of -1 when the 16 pairs of coefficients are perfectly but inversely related to each other.
  • Create a measure of ‘dissimilarity’ or ‘distance’, defined here as (1-Pearson R). The quantity (1-Pearson R) is one of many distance measures that could be used. (1-Pearson R) varies from of a low of 0 when two set of 16 coefficients correlate perfectly (1-R) becomes 0 because for perfect linear correlation R =1. In contrast, when two sets of 16 coefficients move in precise opposite direction (1-R) becomes 2 because R= -1
  • The k-means regression program [14] attempts to classify the respondent, first into two groups (clusters, mind-sets,) and then into three groups, using strictly mathematical criteria. The solution is approximately. The program does not use the meanings of the elements as an aid.
  • It remains the job of the researcher to choose the number of clusters and then to name the clusters. In keep with the orientation of Mind Genomics, namely, to find out how people think, the clusters emerging from the k-means clustering exercise are named Mind-Sets.
  • Once each respondent has been assigned by the clustering program to only one of two emergent mind-sets, or one of three emergent mind-sets, the researcher ca easily rerun the regression models, two times for the two mind-sets (once per mind-set) or three times for the three mind-sets, respectively.
  • Table 4 shows the data array in the form to which we have become accustomed. The rows are the elements, the columns are the respondents. The top of Table 4 (Table 4A) shows the results from the two mind-set-clustering. The bottom of Table 4 (Table 4B) shows the results from the three mind-set-clustering. As before, only positive coefficients are show. Negative coefficients and coefficients of 0 and 1 are also omitted. The stronger coefficients of 7 or higher are shown in shaded cells.
  • Table 4 shows the elements with positive coefficients and the strong performing elements. The names of the mind-sets are used as a mnemonic. The reality is that the respondents are identified by mind-sets for convenience only. It is the content of the message which is important/.

    Table 4: Parameters of the models for Total Panel and for panelist who identify themselves by gender, age, and experience/attitude regard PayPal.

    tab 4a

    tab 4b

    Step 10: How Well Did We Do, the Index of Divergent Thought (IDT)

    A continuing issue in research is the need to measure how ‘good’ the ideas are. Just because the researcher can quantify the ideas using experimental design and regression, the results can be useless. In consumer research one often hears about the quality of ‘insights’, and that it takes a seasoned professional to know what to do. The effort in consumer research and its sister disciplines such as sensory analysis is to follow a set of procedures, doing so meticulously. Yet, to reiterate, just how good are the results?

    S.S. Stevens, the aforementioned Professor of Psychophysics at Harvard University from the 1940’s to the early 1970’s, would often proclaim the truism that ‘validity is a matter of opinion.’ Stevens was actually ‘on to something.’ How does one know the validity of the data, the quality of insights.

    The notion of IDT, the Index of Divergent Thought, was created with the notion that ‘divergent’ is a qualitative number. Divergent means attractive to different groups, rather than divergent from 0. Low IDT values mean that the ideas are simply weak for people who think differently (viz., the mind-sets) High IDT values mean that the ideas are strong among people who think differently. The term ‘divergent’ refers to the nature of the ideas, the different that ideas can take.

    To answer this question, we present one bookkeeping approach shown in Table 5. The idea is to calculate the weighted sum of positive coefficients (1 or higher), based upon the results from the six clearly defined groups: Total, MS1 of 1, MS2 of 2, MS1 of 3, MS2 of 3, and MS3 of 3, respectively. Each group generates a sum of positive coefficients, emerging from the study. Each group has a defined base size from the study. The data in Table 4 suffice to create a weight sum of positive coefficients. The value of the IDT is 44. The IDT is only an indexed value. Other studies have shown IDT values both above and below. High IDT value corresponds to studies with high or even very high coefficients among a relatively sizeable subgroup in the study. These high coefficients belong to elements that respondents believe to be important, elements which should draw attention.

    Table 5: The Index of Divergent Thought (IDT)

    tab 5

    Step 11: Responses to the Open-ended Question

    Our final empirical section involves the open ends. Respondents were instructed to write about their feelings towards PayPal. Step 11 provides an edited version of the open ends, for those respondents who wrote a ‘reasonable’ answer. The open end response is accompanied by the respondent number, gender, age, Q1 (attitude about PayPal), and membership in one of the three mind-sets. Table 6 presents the open-ended responses. The open-ended questions are presented here as background to the analysis of open-ended questions by artificial intelligence, later on in Step xxxx.

    Table 6: Responses to the open-ended question

    tab 6(1)

    tab 6(2)

    tab 6(3)

    Bringing Generative AI into the World of Mind Genomics and Insights

    During the past year or two the idea of artificial intelligence as a critical aspect of intelligence gathering and insights development t seems to be at the tips of everyone’s tongue. From an esoteric approach wonderful to throw around at cocktail parties and business meetings to create an ‘image’, AI has burst on the scene to become a major player. Unlike some of the other hype technologies, ranging from Big Data to neuromarketing, AI seems to be able to deliver beyond its hype.

    As part of the evolution of Mind Genomics as a science and BimiLeap as a program, we have instituted artificial intelligence in the Idea Coach to provide ideas, questions, and answer. The approach works well, or at least seems to do when the task is to generate disparate questions and disparate answers to reasonably well formulated inputs, such as a specific description of a problem to generate questions, or a specific question to generate answer.

    The next step in the use of AI in Mind Genomics may be the interpretation of the winning element of defined subgroups. The elements tell what ideas rise to the topic, but don’t tell us a pattern. Can AI discern patterns, and report them without human guidance?

    The four final tables are more of a demonstration of the AI enhancements to Mind Genomics and placed in the appendix to this paper. It’s important to note that the BimiLeap software used by Mind Genomics instructs the AI using a defined set of pre-programmed templated prompts to learn about the mind-set segments, Total panel, subgroups, and questions and answers themselves generated by Idea Coach.. The prompts command the AI to write summaries that tell a story and aim for completeness in thinking. For example, the prompts ask for “what’s missing,” alternative points of view, and groups or audiences that might hold opposing views. In other words, the summarizer equips researchers not just with data interpretation but adds different perspectives and counterarguments that may be helpful in assessing their results, anticipating disagreements, or suggesting further research.

    Appendix 1 shows us the use of AI to understand the winning elements of each mind-set.

    Appendix 2 shows the use of AI to understand the open-end questions.

    Appendix 3 shows the use of AI to digest and summarize the output of Idea Coach during the creation of the 30 questions. Each separate query to generate 30 question using Idea Coach will produce its own page, to digest and to summarize that particular set of 30 questions generated by Idea Coach.

    Appendix 4 shows the use of AI to digest and summarize the 15 answers produced by Idea Coach for a single question.

    Appendices 3 and 4 show summaries by artificial intelligence of somewhat disconnected ideas, specifically ideas produced by a previous query to the artificial intelligence engine represent by Idea Coach.

    Discussion and Conclusions

    A Google Scholar® search of the combined terms ‘marketing research’ and ‘artificial intelligence’ generates 982,000 ‘hits’, most hits appearing during the past few years as the interest in artificial intelligence has exploded, and the potential applications have expanded due to the widespread availability of AI tools, such as Chat GPT4. A deeper look at these references shows that the term ‘marketing research’ really devolves down to marketing, not research. Indeed, it is hard to find good reference about the use of AI in marketing research as we know marketing research to be. A parallel can be drawn with the introduction of the ‘web’ into the world of the computer, and the interest, but not really ‘new’ applications for the capabilities of ‘on-line research’. There were issues about the ‘quality’ of data that would be obtained in this new and more rapid fashion, and many issues emerging about validating the interviews, but sadly, few truly new vistas emerging in market research. In both the emergence of the internet and the growth of artificial intelligence marketing research has focused primarily on data acquisition, rather than on vistas of a truly new nature [15-22].

    It is on the vision of ‘new’ to the world of marketing research, the world ‘new’ reserved for a new vision of what could be, not just simply a possibly threat of technology to the ‘best practices’ endorsed by the thought leads and the status quo. The focus of this paper has been on the use of a templated system to enhance insights and solutions about a problem, the specific problem here being the self-declared lack of information about solutions to a marketing problem. As the paper unfolds, however, it becomes increasingly clear that the paper moves away from the traditional approaches, best-practice, and wisdom of the consumer research and other insight-based communities, such as sensory evaluation in the world of food, cosmetics, and other consumer products. Rather, the paper moves towards a systemized approach which requires absolutely no knowledge about a topic, an approach easy to use even by school children as young as eight years old [23,24]. The focus is on a process which requires literally no expertise to master, a process which starts with questions and exports actionable answers. In other words, the vision of democratizing research, and liberating it from the bonds of best practices.

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Fractures after Initiation of a Drug Holiday in a Real- Life Setting

DOI: 10.31038/EDMJ.2023712

Abstract

Purpose: We aimed to assess the fracture rate in patients who were placed on a drug holiday (DH) after minimum adequate therapy versus those who continued therapy (CT) in a real-life setting.

Methods: This is a retrospective cohort study conducted in a tertiary academic center. Inclusion criteria involved osteoporotic adults who received minimum adequate bisphosphonate therapy (≥ 3 years), otherwise, patients were excluded.

Results: Of 1,814 charts randomly selected and reviewed, 272 patients met the inclusion criteria. In our cohort, females were 90.9%, White 50.0%, and African American 40.5%. A DH was initiated in 119 patients (43.8%). In the CT versus DH cohorts, the mean duration of therapy was 6.0 ± 2.6 versus 5.7 ± 2.3 years, total duration of follow-up 6.9 ± 2.9 versus 7.8 ± 2.7 years, and fractures occurred in 11.7% versus 9.2% respectively, not statistically different. The mean duration of follow-up after starting DH was 2.5 ± 1.9 years. Upon risk stratification using FRAX scoring, in the high-risk cohort, fragility fractures occurred in 16.5% (n=22/133) of the CT group versus 13.5% (n=7/52) of the DH cohort (P=0.66). In the lower risk cohort based on FRAX scoring, fragility fractures occurred in 7.1% (n=10/131) of the CT group versus 6.0% (n=4/63) of the DH cohort (P=1.0).

Conclusion: In our cohort, continued drug therapy did not provide additional fracture protective benefits beyond the minimum adequate duration of therapy. A drug holiday after three to five years of treatment may be considered after review of risk factors for future fracture.

Keywords

Osteoporosis, Fracture, Fragility fracture, Drug holiday, Continuous therapy

Introduction

Osteoporosis (OP) is a silent disease that may initially present as a fragility fracture with subsequent high morbidity, mortality, and healthcare financial burden [1]. Screening patients using fracture risk assessment modalities is suggested for case detection and institution of appropriate preventative therapeutics to prevent fragility fractures [2]. Fracture risk assessment modalities include DXA scanning (Dual-Energy X-ray Absorptiometry), online risk assessment tools such as the FRAX algorithm, and determining the presence of prevalent or incident fragility fractures [3]. High-risk patients are candidates for treatment while intermediate-risk patients may be monitored more frequently versus initiating a moderate intensity therapy like zoledronate 5 mg every other year [4].

Several classes of effective OP medications are available that significantly decrease the risk of initial and subsequent fragility fractures [5]. The pharmacological therapies for osteoporosis at the time of this analysis were broadly classified as antiresorptive therapies (bisphosphonates, denosumab, hormonal therapy, selective estrogen receptor modulators [SERM]) and osteoanabolic therapies (teriparatide, abaloparatide). Bisphosphonates (BP) include alendronate, risedronate, ibandronate, and zoledronate (FDA approved 1995, 2000, 2005, and 2007, respectively).

The concept of a drug holiday (DH) was introduced in 2008 after several reports of rare severe side effects including osteonecrosis of the jaw and atypical femur fracture [6]. Accurate fracture risk assessment is critical for appropriate risk stratification in a variety of clinical settings inclusive of whether a patient should be initially started on medical therapy, when to consider a DH, and continued surveillance every 1-2 years while on a DH to determine when reinstitution of pharmacological therapy will be necessary [7]. It is important to note that a DH is presently considered for only bisphosphonate therapy, it should not apply to other classes of therapy due to the rapid loss of bone mineral density (BMD) and increased fracture risk associated with their withdrawal [8].

In this study, we aimed to retrospectively assess incidence rates of fractures between patients on continuous osteoporosis treatment versus patients placed on a DH after minimum adequate therapy in a tertiary academic center.

Methods

This is a retrospective cohort study. Data were collected by chart review of patients who were followed at a tertiary academic center from October 2007 to September 2016 for treatment of osteoporosis.

Definitions

  • Osteoporotic fracture: a fracture caused by an injury that would be insufficient to fracture a normal bone as a result of reduced compressive and/or torsional strength of bone [9]. Typical fractures in patients with osteoporosis include vertebral (spine), proximal femur (hip), distal forearm (wrist), and proximal humerus [9,10]. Osteoporotic fractures may involve any bone except the hand (distal to carpal bones), foot (distal to ankle), face, and skull [11]. Osteoporotic fractures are also termed fragility fractures in this study.
  • DXA scan: Dual-energy X-ray Absorptiometry
  • Drug holiday: A period when treatment is stopped after a patient has been on continuous treatment. However, the term ‘holiday’ implies the temporary withdrawal of treatment that may be restarted in the future [12]
  • FRAX score: An online validated tool for fracture risk assessment (https://www.shef.ac.uk/FRAX/tool.jsp), FRAX web version 4.0 was utilized in this study.

Risk Stratification

Risk Assessment was based on the recommendations of the National Osteoporosis Foundation (NOF) (USA) [13-16]:

  • High risk:
  • FRAX Score: Major Osteoporotic Fracture [MOF] risk ≥20% and/or Hip Fracture [HF] risk ≥3%
  • DXA scan findings: T-score ≤ -2.5 SD at the lumbar spine, femur neck, or total hip
  • Presence of a fragility fracture (sites as previously mentioned in the protocol)
  • Only one positive high risk categorical finding is enough to be classified as “high-risk”.
  • Intermediate risk:
  • FRAX Score: MOF risk 10-19% and/or HF risk 1.5-2.9%
  • Low risk:
  • FRAX Score: MOF risk <10% and/or HF risk <1.5%
  • Lower risk:
  • Patients in the low or intermediate-risk categories to facilitate their combined risk as compared to high-risk patients.

Medications for the treatment of osteoporosis [16]:

Bisphosphonates: Alendronate, ibandronate, risedronate, and zoledronate.

Inclusion and Exclusion Criteria

Inclusion criteria consisted of adults aged ≥18-year-old with a history of receiving continuous bisphosphonate therapy (alendronate, ibandronate, risedronate, zoledronate) for treatment of osteoporosis or patients at high risk of fracture. Continuous therapy was defined as a minimum of three years of continuous bisphosphonates therapy.

Exclusion criteria included adult patients who received a shorter duration of bisphosphonates therapy for treatment of osteoporosis or receiving other osteoporosis treatment medications solely; receiving treatment to manage hypercalcemia or osteolytic lesions related to malignancy or other medical conditions. Institutional Review Board (IRB) approval was obtained.

Aim, Data, and Analysis

We aimed to assess fracture incidence rates between patients on continuous treatment (CT) for osteoporosis versus patients placed on a drug holiday (DH) after minimum adequate therapy.

Descriptive analysis was performed to assess baseline patient demographics, clinical characteristics, duration of therapy, and fracture rates. Categorical variables were presented as frequencies, proportions, and percentages. Continuous variables were presented as means ± standard deviations. The χ2 test was used for the analysis of categorical variables and the t-test was used for continuous variables. Fracture-free survival analysis was performed using the Kaplan-Meier method, comparison and assessment of statistical difference were performed using Mantel-Cox analysis. SPSS (Statistical Package for the Social Sciences) ≥23 was used for all the statistical analyses.

To compare data between different proportions or means, a fixed-effects statistical model for meta-analysis was used [17]. The means, SD, and proportions were weighted based on the sample sizes of the different cohorts in each study. The confidence intervals for the variables were calculated for the p values of 0.05, 0.01, and 0.001. These were compared with corresponding means and proportions in the other cohort to determine the statistical significance [17].

Results

A total of 12,885 patients were identified based on the presence of at least one prescription for an osteoporosis medication in the electronic medical records from 2007 to 2016. The research group reviewed 1,814 randomly selected charts and 272 patients met the inclusion criteria as shown in Figure 1. The mean age of the cohort ( ± standard deviation) was 68.8 ± 10.7 years, females accounted for 90.9%. Most of the patients were Caucasian (50.0%) and African American (40.5%). A Drug holiday was initiated in 119 (43.8) patients. Table 1 summarizes the baseline clinical characteristics of the cohort and the medical specialty of the treating providers. Table 1 discloses the prevalence of comorbidities and risk factors for osteoporosis and fragility fractures in our cohort.

fig 1

Figure 1: Consort Table

Table 1: Clinical characteristics, and comorbidities and risk factors for osteoporosis and fractures

Age (years, mean ± SD)

68.8 ± 10.7

Female gender [n (%)]

248 (91.2%)

Race [n (%)]
Caucasian

135 (49.6%)

African American

111 (40.8%)

Hispanic

22 (8.1%)

Asian

3 (1.1%)

Unknown

1 (0.4%)

Treating Provider
PCP (IM)

132 (48.5%)

Rheumatologist

62 (22.6%)

PCP (FM)

34 (12.5%)

Endocrinology

19 (6.9%)

PCP (Geriatrics)

12 (4.4%)

Others

8 (2.9%)

Oncology

5 (1.8%)

Comorbidities and risk factors for osteoporosis and fractures
Falls

146 (53.7%)

Smoking

90 (33.1%)

Glucocorticoids

59 (21.7%)

Prednisone (or equivalent) ≥7.5mg

32/59 (54.2%)

Diabetes mellitus

53 (19.5%)

Rheumatoid arthritis

28 (10.3%)

Parent fractured hip

10 (3.7%)

Premature menopause

8 (2.9%)

Liver disease

7 (2.6%)

Hyperthyroidism

6 (2.2%)

Hypogonadism

4 (1.5%)

Alcohol abuse

1 (0.4%)

Osteogenesis imperfect

0 (0%)

Abbreviations: SD=Standard Deviation; DH=Drug Holiday; PCP=Primary Care Physician; IM=Internal Medicine; FM=Family Medicine.

The entire cohort received continued therapy beyond the minimum of three years and therefore, all the patients (n=272) were included in the analysis for the continued therapy (CT) group while they were receiving uninterrupted treatment. The mean duration of therapy in the CT group was 6.0 ± 2.6 years. A total of 119 patients were placed on a DH after a mean duration of prior bisphosphonate therapy of 5.7 ± 2.3 years. Any fragility fractures that occurred while receiving therapy and before initiating their DH were analyzed as being in the CT group. Fragility fractures that were present before starting anti-osteoporosis therapy were documented in 82 (29.9%) patients but were not included as occurring during therapy in the CT group. In the CT group, fragility fractures occurring during the initial three years of therapy were noted in 30/272 (11.0%) patients, as observed in Table 2 (fragility fractures within the first 3 years of therapy). These fractures were included in the calculation of each patient’s FRAX fracture risk assessment at the time of institution of their DH but were not considered a failure of therapy since these patients had not completed the predefined minimum adequate therapy of three years. A total of 159 patients received 5 or more years of continuous therapy.

Table 2: Continued therapy and drug holiday

 

Continued Therapy

Drug Holiday

P-Value

Number of patients

272

119

Duration of therapy (y; mean ± SD)

6.0 ± 2.6

5.7 ± 2.3

P>0.05

Follow-up duration (y; mean ± SD)

6.9 ± 2.9

7.8 ± 2.7

P=0.05

Fragility fractures within the first 3 years of therapy (%; n)
Total

11.0% (30/272)

13.4% (16/119)

P>0.05

During 1st year of Rx

3.3% (9/272)

3.4% (4/119)

P>0.05

During 2nd year of Rx

2.2% (6/272)

4.2% (5/119)

P>0.05

During 3rd year of Rx

5.5% (15/272)

5.9% (7/119)

P>0.05

Fragility fractures beyond the first 3 years of therapy (%; n)
Total

11.7% (32)

9.2% (11)

P>0.05

3-4.9y of therapy

6.3% (17/272)

14.0% (8/57)

P>0.05

≥5y of therapy

9.4% (15/159)

4.8% (3/62)

P>0.05

Fragility Fractures in the Continued Therapy versus Drug Holiday Cohorts

In the CT versus DH cohorts, mean duration of therapy was 6.0 ± 2.6 versus 5.7 ± 2.3 years (p>0.05) and total duration of follow-up was 6.9 ± 2.9 in CT group versus 7.8 ± 2.7 years in DH group (P=0.05). The mean duration of follow-up after starting DH was 2.5 ± 1.9 years. The mean duration of follow-up until the occurrence of first fracture (after a minimum of three years of therapy) or last follow-up if there were no fractures was 2.6 ± 2.3 years for the CT group and 2.3 ± 1.8 years for the DH group. As observed in Table 2, the total number of fragility fractures during the entire study period were 32/272 (11.8%) of the CT group versus 11/119 (9.2%) of the DH cohort (P=0.60). A total of 272 patients continued to receive therapy beyond three years and 159 patients received therapy for ≥5 years. Fragility fractures occurred in 17/272 (6.3%) patients on CT for 3-4.9 years and in 15/159 (9.4%) patients on CT for 5 or more years (p>0.05). Fragility fractures after initiation of a DH occurred in 8/57 (14.0%) patients who completed 3-4.9 years of prior bisphosphonate therapy and 3/62 (4.8%) patients who received ≥5 prior treatment, P>0.05. The mean duration for the occurrence of the first fragility fracture was 2.3 ± 2.7 years in the CT cohort versus 1.5 ± 1.2 years in the DH cohort (P<0.01). The fracture-free survival analysis for the whole cohort using Kaplan Meier analysis revealed no significant difference in fracture rates between the CT and DH groups (P = 0.74) as shown in Figure 2.

fig 2(1)

fig 2(2)

fig 2(3)

Figure 2: Fracture-free survival using Kaplan-Meier analysis.
Analysis for the whole cohort using continued therapy after a minimum of 3 years is presented in figure A. Analysis for the whole cohort using continued therapy after a minimum of 5 years is presented in figure B. Analysis based on risk assessment using FRAX scoring are presented in figures C (high risk with continued therapy ≥3 y), D (high risk with continued therapy ≥5 y), E (lower risk with continued therapy ≥3 y), and F (lower risk with continued therapy ≥5 y). High risk patients based on FRAX score were defined as having major osteoporotic fracture risk ≥20% and/or hip fracture risk ≥3. Censored data refers to incomplete data for patients like those who lost follow up or deceased before experiencing the primary outcome (fractures) and who could have otherwise experienced it if continued followed up [2]. Abbreviations: CT=Continued Therapy; DH=Drug Holiday; FRAX=An Online Fracture Risk Assessment Tool.

Fragility Fractures Using Different Risk Assessment Tools

Fragility fractures in the high risk versus lower-risk patients in the CT cohort based on FRAX high risk (HR) were 16.5% versus 7.1% (P=0.01). In the combined FRAX HR plus DXA HR groups, fragility fractures occurred in 13.2% of the high-risk group versus 9.0% in the lower-risk groups (P=0.20). Based on fragility fractures that occurred during the first three years of therapy, 0.0% in the higher risk group versus 13.2% in the lower risk group (P=0.02) respectively. Fragility fractures in the high-risk versus lower-risk patients in the DH cohort based on FRAX HR were 13.5% versus 6.0% (P=0.14). In the combined FRAX HR plus DXA HR group, fragility fractures occurred in 11.3% versus 6.3% in the lower risk group (P=0.28). Based on the presence of fragility fractures during the first three years of therapy, 14.3% were in the high risk versus 8.2% in the lower risk group (P=0.30).

Fragility Fractures in FRAX High Risk versus Lower Risk Patients and Drug Holiday

In the FRAX high-risk group of 133 patients, 87/133 (65.4%) continued therapy whereas 46/133 (34.6%) were placed on a drug holiday. For the high-risk cohort, the mean duration of follow-up until the time of the first fracture or last follow-up if no fractures occurred ( ± standard deviation) was 2.4 ± 2.0 years for the CT group (after 3 years of minimum therapy), and 2.1 ± 1.8 years for the DH group. Among the high-risk patients at initial FRAX risk stratification, fragility fractures occurred in 22/133 (16.5%) of the CT group versus 7/52 (13.5%) of the DH cohort (P=0.66). The mean duration for the occurrence of the first fragility fracture was 2.5 ± 3.1 years in the CT cohort after minimum adequate therapy versus 1.4 ± 1.4 years in the DH cohort.

In the 141 lower-risk patients, 68 (48.2%) continued therapy and 73 (51.8%) were placed on a DH. For the lower risk cohort, the mean duration of follow-up until the time of first fracture or last follow-up if no fractures occurred ( ± standard deviation) was 2.8 ± 2.6 years for the CT group (after 3 years of minimum therapy), and 2.4 ± 1.8 years for the DH group. Among the lower risk patients at initial FRAX risk stratification, fragility fractures occurred in 10/141 (7.1%) of the CT group versus 4/67 (6.0%) of the DH cohort (P=1.0). The mean duration for the occurrence of the first fragility fracture was 2.0 ± 1.9 years in the CT cohort after 3 years of therapy versus 1.6 ± 0.8 years in the DH cohort. The fracture-free survival analysis for the high-risk and low-risk cohorts using Kaplan Meier analysis revealed no significant difference in the fracture rates between the CT and DH groups (P = 0.87 and 0.88 respectively) as shown in Figure 2.

Five Years of Therapy

The rate of fractures was also assessed for patients who continued therapy for a minimum of five years. In FRAX high-risk patients on CT for 3-4.9 years versus ≥5 years of minimum therapy, fractures occurred in 11/63 (17.5%) versus 11/70 (15.7%) patients, respectively, P=0.88. In FRAX lower-risk patients on CT for 3-4.9 years versus ≥5 years of minimum therapy, fractures occurred in 6/52 (11.5%) versus 4/89 (4.5%) patients, respectively, P=0.34. Among the entire cohort, 159/272 patients continued therapy ≥5 years (mean 7.1 ± 2.5y) while the mean duration of therapy for the DH cohort (n=119) was 5.7 ± 2.3 years. Fracture rates were comparable between both groups as shown in Figure 2, P=0.61.

Discussion

The duration of osteoporosis therapy and when institution of a drug holiday should be considered is an under-researched area. There are differences in guidance regarding a DH among the osteoporosis-related societies [7,18-23]. At present, there are few prospective clinical trials or retrospective studies available to assess the risk of fracture while on continuous osteoporosis pharmacological therapy versus a drug holiday. The present consensus states that high-risk patients should continue therapy for no less than 5 years. Our goal was to assess the pattern of osteoporosis pharmacological treatment and fracture rates in a real-life setting in patients on continued therapy (CT) and a drug holiday (DH). Patients in the CT and DH subgroups were further stratified by FRAX scoring into high risk versus lower risk categories.

The first clinical trial to prospectively assess the concept of DH was the FLEX trial comparing continuing alendronate for a total of 10 years versus a DH after 5 years of therapy [24]. DH did not increase the risk of non-vertebral fractures or x-ray-detected vertebral fractures over the 5 years of follow-up, but the risk of clinically diagnosed vertebral fractures was significantly lower among CT 2.4% (16/662) versus DH cohort 5.3% (n=23/437); relative risk 0.45; 95% confidence interval 0.24–0.85). However, post hoc analysis of this data disclosed increased risk of fractures in the DH group was associated with lower baseline BMD and increased number of fractures prior to starting therapy. Significant limitations of the FLEX trial included the lack of assessing shorter duration of therapy (namely three years of treatment) and inability to utilize fracture risk assessment tools such as FRAX scoring (2008) [24]. The second clinical trial to prospectively assess CT versus DH was the Zoledronate HORIZON-Pivotal Fracture Trial, 3 years of therapy (Z3) versus placebo (P3) [25]. Two subsequent extension trials assessed CT versus DH, 6 years of CT (Z6) versus 3 years of therapy followed by a DH (Z3P3), followed by 9 years of CT (Z9) versus 6 years of therapy followed by a DH (Z6P3) [26,27]. In the first extension trial (Z6 versus Z3P3), there was no significant difference in non-vertebral or hip fractures, although patients who continued therapy had a lower rate of new vertebral fractures: 3.0% versus 6.2% (Odds ratio 0.51, 95% confidence interval [0.26, 0.95], P 0.035), and >60% of the patients in each cohort were at high risk of fractures. In the second extension trial (Z9 versus Z6P3), there was no significant difference in fracture rates between CT versus DH. Limitations of the HORIZON extension trials included the lack of risk stratification at either baseline or at the time of starting a drug holiday using a well-validated fracture risk assessment tool. In the study assessing Risedronate in osteoporosis, there was no DH comparator group but rather a comparison of 7 years of CT versus 5 years of placebo followed by 2 years of therapy [28]. DH after the use of denosumab was found to be associated with a rebound rapid increase in bone remodeling rates and a high risk of vertebral fragility fractures [29]. DH after teriparatide therapy is associated with loss of accrued bone mass and loss of the fracture protective effect of the drug and as such the general recommendation has been to follow osteoanabolic therapy with an antiresorptive therapy [19]. It should be noted that all the recommendations regarding drug holidays are primarily based on the alendronate and zoledronate clinical trials with the noted limitations of the trials and reliance on expert opinion.

Based on the previously mentioned two prospective placebo-controlled trials and their extensions, the general recommendation has been to consider a DH after 5 years of oral bisphosphonate therapy (FLEX Trial for alendronate) and 3 years for intravenous zoledronate. In our study, the statistical analysis was performed after a minimum of 3 years of therapy that is comparable to all bisphosphonate registration trials with assessment of fracture rates in both CT and DH groups. We performed our preliminary analysis after collecting data for 272 patients with the aim of re-estimating the power analysis and the number of patients to be reviewed afterward. Unexpectedly, the rate of fractures was not statistically different in CT as compared to DH. The absolute rate of fractures was numerically higher in the CT group, and therefore the study was terminated at that point.

In our study, the rate of fractures was assessed for the entire cohort and FRAX high and lower-risk patients. Comparison of the rate of fractures between CT and DH cohorts in each of these groups was performed at treatment thresholds of ≥3 and ≥5 years. The cut-off of 3 years was suggested to assess the efficacy after the use of 3 years of oral bisphosphonate therapy. The mean duration of therapy in patients who were placed on a drug holiday was 5.7 ± 2.3 years, and as most of the initial therapy was oral bisphosphonates, followed the general recommended guidelines of 5 years of oral therapy. Therefore, analysis of CT ≥5 years was necessary as well to avoid the bias of under-treatment using the cut-off of 3 years and having a falsely higher number of fractures in the CT cohort. Among the 6 comparison studies as shown in Figure 2, there was no significant difference between the patients on CT versus DH, independent of the risk status (high or lower FRAX risk) or duration of therapy (≥3 or ≥5 years).

The position statements of the American Society of Bone and Mineral Research, International Osteoporosis Foundation (IOF), AACE/ACE, FDA commentary, and the Endocrine Society guidelines agree that initial therapy with oral bisphosphonates of 5 years or 3 years of intravenous zoledronate should be considered standard of care [7,18-23]. In high-risk patients, these guidelines suggest the continuation of therapy with some advocating at least 10 years of oral therapy and 6 years of intravenous zoledronate. In low to intermediate-risk patients, it was suggested that clinicians consider a DH with frequent risk assessment every 2-4 years [7,18]. Although it is a reasonable approach to consider continuation of therapy and avoidance of fragility fractures in high fracture risk patients started on a premature DH after less than 5 years of therapy, there is little objective evidence to confirm this position. In our study, the rate of fractures was comparable between the high-risk patients who continued therapy as compared to those who were placed on a DH.

Our study is the first retrospective cohort study to perform an in-depth fracture risk assessment based on calculating FRAX scores and assessing fracture rates in different risk strata. The pre-treatment fracture rate in our cohort was 29.9% consistent with the inclusion of a significant number of high-risk patients comparable to several prospective studies and as such avoiding under-powering of the study. The mean duration of therapy, as well as post-drug holiday follow-up, is reasonable considering the introduction of electronic health records in 2007. There are some limitations of this study including the retrospective nature of the study, small number of patients, and relatively short duration of follow-up. Patients who had their bone density scans or received treatment at outside facilities were not available in the EMR via notes/charts, per verbal discussion with the provider, or through use of cross-EMR observations (Care Everywhere®) reference. Most of our patients received alendronate without sufficient information available in the EMR regarding medication compliance. Bone remodeling markers were rarely checked. Lastly, no significant episodes of ONJ or AFF were observed although outside medical records were not always available, and assessment of these rare complications was limited.

Conclusion

In our cohort study, continued drug therapy beyond 3 years did not provide additional protective benefit as compared to a drug holiday in high-risk patients. Future studies with larger cohorts and a longer duration of follow-up are needed to validate these findings. Although not uniformly performed in all patients of our cohort, annual reassessment of the response to pharmacological therapy and fracture risk assessment should be performed. The present common use of the term “Drug Holiday” in osteoporosis management should be replaced and endorsed by all societies as “Bisphosphonate Drug Holiday”.

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Chronic Hepatitis B and Hepatocellular Carcinoma: Novel Therapeutic Concepts

DOI: 10.31038/IDT.2023411

Abstract

Hepatitis B virus (HBV) is a partially double-stranded hepatotropic DNA virus that currently infects about 4% of the population world-wide (ca. 296 million people) with the highest prevalence in Asia and Africa and more than half a million deaths annually. Clinically, HBV infection can be asymptomatic with normal or near normal aminotransferase levels or with elevated alanine aminotransferase levels, significant necroinflammation and eventually progression to advanced liver cirrhosis and hepatocellular carcinoma. Indications for treatment of chronic hepatitis B are HBV DNA levels >2000 IU per milliliter and liver cirrhosis. Different from the now available curative oral therapies of chronic hepatitis C by direct-acting antiviral agents (DAAs), to date there exists no curative therapeutic strategy for chronic hepatitis B. Therefore, multiple new investigational therapeutic antiviral concepts are currently explored.

Globally, HCC is the sixth most diagnosed cancer and the third leading cancer-related death in 2020. The management of HCC is complex and depends on the stage of the disease at the time of diagnosis. HCC is largely chemotherapy-resistant and no systemic treatments improved survival until recently. In the early 2000s HCC treatment was revolutionized by sorafenib, a modestly effective orally available tyrosine kinase inhibitor (TKI). In 2018 levantinib was also approved as first-line treatment, followed by several antiangiogenic agents, including among others regorafinib, ramucirumab, and cabozantinib as second-line treatments. Unfortunately, 5-year overall survival of advanced or metastatic disease is still <10%. Therefore, numerous clinical trials are ongoing, assessing immune checkpoint inhibitors (ICIs) in combination with each other or with targeted agents in the treatment of HCCs. Further, ICI incorporation into the treatment of very early-stage HCC by resection or ablation may lower recurrence rate or even cure these patients.

Abbreviations

CHB: Chronic Hepatitis B, HBV: Hepatitis B Virus, HCC: Hepatocellular Carcinoma, ICI: Immune Checkpoint Inhibitors, TKI: Tyrosine Kinase Inhibitor

Introduction

Hepatitis B is a major global public health problem. Hepatitis B virus (HBV) causes acute and chronic infection. The long-term consequences, i.e. liver cirrhosis and hepatocellular carcinoma (HCC) arising from chronic HBV infection carry a risk of premature death in 25% of individuals. The World Health Assembly adopted in 2016 the WHO Global Health Sector Strategy on Viral Hepatitis (WHO-GHSS) aiming at a 30% reduction of new hepatitis B infections and a 10% reduction of HBV-related deaths by 2020 and a 95% reduction of new HBV infections and a 6% reduction of HBV-related deaths by 2030, compared to the baseline year 2015 [1-4]. Vaccines, virus testing and antiviral therapies already exist to prevent HBV infection as well as HBV-related disease progression. While new cases of hepatitis B have been reduced by vaccination [1]. HBV-related deaths are expected to rise under the current pace of testing and the available treatment interventions. The same holds true for the early detection of advanced hepatocellular carcinoma and the medical treatment of advanced tumor stages.

In the following novel concepts for the medical treatment of chronic hepatitis B and of advanced HCC will be discussed.

Novel Antiviral Strategies against Chronic HBV Infection

HBV infects and replicates in hepatocytes after it binds to the cell surface via the pre-S glycoprotein and interacts with the hepatic bile acid transporter sodium taurocholate cotransporting polypeptide. The relaxed circular DNA genome is transported to the nucleus and converted to covalently closed circular DNA (cccDNA) that is transcribed into pregenomic RNA which serves as template for reverse transcription into HBV RNA and the translational template for the core protein and polymerase. After the partially double-stranded HBV DNA is enveloped, the virion is secreted or recycles back into the nucleus [2-4].

Therapy of chronic hepatitis B at present rests mostly on pegylated interferons alpha and nucleos(t)ide analogues, such as adefovir, entecavir, lamivudine, telbivudine, tenofovir disoproxil fumarate and tenofovir alafenamide. The nucleos(t)ide analogues result in a sustained viral suppression, improvement of ALT levels and ultimately in a decrease of liver cirrhosis and liver cancer [5,6]. However, even with clearance of serum HBV DNA and hepatitis B e antigen, HBsAg and cccDNA can persist, putting the patient at risk for relapse if therapy is stopped with a potentially severe or even fatal clinical course. To reduce the need for lifelong treatment, novel strategies are aimed at a functional or complete cure (Table 1). Numerous new anti-HBV compounds that are expected to fulfill these requirements have been or are presently evaluated in clinical studies [2-4].

Table 1: Therapeutic Antiviral Response

Liver cccDNA

Serum ALT

Serum HBV DNA

Serum HBsAg

Anti-HBs

Virologic + Variable

+

Biochemical + Normal

variable

+

Functional + * Normal

-/+

-/+

-/+

Cure – ** Normal

+

* Time-limited therapy, e.g. 1 yr
** Long-term therapy, yrs.

While none of the antivirals evaluated to date in clinical trials result in a functional or complete cure (Table 2), one can hope that innovative curative therapeutic concepts will be developed in the future. For the time being the major focus will be the worldwide implementation of HBV vaccination, the consequent clinical testing of individuals at risk and the antiviral treatment of those already infected. Given the seminal development of effective drugs against chronic hepatitis C [7], it is hoped that a similar success will eventually eradicate HBV infections and its associated morbidity and mortality.

Table 2: HBV antivirals in clinical studies

Drug

Mode of Action

Myrcludex B Entry inhibitor
Nitazoanide HBx target
CRV-431
GSK 3228836 RNA degradation
JNJ-3989
AB-729 RNAi
ALN-HBV (VIR-2218) RNA degradation
   
Vebicorvir Capsid Assembly Modulator
ABI-H3733
ABI-4334
Morphodiadin
JNJ-6379
EDP-514
RG7907
QL-007
ALGH-000184
AB-836
VNRX-9945
O7049839
RG7336 iRNA agent
JNJ-3989 “ [15]
AB7-29-001
VIR-22198
ALG-125755
Bepirovirsen Antisense oligo [16,17,18]
   
ALG-020572-401
Nivolumab Anti-PD-1
Cemiplimab

Novel Therapeutic Strategies for Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, the sixth most frequent cancer and the third leading cause of cancer-related death worldwide [8]. HCC is an aggressive tumor that usually occurs in the setting of chronic liver diseases and cirrhosis [9]. A widely accepted treatment algorithm has been proposed by the Barcelona Clinic [10]. Depending on the stage of the HCC, treatment options are divided into surgical (resection, cryoablation, liver transplantation) and liver-directed non-surgical procedures (percutaneous ethanol or acetic acid injection, radiofrequency/microwave ablation, transarterial embolization, external beam radiation) and systemic treatment modalities (chemotherapy, molecularly targeted therapy and immunotherapy with immune checkpoint inhibitors (ICIs) [10].

Systemic treatment approaches for patients with advanced, unresectable HCCs in most cases are inappropriate for surgical or liver-directed non-surgical interventions, due the patient’s limited hepatic reserve. Unfortunately, in clinical practice >20% of HCCs are detected late, at already advanced stages. Further, HCCs are relatively chemotherapy-refractory tumors.

With a better understanding of the pathophysiology of HCCs, its hypervascularity and vascular abnormalities, the role of proangiogenic factors such as VEGF was identified in the early 2000s. With the development of the small molecule sorafenib, blocking the VEGFR, PDGFR, cRAF1, B-Raf, as orally available tyrosine kinase inhibitors (TKIs) or humanized monoclonal antibodies bevacizumab, cetuximab, e.g., VEGF, EGF, into clinical practice [11,12] this strategy gained momentum]. While the single-agent anti-programmed cell death (anti-PD-1) ICIs resulted in a modest response, the combination of atezolizumab (an anti-PFD-L1 ICI) with bevacizumab (an anti-VEGF antibody) was approved as first-line therapy in 2020. It showed a significant improvement in response rate, progression free survival and overall survival compared to sorafenib, the previous standard of care. This study established the combination of the antibody anti-PD-L1 atezolizumab with the VEGF-Inhibitor bevacizumab as first-line therapy for the advanced HCC [S]. While pembrolizumab and nivolumab were conditionally approved, a decision whether to keep or withdraw the approval is still pending [13, 14].

Despite these promising results of the combination of atezolizumab and bevacizumab for advanced HCC, several issues need to be carefully considered, especially the hepatic reserve and possibly the cause of liver disease. Further, a word of caution is in order, regarding the efficacy of multiple combination therapies. A recent study evaluating the combination of siRNA (JNJ-3989) with or without a CpAM (JNJ-6379) had the lowest rate of response compared with the 2 siRNA plus NA for comparison. This raises the possibility of an interaction between CpAM and siRNA and suggests that not all combinations will result in synergy.

Discussion and Conclusion

Chronic HBV infection results in chronic hepatitis with a life-time risk for progression to cirrhosis and HCC. Consequently, life-long monitoring is required to detect disease progression and surveillance is recommended to identify individuals at increased risk for HCC development. Current therapeutic options against chronic hepatitis B improve clinical outcome, but are not curative because they have no effect on cccDNA and integrated HBV DNA. While to date, none of the numerous therapeutic options (Table 2) have resulted in a functional or curative response. Given the global burden of disease there is an urgent need for more effective therapies, increased efforts to identify the patients already infected and to expand the vaccination programs with the aim to eliminate HBV infection worldwide.

With respect to the dismal prognosis of patients with advanced HCC at the time of diagnosis numerous clinical trials are assessing ICIs in combination with each other and with targeted agents. At the same time, major efforts are directed at the earlier detection of HCCs that are amenable to surgical and non-surgical liver-directed therapeutic strategies.

Conflict of Interest

No financial interest or conflict of interest exists.

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