Monthly Archives: April 2023

The Decision-Making Process for Percutaneous Endoscopic Gastrostomy in People with Amyotrophic Lateral Sclerosis

DOI: 10.31038/ASMHS.2023714

Abstract

Percutaneous endoscopic gastrostomy (PEG) insertion is recommended for people with amyotrophic lateral sclerosis (PALS) who are experiencing dysphagia resulting in diminished food and oral intake. Unintended weight loss and malnutrition are negative prognostic factors in PALS. Insertion of a PEG tube provides reliable access for nutrition, hydration, and medication, and can diminish the risk for aspiration pneumonia, choking, weight loss and fatigue. PEG use can significantly increase survival time for PALS; however, less than half of PALS who meet the criteria for PEG tube placement undergo the procedure. The factors influencing PALS in making this decision have not been extensively explored. This qualitative case study investigated the decision-making process in accepting a PEG as an alternative means of feeding. A purposive sample of 5 participants utilizing a PEG tube was recruited. Data was collected using in-depth semi structured interviews consisting of open-ended questions. Interviews were completed face to face through Zoom, a virtual platform. A thematic analysis was conducted to understand the unified subjective experiences of the participants. The analysis revealed four themes: (1) Survival; (2) Scary and Anxiety Provoking Process; (3) Wanted to Live Longer; and (4) Not Alone in My Decision. Conclusions: The decision-making process for PALs is highly emotive and challenging. Lack of appropriate education and comprehensive discussions with health care providers were negative factors that influenced the decision making process. Social supports and the will to live were positive factors that facilitated autonomous decision-making and eased the angst in PALS during this very difficult process.

Keywords

Amyotrophic lateral sclerosis, Percutaneous endoscopic gastrostomy, Decision-Making, Feeding tube, Dysphagia

Introduction

Amyotrophic lateral sclerosis (ALS) is an uncurable, progressive, fatal neurodegenerative disorder that destroys motor neurons in the nervous system. Motor neurons are key in the transmission of impulses from the spinal cord to skeletal muscles, as they enable individuals to have direct control of all muscle movements. As such, this neurodegenerative disease ultimately leads to progressive muscle weakness and loss of voluntary muscle control [1]. ALS has an incidence of 5.2 per 100,000 people in the United States [2]. The average life expectancy for patients with this disease is 2-5 years post diagnosis, with most deaths resulting from respiratory failure, often precipitated by pneumonia [3]. Several subtypes of ALS exist, with the most common resulting in limb onset (70%) and bulbar onset (25%) [4]. Both subtypes are characterized by upper motor neuron (UMN) symptoms, including hyperreflexia, spasticity, and bradykinesia, and lower motor neuron (LMN) symptoms, including fasciculations, muscle weakness, and atrophy. Despite the decreased mobility of people with ALS (PALS), the metabolic demands increase secondary to continuous muscle spasms and fasciculations [5]. The decreased nutritional intake due to difficulty swallowing results in negative caloric balance, further exacerbating muscle wasting, reducing body mass index (BMI), and worsening functional status. Furthermore, weakness and atrophy of the tongue and muscles of mastication contribute to fatigue in chewing and increase the time required for feeding. Other serious complications such as aspiration pneumonia and acute episodes of choking, either of which can be life threatening, have also been observed. Similarly, progressive dysphagia diminishes patients’ respiratory reserve, which will become a crucial factor in recommending and evaluating for further intervention [4].

Although the progression of symptoms and the areas of the body affected vary by subtype, approximately 85% of all PALS develop dysphagia [6], or difficulty swallowing, over the course of the disease. PALS with bulbar onset have a greater incidence of dysphagia early in the progression of the disease, whereas those with spinal onset develop dysphagia in the late stages [7]. Statistics reflect that dysphagia in those with bulbar onset increased from an initial incidence of 95% to 98% and those with spinal onset from 35% to 73% over a 2-year period [8]. Depending on the severity and onset of dysphagia, many PALS need additional support for receiving proper nourishment. Negative prognostic factors in PALS includes weight loss and malnutrition. Guidelines for intervention for dysphagia include placement of an enteral gastrostomy tube [1]. There are different enteral tube procedures utilized for tube placement, with the two most common procedures being the percutaneous endoscopic gastrostomy (PEG) and the Radiologically Inserted Gastrostomy (RIG). The RIG is less desirable than PEG because it has been associated with increased rates of dislodgement, tube blockages, and infections [9,10]. Further, a meta-analysis [11], studied the technical success rates, complication rates, and mortality rates between PEG and RIG resulting in the PEG having an increased success rate, with complications and mortality comparable after placement. Similarly, a prospective study [12], found mortality and complication rates comparable involving 50 patients with ALS who underwent a PEG or RIG procedure. Another meta-analysis evaluated postoperative complications, procedural success rate, and survival outcomes. In contrast, the PEG procedure was associated with less post-operative pain, but again had a lower success rate without any differences in survival [13]. An important advantage of the RIG procedure is that it does not require general anesthesia which lessens the possibility of respiratory complications, especially in patients with a reduced forced vital capacity (FVC) less than 50%, as measured by spirometry [12-14].

Furthermore, feeding tubes require specialized care and maintenance which oftentimes causes considerable burden on PALS and their caregivers leading to significant emotional impact and decreased quality of life. Although medically necessary, there is a limited amount of qualitative literature on the factors that influence the patients’ decision-making process to undergo such a procedure. Current studies [15,16], have shown that PEG tube acceptance in patients with ALS varies across countries and that patients are often reluctant to undergo this procedure [17].

In a review, Bradly [18], evaluated changes (in terms of ALS management) established in the 1999 American Academy of Neurology ALS Practice Parameters publication and reported that only 46% of patients were recommended for a PEG tube and of those only 43% received one. This amounts to an overall 20% PEG insertion rate. The timely implementation of a PEG tube is important, as there is a limited window of opportunity to receive this type of treatment. Without a PEG tube, PALs nutritional intake is compromised and thus negatively impacts health.

Initial studies have failed to demonstrate the benefit of enteral feeding in survival duration in the ALS population. However, more recent research has shown a trend toward a positive effect, especially in studies following the most recent guidelines and larger sample sizes [7]. A retrospective study combined with a meta-analysis demonstrated that enteral feeding increased survival duration irrespective of ALS subtype and stabilized BMI. Furthermore, analysis determined that enteral tube placement in patients with an FVC greater than 50% had a better survival duration than those with a FVC less than 50%. This trend was magnified in patients with a FVC greater than 60% [19]. Lastly, the American Academy of Neurology (AAN) recommends a FVC of below 50% as a threshold where complication rates are increased [20]. However, other studies have proposed higher FVC, such as 60% to 70%, to improve outcomes [19,21,22].

Currently, there are no established criteria to determine the optimal timing of a tube placement. This may result in a delay in recommendations and patients missing a window of opportunity for the most beneficial outcomes and maximal risk reduction. To assist a patient in the decision-making process, it is important to understand the factors that influence and motivate an individual in choosing a course of action. Thus, the purpose of this study was to explore the decision-making process that contributed to the placement of a PEG feeding tube in people with ALS. The study also sought to highlight the influences and experiences, while obtaining such an invasive alternate feeding device.

Methods and Materials

Study Design

This research used qualitative case study methodology based on thematic analysis to conduct an in-depth exploration of the phenomena of the decision-making process among PALS who opted for PEG tube insertion. The question “how do PALS describe their decision-making process in obtaining a PEG “feeding tube”?” guided this study. Secondary questions included “how do people with ALS describe the experience of obtaining a PEG feeding tube?” and “what were the influences that impacted the decision to accept a feeding tube?”.

The number of participants recruited for this study was based on previous qualitative studies. The literature suggests a small sample size, which enables a more in-depth perspective on the phenomena (decision-making process). Specifically, a purposive sample of 5 participants would offer a more in-depth perspective on the decision-making process of these individuals [23].

Approval from Hofstra University’s Institutional Review Board (IRB) was obtained (HUIRB Approval Ref#: 20220727-OT-HPHS-CIA-1) prior to recruitment of participants.

Participants

A purposive sampling was used to recruit PALS who use PEG tube feedings. Recruitment occurred via ALS care teams in multidisciplinary clinics located in various areas of the northeast USA. Members of care teams were asked to inform PALS with PEGs of our study. Those PALS who were interested were contacted by the first author. Participation was voluntary and informed consent was obtained from all participants. Confidentiality and anonymity were assured as well as the right to withdraw from the study at any time.

Five participants, 3 male and 2 female, were interviewed for this study. The mean age of the participants was 55.4 (range=36-75 years old). The mean time from diagnosis to PEG insertion was 5.6 years (range=2-11 years). All participants had a diagnosis of ALS, and all were using PEG tube for nutrition and hydration. All participants attend specialized multi-disciplinary clinics for ALS located in the northeast of the United States. None of the participants held any form of paid or volunteer employment, all resided with family, and all utilized a power wheelchair to meet their mobility needs (Table 1).

Table 1: Study participants demographics and related information

Participant

Information

1 Diagnosed with ALS in 2014; PEG inserted in 2016; ventilator dependent, uses assistive technology devices for augmentative and alternative communication. Lives with spouse and dependent child.
2 Diagnosed with ALS in 2017; PEG inserted in 2021. Lives with spouse and adult children.
3 Diagnosed with ALS in 2008; PEG inserted in 2017; ventilator dependent. Lives with adult child.
4 Diagnosed with ALS in 2010; PEG inserted in 2021. Lives with spouse and adult children.
5 Diagnosed with ALS in 2019; a PEG inserted in 2022; uses assistive technology devices for augmentative and alternative communication. Lives with parents.

Data Collection

Participants were interviewed between August and September of 2023 by one of the researchers (GC) using a semi-structured interview format. Semi-structured interviews addressed the aims of this research and facilitated a deep understanding of the decision-making process, which was further appreciated by encouraging a bidirectional dialogue between researcher and participant. This is an inherent strength of interviews over questionnaires [24].

All interviews were conducted face-to-face using the online platform Zoom. Interviews were video and audio recorded. Participants reaffirmed consent verbally prior to the interviews. All interviews were scheduled at a time of the participant’s choosing. Interview duration ranged from 55 to 89 minutes, as is typical for a semi-structured interview [25]. Interview time was longer for participants who used augmentative and alternative communication. A personal zoom account through the University was used to allow for great control of privacy and security. A unique private meeting ID and passcode was created for each interview. Unique identifiers were applied to each participant for referencing purposes and to protect confidentiality.

Data collection consisted of participants responding to demographic questions and semi-structured questions developed prior to the interviews which focused on the decision-making experience of having a PEG placement. The use of open-ended questions in a semi-structured interview format permitted the participants to expound upon their experience while allowing the interviewer to obtain relevant data across the participant sample. Data collected provided researchers with descriptive and personal findings from each participant.

Data Analysis

All interviews were audio recorded, transcribed, and anonymized. Demographic information was recorded and included age, sex, social support, living arrangements, date of ALS diagnosis and the date of the PEG procedure. Additional informational data recorded was the time, date, and location of each interview. Two researchers (GG and IS) independently analyzed and coded the five transcripts for description and themes. [26] This process assisted in isolating common responses between participants to assist in theme development. Using this method built textural and structural description of the participants’ experiences [27]. Due to the qualitative design of this study, the information obtained is highly subjective. Participants had different reasons for agreeing to a PEG tube insertion and experiences surrounding the process. Several steps were implemented to enhance trustworthiness and increase the rigor within the study design. Trustworthiness was established through formulating structured questions in advance to minimize bias and increase consistency between questions asked. This uniformity prevented the use of “lead in” questions, which also tends to bias responses from research participants [28]. Data collection was completed through a consistent interview technique involving open-ended non-leading questions. All interviews were voice recorded with typed verbatim transcriptions for researchers to verify for accuracy.

To confirm the accuracy of the researchers’ interpretations, inductive thematic analysis was utilized to evaluate the data [29]. Researchers familiarized themselves with the data collected and initial construction of data was created, and hierarchies developed. This was then analyzed and aggregated to develop themes. Themes were further reviewed, defined, named, and refined by returning to the raw data for confirmation of an accurate representation of the participants’ experiences. A written summary on each theme was completed with participants’ responses linked to the themes that shared the essence of that theme. Results of their analysis were compared, and discrepancies discussed to enhance the credibility of the results and to minimize interpretation bias.

Results

Results of the thematic analysis illuminated the many challenges that impact the decision-making process of undergoing an invasive procedure as a PEG insertion. Analysis produced 4 themes and included the following: (1) survival; (2) scary and anxiety provoking process; (3) wanting to live longer; and (4) not alone in my decision.

Theme 1: Survival

As the disease progressed, participants described the ability to swallow becoming more difficult with various type of food consistencies. Participants reported starting with solid foods, then moving to solids cut into very small pieces and eventually progressing to puree. Besides the physiology intricacies of swallowing, the psychological fear of choking became apparent (Table 2).

Table 2: Participant responses related to survival

Participant

Exemplar Responses

1 I was having trouble swallowing solid foods; ALS, and that the expected progression, the next step would be that I wouldn’t be able to feed myself; Went from cut up food very small then to puree then to straining the food. You know we’d rather do it earlier then wait till it’s too late … I choked a couple of times, scared the hell out of me…It was an awful submission to come to.
2 “I knew it had to be done, do it now before it is too late”
4 I was having trouble swallowing solid foods so I thought that with ALS that was the expected progression, the next step I wouldn’t be able to feed myself.
5 I was losing weight and my ability for chewing and swallowing…and muscles in my mouth got weaker… I was having trouble swallowing solids- food…concerned I wouldn’t be able to feed myself to stay alive”

Theme 2: Scary and Anxiety Provoking Process

Participants experienced a range of emotions from being scared to having anxiety in the decision-making process to obtain a PEG. These feeling stemmed from the lack of education and misinformation from the medical team who conveyed the urgency for a PEG, although not necessarily needed at the time. Participants expressed that medical teams were overly assertive and too comfortable in recommending such an invasive procedure that would have a lasting impact in their lives. The fear of the procedure was only heightened when participants were told they would not be able to feed orally post PEG placement. These factors and inconsistencies contributed to the theme of scary and anxiety provoking process, which is reflected in the following statements (Table 3).

Table 3: Participant responses related to scary and anxiety provoking process

Participant

Exemplar Responses

1 It was awful!! It was scary. I saw the doctor and he wanted to PEG me right away even though my vital capacity was near 70……not the type of bedside manner I could handle ….Awful submission to come to.
2 “They wanted to do it preemptively….I did not want to stop eating. I was concerned that I could no longer eat my favorite food. I mean…you know…my gosh!”
3 The doctor decided, I went to the hospital because of pneumonia and ending up with a tracheostomy and a PEG inserted…It was very terrifying… I was misinformed by the doctors as I was still able to eat by mouth. At that time, no one believe in those guys (doctors)… I didn’t need this as I never had a swallowing issue…I don’t recall them (doctors) sorry about the issue. Not well informed.” “I was misinformed by the MDs, as they told me I need it (PEG) as I would not be able to eat…. I still eat by mouth. Either I get the tracheotomy and the feeding tube, or they (doctors) unhook me. It was terrible… It was terrible.
4 I had a bad experience… the anesthesiologist, she scared the heck out of me; she had no experience. We were told that it was going to be a very simple procedure, it’s a common procedure, it happens all the time, it’s not a big deal. And we had a very different experience. When the anesthesiologist wasn’t experienced with ALS patients, apparently, and said in a nutshell that I was going to have to be intubated in order to do this procedure, and there was a very strong possibility that I would have a tracheostomy for the rest of his life, after that procedure. There was discussion when we went to the ALS Clinic, that you should get a feeding tube before you need it, but at that time I was eating food just fine; Overall it was scary…I fear procedures.
5  “The ALS clinic very persistent (in PEG placement). ”I was told that there was a possibility that if I didn’t come out of anesthesia I would be put on a vent and they weren’t sure if it could be reversed”

Theme 3: Wanted to Live Longer

Although the participants ranged in age, the need to live longer was an overarching theme for different reasons. The decision to have a PEG insertion weighed heavily as participants wanted to spend time with their children and see them through the stages of their lives. Besides their own children, the thought of not meeting future grandchildren seemed apparent. Other participants wanted to be able to live longer to spend time with family (Table 4).

Table 4: Participant responses related to wanting to live longer

Participant

Exemplar Responses

1 I did it (PEG insertion) for my daughter, I wanted to be here longer for her. The practical reasons were lost on me. I just needed more time with my daughter.
2 “It was all steppingstones, I walked with the walker, then a scooter. I couldn’t drive my car anymore. So it’s like each step…O.k., this is real, I’m not getting better.
3 They (doctors)could do anything they want; I want to live…all I want was to live a few more years. That’s what I’m thinking about. The day I can’t eat or swallow is the day that I’ll lose all hope.
4 I want to be here to see my kids grow up, see my grandchildren…so it’s my driving force.
5 “losing weight, not being able to chew or swallow, not having enough nutrition, I want to go on”

Theme 4: Not Alone in My Decision

The decision-making process to have a PEG placement can be influenced by an individual’s immediate or extended family to a health care provider, having the knowledge of the outcomes of prior patients. In this study, participants cited that both family and healthcare team members were instrumental in the decision-making process. These influences in decision-making were reflected in participants’ statements (Table 5).

Table 5: Participant responses related to not alone in my decision

Participant

Exemplar Responses

1 I was bombarded by them, my family. My mom, spouse, siblings, mother-in-law who wanted me to live longer…There were just a lot of them… you should do it sooner, don’t wait too long… The person that helped me agree to it was my nurse practitioner working for my neurologist.. She had a nice bedside manner and explained the process.
2 My spouse and I…We talked about it; it was scary… My spouse, together we made the decision… We knew it had to be done. I started to cry…just another step further into the disease…We knew it was time…do it earlier than wait till it’s too late…My RN played a huge role in my decision. She knows everything, she’s really smart
4 My spouse and I made the decision… didn’t want to get it until I needed it…when I had difficulty that would be the time to get it.
5 ” Family, brothers, sister- in- laws, parents, aunts, uncles, cousins, all encouraged and supported that this would be the best thing before my lungs got worse”

Discussion and Conclusion

Participants of this study went through a myriad of feelings and emotions including fear and anxiety when faced with the decision to have a PEG tube inserted. The decision-making process was described as very difficult and layered, filled with an array of varying opinions, facts, and influences from family members, friends, and health care professionals. Participants described the support from family and friends and the need to survive and live on as greatly contributing to the decision-making process. Two participants identified the nurse or nurse practitioner at multidisciplinary clinics as being instrumental in the decision-making process because they took the time to explain and educate on what the procedure and what living with a PEG might be like.

Some participants expressed frustration and resentment over feeling pushed by into the decision even though they were not quite ready. These feelings were exacerbated by receiving differing or no information from healthcare professionals about the PEG procedure, the need for the PEG, and what to expect after the procedure. Additionally, participants described some healthcare professionals as being cavalier in their discussions with them, which left them feeling disrespected and not heard. The experience in decision making of our participants was found to be congruent with research reviewed. Shaghayegh (2016) found that inconsistent or poor patient involvement between the medical team and patients led to patients’ loss of autonomy and responsibility for their own care [30]. Similarly, Covvey et al. 2019, identified themes for barriers to shared decision making were uncertainty in the treatment decision, concern regarding adverse effects, and poor physician communication [31].

Research reflects that patients are often fearful to engage health professionals in discussions regarding medical issues beyond their understanding, placing patients in a negotiating position from fear and confusion, rather than knowledge and shared discussion, Berry (2017) refers to as “hostage bargaining syndrome” (HBS) [32]. This idea of HBS, where an imbalance of knowledge exist, will only further breakdown shared decision-making and lead to a sense of frustration, anger, or helplessness on part of the patient. The outcome of this study reflects some participants who were offered little options or medical justification for the PEG insertion, rather “since you’re here in the clinic already, you will need a PEG eventually”. This mindset left participants with increased anxiety and a loss of autonomy over their own care. Although participants were able to cope with these challenges, it was not without exerting a toll on their emotional well-being. The data also suggests collaborative decision-making can provide benefits in terms of a reduction of conflict between families and healthcare members to improve the overall decision-making process. Effective communication is a medical necessity for the delivery of quality professional care to PALS and their families, as vital decisions cannot be made lightly.

The study further shows that the decision-making process is multifaceted, from participants’ healthcare team, spouses, children, to extended family and friends. Participants highlighted that family played an integral role supporting them in the process. Although family may have not understood the process, through their eyes, it was an extension of life. Besides family, participants discussed their healthcare teams in both a positive and negative context. Some PALS found the nurses and nurse practitioners in the multidisciplinary ALS clinics that they attend, to be helpful. Some PALS perceived that some members of their health care team showed little compassion or that they treated the situation as “another day on the job”. All participants wished that they had received better education on PEG tubes from their health care teams. Patients with ALS face a difficult and multifaceted decision when it comes to accepting or refusing the placement of a permanent feeding tube. Interviewing these participants who decided to obtain a PEG tube allowed us to obtain first-hand information on the factors that went into their decision-making process. Beside researchers, healthcare teams may be better equipped in meeting patients’ needs in preplacement stages to reduce overall stress and anxiety. Ultimately, the study shed light on the reasons that participants choose to receive a feeding tube despite the procedure’s implications. Given that patient participation results in improved health outcomes, increased quality of life, and provision of more client-centered interventions, patients need to be involved in the shared decision making process [33-35]. Based on the information widely available through current technology, patients need to be regarded as equal partners in the discussion of their own health care process, to better make more informed decisions.

Finally, we note that the results of this study cannot be generalized to the rest of the ALS population. Findings are not intended to speak for the experiences of other PALS who made the decision to receive a feeding tube. However, the study collected meaningful, individualized data, allowing participants the opportunity to share their personal experiences and tell their stories. This will contribute to the knowledge base regarding PEG feeding and have the potential to help other PALS, caregivers, and healthcare professionals. There are several limitations to this study. There are a small number of participants, all attending multidisciplinary ALS clinics, and all living in the same region of the United States. As such, these factors may limit the generalizability to PALS living in other geographical locations.

Acknowledgments

The authors thank Erin Callahan, OTS, Sara Long, OTS, and Samantha Sewell, OTS, (Hofstra University) for assisting with this research study.

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The Use of a Novel Graphitic Carbon Nitride/Cerium Dioxide (g-C3N4/CeO2) Nanocomposites for the Ofloxacin Removal by Photocatalytic Degradation in Pharmaceutical Industry Wastewaters and the Evaluation of Microtox (Aliivibrio fischeri) and Daphnia magna Acute Toxicity Assays

DOI: 10.31038/NAMS.2023621

Abstract

In this study, a novel graphitic carbon nitride/cobalt molybdate (g-C3N4/CeO2) nanocomposites (NCs) as a photocatalys was examined during photocatalytic degradation process in the efficient removal of Ofloxacin (OFX) from pharmaceutical industry wastewater plant, İzmir, Turkey. Different pH values (3.0, 4.0, 6.0, 7.0, 9.0 and 11.0), increasing OFX concentrations (5 mg/l, 10 mg/l, 20 mg/l and 40 mg/l), increasing g-C3N4/CeO2 NCs concentrations (1 mg/l, 2 mg/l, 4 mg/l, 6 mg/l, 8 mg/l and 10 mg/l), different g-C3N4/CeO2 NCs mass ratios (5/5, 6/4, 7/3, 8/2, 9/1, 1/9, 2/8, 3/7 and 4/6), increasing recycle times (1., 2., 3., 4., 5., 6. and 7.) was operated during photocatalytic degradation process in the efficient removal of OFX in pharmaceutical industry wastewater. 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), and Diffuse reflectance UV-Vis spectra (DRS) analyses, respectively. The acute toxicity assays were operated with Microtox (Aliivibrio fischeri also called Vibrio fischeri) and Daphnia magna acute toxicity tests. The photocatalytic degradation mechanisms of g-C3N4/CeO2 NCs and the reaction kinetics of OFX were evaluated in pharmaceutical industry wastewater during photocatalytic degradation process. ANOVA statistical analysis was used for all experimental samples. The maximum 99% OFX removal efficiency was obtained during photocatalytic degradation process in pharmaceutical industry wastewater, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively. The maximum 99% OFX removal efficieny was found with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min, at pH=6.0 and at 25°C, respectively. The maximum 99% OFX removal efficieny was measured to 8 mg/l g-C3N4/CeO2 NCs with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min, at pH=6.0 and at 25°C, respectively. The maximum 99% OFX removal efficiency was measured at 2/8wt g-C3N4/CeO2 NCs mass ratios at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min, at pH=6.0 and at 25°C, respectively. The maximum 99% OFX removal efficiency was measured in pharmaceutical industry wastewater during photocatalytic degradation process, after 1. recycle time, at 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, after 180 min, at pH=6.0 and at 25°C, respectively. 96.41% maximum Microtox (Aliivibrio fischeri) acute toxicity removal yield was found in OFX=20 mg/l after 180 min photocatalytic degradation time and at 60°C. It was observed an inhibition effect of OFX=40 mg/l to Microtox with Vibrio fischeri after 180 min and at 60°C. 92.38% maximum Daphnia magna acute toxicity removal was obtained in OFX=20 mg/l after 180 min photocatalytic degradation time and at 60°C, respectively. It was observed an inhibition effect of OFX=40 mg/l to Daphnia magna after 180 min and at 60°C. OFX concentrations > 20 mg/l decreased the acute toxicity removals by hindering the photocatalytic degradation process. Similarly, a significant contribution of increasing OFX concentrations to acute toxicity removal at 60°C after 180 min, was not observed. It can be concluded that the toxicity originating from the OFX is not significant and the real acute toxicity throughout photocatalytic degradation process was attributed to the pharmaceutical industry wastewater, to their metabolites and to the photocatalytic degradation process by-products. As a result, the a novel g-C3N4/CeO2 NCs photocatalyst during photocatalytic degradation process in pharmaceutical industry wastewater 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 g-C3N4/CeO2 NCs photocatalys during photocatalytic degradation process performance was still considerable. The synthesis and optimization of g-C3N4/CeO2 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 antibiotics, which can potentially be deployed for purifying wastewater, especially pharmaceutical wastewater. Finally, the combination of a simple, easy operation preparation process, excellent performance and cost effective, makes this a novel g-C3N4/CeO2 NCs a promising option during photocatalytic degradation process in pharmaceutical industry wastewater treatment.

Keywords

ANOVA statistical analysis, Antibiotics, Coronavirus Disease-2019 (COVID-19), Cost analysis, Diffuse reflectance UV-Vis spectra (DRS), Electrochemical filtration process, Energy-dispersive X-ray (EDX), Field emission scanning electron microscopy (FESEM), Fourier transform infrared spectroscopy (FTIR), Hydrothermal-calcination method, Hydroxly (OH●) radicals, Microtox (Aliivibrio fischeri or Vibrio fischeri) and Daphnia magna acute toxicity tests, Nanoparticles (NPs), Novel graphitic carbon nitride/cerium dioxide nanocomposites (g-C3N4/CeO2 NCs), Ofloxacin (OFX), Pharmaceutical industry wastewater, Photocatalytic degradation mechanisms, Reaction kinetics, Sol–gel method, Transmission Electron Microscopy (TEM), Ultraviolet (UV), X-ray difraction (XRD)

Introductıon

Emerging contaminants (ECs), sometimes known as contaminants of emerging concern (CECs) can refer to a wide variety of artificial or naturally occurring chemicals or materials that are harmful to human health after long-term disclosure. ECs can be classified into several classes, including agricultural contaminants (pesticides and fertilizers), medicines and antidote drugs, industrial and consumer waste products, and personal care and household cleaning products [1,2]. Antibiotics are one of the ECs that have raised concerns in the previous two decades because they have been routinely and widely used in human and animal health care, resulting in widespread antibiotic residues discharged in surface, groundwater, and wastewater.

Antibiotics, which are widely utilized in medicine, poultry farming and food processing, have attracted considerable attention due to their abuse and their harmful effects on human health and the ecological environment. The misuse of antibiotics induces Deoxyribonucleic Acid (DNA) contamination and accelerates the generation of drug-resistant bacteria and super-bacteria thus, some diseases are more difficult to cure . A number of studies have revealed that the level of antibiotics in the soil, air and surface water, and even in potable water, is excessive in many areas, which will ultimately accumulate in the human body via drinking water and then damage the body’s nervous system, kidneys and blood system. Therefore, it is necessary to develop an efficient method to remove antibiotics present in pharmaceutical industry wastewater [3-13].

The uncontrolled, ever-growing accumulation of antibiotics and their residues in the environment is an acute modern problem. Their presence in water and soil is a potential hazard to the environment, humans, and other living beings. Many therapeutic agents are not completely metabolized, which leads to the penetration of active drug molecules into the biological environment, the emergence of new contamination sources, the wide spread of bacteria and microorganisms with multidrug resistance. Modern pharmaceutical wastewater facilities do not allow efficient removal of antibiotic residues from the environment, which leads to their accumulation in ecological systems . Global studies of river pollution with antibiotics have shown that 65% of surveyed rivers in 72 countries on 6 continents are contaminated with antibiotics. According to the World Health Organization (WHO), surface and groundwater, as well as partially treated water, containing antibiotics residue and other pharmaceuticals, typically at < 100 ng/l concentrations, whereas treated water has < 50 ng/l concentrations, respectively . However, the discovery of ECs in numerous natural freshwater sources worldwide is growing yearly. Several antibiotic residues have been reported to have been traced at concentrations greater than their ecotoxicity endpoints in the marine environment, specifically in Europe and Africa . Thus, the European Union’s Water Framework Directive enumerated certain antibiotics as priority contaminants. In some rivers, the concentrations were so high that they posed a real danger to both the ecosystem and human health. This matter, the development of effective approaches to the removal of antibiotics from the aquatic environment is of great importance [14-26].

The removal of antibiotics and their residues from water and wastewater prior to their final release into the environment is of particular concern. Modern purification methods can be roughly divided into the following three categories depending on the purification mechanism: biological treatment, chemical degradation, and physical removal. Each of these methods has its own advantages and disadvantages. For example, biological purification can remove most antibiotic residues, but the introduction of active organisms into the aquatic environment can upset the ecological balance. Various chemical approaches (ozonation, chlorination, and Fenton oxidation) cannot provide complete purification and, in some cases, lead to the death of beneficial microorganisms due to low selectivity. Photocatalysis is widely used in new environmental control strategies. However, this method has a number of key disadvantages, such as insufficient use of visible light, rapid annihilation of photogenerated carriers, and incomplete mineralization, which greatly limits its application [27-33].

Ofloxacin (OFX) is a quinolone antibiotic useful for the treatment of a number of bacterial infections . A quinolone antibiotic is a member of a large group of broad-spectrum bacteriocidals that share a bicyclic core structure related to the substance 4-quinolone . They are used in human and veterinary medicine to treat bacterial infections, as well as in animal husbandry, specifically poultry production . OFX is well-known for their antimicrobial and anti-inflammatory capabilities . OFX is used to treat pneumonia, skin and urinary tract infections . Severe acute respiratory syndrome (SARS)-CoV-2 (COVID-19) pandemic, which has killed and infected people in 216 countries/territories, has become the most significant pandemic of the century . OFX combined with other drugs, has been widely used to minimise COVID-19-induced inflammation in 2020.OFX is a typical fluoroquinolone antibiotic administered to both humans and animals, and after administration, approximately 78% of OFX is excreted. OFX pharmaceutical compounds enter water resources in various ways, such as human and animal excretions and inefficient industrial wastewater treatment. In the class of antibiotics, OFX is also recognised as highly refractory and persistent in aquatic water systems. As the biodegradation of OFX is difficult, sewage treatment plants (STPs) have a low removal rate, and the OFX concentrations in the STP effluents of Beijing, Hangzhou, and Vancouver have been determined to be between 6×10-7 and 1.405×10-3 mg/l [34-41].

Generally, the advanced oxidation processes (AOPs), such as the Fenton or Fenton-like reaction, ozonation or catalytic ozonation, photocatalytic oxidation, electrochemical oxidation, and ionizing radiation, have been widely used for antibiotics degradation in recent years . One of the most promising techniques applied for efficient degradation of antibiotics are Advanced Oxidation Processes (AOPs). Nowadays, particular attention is paid to photocatalytic reactions, in which highly oxidizing species responsible for mineralization of organic pollutants are formed in-situ in the reaction media by means of light and a photocatalyst . The photocatalytic activity is closely related to the physicochemical properties but also to the morphology and texture of the materials studied, for this reason the synthesis techniques are often of great importance. Photocatalysis, which occurs under exposure to UV light, is also a common method for the environmental pollutant elimination . The conventional photocatalysis utilizes mostly UV from sunlight, which accounts for only 4% of the solar energy. Therefore, through the introduction of catalysts, the utilization rate of sunlight can be effectively improved. To overcome the low-efficiency problem of the photocatalysis, the development of a more efficient catalyst system that would effectively improve the catalytic oxidation efficiency and overcome the existing limitations is important. The catalytic activity of the catalyst can be effectively improved by modulating its surface area, preparation method, and changing its properties and structures [42-57].

Numerous materials have been reported to have the potential and capacity to treat water or wastewater polluted with these antibiotics residue by applying the processes of adsorption and catalytic oxidation during the last few decades. The reported materials include mesoporous carbon beads, clay minerals, activated carbon, cellulose, and chitosan. As a result of engineering and science evolution, and in complement to the urgent need to increase the adsorption capability of antibiotic contaminants, more advanced materials such as carbon nanotube (CnT), nano-zero valent iron (nZVI), nanoporous carbons, porous graphene and graphene oxide (GO), to date have been analyzed and improved in their ability to remove these ECs from water [58-85].

Nanomaterials with a high specific surface area are a promising platform for the development and production of low-cost and highly efficient sorbents for various pollution molecules. For example, graphene-based nanomaterials were utilized to remove antibiotics, which are adsorbed on the material surfaces due to π-π-, electrostatic or hydrophobic interactions, as well as the formation of hydrogen bonds. Highly efficient antibiotic sorption was also observed when using highly porous, surface-active, and structurally stable silica-based materials, metal oxide NPs, and metal-organic frameworks. The photocatalysts, which mainly rely on the production of highly oxidizing species such as hydroxyl radical (OH) and superoxide anion radical (O2− ●), have been considered an effective approach for the degradation of antibiotics in water [86-103].

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. 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. 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. There are many studies on g-C3N4-based Z-scheme heterojunction photocatalysts, such as ZnO/g-C3N4, WO3/g-C3N4, g-C3N4/ZnS,, g-C3N4/NiFe2O4, g-C3N4/graphene/NiFe2O4, NiCo/ZnO/g-C3N4 and Bi2Zr2O7/g-C3N4/Ag3PO4, 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 [104-121].

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. 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, nonmetal and metal doping, and coupling with other photocatalysts. 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 [122-131].

CeO2 (Ceria or Cerium(IV) oxide) is a versatile, inert, and physically and chemically stable material with multiple and diverse applications. Due to its hardness (Mohs scale 7), it was initially used as an abrasive material, but today it is used (alone or in binary or complex mixtures) in the field of heterogeneous catalysis (oxidation of hydrocarbons) or in the field of sensors, energy, and fuels such as solid oxide fuel cells, but also in water-splitting processes or photocatalysis. CeO2 applications in the dermato-cosmetics industry and in the biomedical field (antibacterial effect) should also be mentioned here. CeO2 is also possible to combine two or more properties, for example, the infrared filtering properties with the photocatalytic ones, to optimize practical applications. CeO2 is semiconductor photocatalyst with various applications and similar properties to TiO2. However, its band gap is in the wide range of 2.6 to 3.4 eV, depending on the preparation method. Furthermore, CeO2 exhibits promising photocatalytic activity. Nonetheless, the position of CB and VB limits its application as an efficient photocatalyst utilizing solar energy, even though CeO2 can absorb a larger fraction of the solar spectrum than TiO2. The photocatalytic and photoelectrocatalytic activity of CeO2 in wastewater treatment can be improved by various modification techniques, including changes in morphology, doping with metal cation dopants and non-metal dopants, coupling with other semiconductors, combining it with carbon supporting materials, etc.. The main properties that make CeO2 significant as a photocatalyst and photoelectrode material applied in the degradation of various pollutants result from its high band gap energy, high refractive index, high optical transparency in the visible region, high oxygen storage capacity, and chemical reactivity. The other properties of CeO2 which should be mentioned include its high thermal stability, high hardness, oxygen ion conductivity, special redox features, and easy conversion between Ce+3 and Ce+4 oxidation states [132-156].

The conduction band (CB) of g-C3N4 is more negative than that of CeO2 (-1.24 eV and -0.44, respectively), while CeO2 possesses a relatively positive valance band (VB) (2.56 eV) compared to the conduction band of g-C3N4, would theoretically facilitate the electron transition within the coupled photocatalyst to prolong the electron-hole separation [157]. Particularly, under the illumination of visible light, g-C3N4 can be excited to generate electron-hole pairs. Cerium (Ce) has exciting catalytic characteristics because 4d and 5p electrons sufficiently defend the 4f orbitals. The photogenerated electrons in the conduction band of CeO2 tend to transfer and recombine with the photogenerated holes in the valence band of g-C3N4. Like this, the larger number of photogenerated electrons accumulated in the conduction band of g-C3N4 can reduce the adsorbed O2 to form more O2– ●. At the same time, the photogenerated holes left behind in the valence band of CeO2 can oxidize the adsorbed H2O to give OH. But, the photocatalytic activity of the g-C3N4/CeO2 system would be significantly increased, leading to the decomposition of organic compounds by O2– ● and OHreactive species.

In this study, a novel g-C3N4/CeO2 NCs as a photocatalys was examined during photocatalytic degradation process in the efficient removal of OFX from pharmaceutical industry wastewater plant, İzmir, Turkey. Different pH values (3.0, 4.0, 6.0, 7.0, 9.0 and 11.0), increasing OFX concentrations (5 mg/l, 10 mg/l, 20 mg/l and 40 mg/l), increasing g-C3N4/CeCO2 NCs concentrations (1 mg/l, 2 mg/l, 4 mg/l, 6 mg/l, 8 mg/l and 10 mg/l), different g-C3N4/CeO2 NCs mass ratios (5/5, 6/4, 7/3, 8/2, 9/1, 1/9, 2/8, 3/7 and 4/6), increasing recycle times (1., 2., 3., 4., 5., 6. and 7.) was operated during photocatalytic degradation process in the efficient removal of OFX in pharmaceutical industry wastewater. The characteristics of the synthesized NPs were XRD, FESEM, EDX, FTIR, TEM and DRS analyses, respectively. The acute toxicity assays were operated with Microtox (Aliivibrio fischeri also called Vibrio fischeri) and Daphnia magna acute toxicity tests. The photocatalytic degradation mechanisms of g-C3N4/CeO2 NCs and the reaction kinetics of OFX were evaluated in pharmaceutical industry wastewater during photocatalytic degradation process. ANOVA statistical analysis was used for all experimental samples.

Materıals and Methods

Characterization of Pharmaceutical Industry Wastewater

Characterization of the biological aerobic activated sludge proses from a pharmaceutical industry wastewater plant, İzmir, Turkey was performed. The results are given as the mean value of triplicate samplings (Table 1).

Table 1: Characterization of Pharmaceutical Industry Wastewater

Parameters

Unit

Concentrations

Chemical oxygen demand-total (CODtotal) (mg/l)

4000

Chemical oxygen demand-dissolved (CODdissolved) (mg/l)

3200

Biological oxygen demand-5 days (BOD5) (mg/l)

1500

BOD5/CODdissolved

0.5

Total organic carbons (TOC) (mg/l)

1800

Dissolved organic carbons (DOC) (mg/l)

1100

pH

8.3

Salinity as Electrical conductivity (EC) (mS/cm)

1552

Total alkalinity as CaCO3 (mg/l)

750

Total volatile acids (TVA) (mg/l)

380

Turbidity (Nephelometric Turbidity unit, NTU) NTU

7.2

Color 1/m

50

Total suspended solids (TSS) (mg/l)

250

Volatile suspended solids (VSS) (mg/l)

187

Total dissolved solids (TDS) (mg/l)

825

Nitride (NO2) (mg/l)

1.7

Nitrate (NO3) (mg/l)

1.91

Ammonium (NH4+) (mg/l)

2.3

Total Nitrogen (Total-N) (mg/l)

3.2

SO3-2 (mg/l)

21.4

SO4-2 (mg/l)

29.3

Chloride (Cl) (mg/l)

37.4

Bicarbonate (HCO3) (mg/l)

161

Phosphate (PO4-3) (mg/l)

16

Total Phosphorus (Total-P) (mg/l)

40

Total Phenols (mg/l)

70

Oil & Grease (mg/l)

220

Cobalt (Co+3) (mg/l)

0.2

Lead (Pb+2) (mg/l)

0.4

Potassium (K+) (mg/l)

17

Iron (Fe+2) (mg/l)

0.42

Chromium (Cr+2) (mg/l)

0.44

Mercury (Hg+2) (mg/l)

0.35

Zinc (Zn+2) (mg/l)

0.11

Preparation of Graphitic Carbon Nitride (g-C3N4) Nanoparticles

g-C3N4 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 Cerium Dioxide (CeO2) Nanoparticles

CeO2 NPs were prepared by sol–gel method. Nano-sized CeO2 was also prepared by the sol–gel procedure using Cerium nitrate hexahydrate [Ce(NO3)3.6H2O] and 20 ml of Triethanolamine (C6H15NO3). Then, they were mixed together by a magnetic stirrer on a hot plate to insure that the cerium salt was dissolved in C6H15NO3. After that the solution was heated up to 90°C until the clear dark brown homogenous solution, sol, was observed. To prepare black colloidal solution (gel), it was kept in a digital furnace at 270°C for 2 h. As gel was produced, it was cooled to 25°C room temperature. In order to form the expected precipitate, the volume of the gel solution was adjusted to 100 ml by adding ethanol (C₂H₆O). Then, synthesized precipitate was separated by centrifugation and washed by deionized water and C₂H₆O. Finally, the produced CeO2 NPs was dried at 90°C and calcinated.

Preparation of A Novel Graphitic Carbon Nitride/Cerium Dioxide (g-C3N4/CeO2) Nanocomposites

The g-C3N4/CeO2 NCs was synthesized by the hydrothermal-calcination method. Firstly, 1 gram g-C3N4 NPs was added into distilled water and magnetically stirred for 30 min. Then, the portions of prepared g-C3N4 NPs were added to the mixtures to obtain the mass ratios of g-C3N4 to CeO2 of 5/5, 6/4, 7/3, 8/2, 9/1, 1/9, 2/8, 3/7 and 4/6, respectively, and kept being stirred for another 1 h. The final mixtures were transferred into a 100 ml autoclave and reacted at 180°C for different hydrothermal (HT) times of 2 h, 4 h and 6 h. The final samples were centrifuged and washed with distilled water and C₂H₆O for 2 times. Then, the samples were dried, and finally, the dried products were heated in a Muffle furnace at different calcination temperatures of 300°C, 400°C and 500°C for 4 h to get the target composites. The synthesis conditions and the corresponding sample names were summarized at Table 2.

Table 2: The optimization parameters of g-C3N4/CeO2 NCs samples

 

Sample Name

Mass Ratios of g-C3N4/CeO2 NCs

Calcination Temperature (°C)

in 240 min

Hydrothermal Time (min) at 180°C

HT-2h-Cal300

8/2

300°C

120

HT-2h-Cal400

8/2

400°C

120

HT-2h-Cal500

8/2

500°C

120

HT-4h-Cal300

8/2

300°C

240

HT-4h-Cal400

8/2

400°C

240

HT-4h-Cal500

8/2

500°C

240

HT-6h-Cal300

8/2

300°C

360

HT-6h-Cal400

8/2

400°C

360

HT-6h-Cal500

8/2

500°C

360

5/5 wt, g-C3N4/CeO2

5/5

500°C

360

6/4 wt, g-C3N4/CeO2

6/4

500°C

360

7/3 wt, g-C3N4/CeO2

7/3

500°C

360

8/2 wt, g-C3N4/CeO2

8/2

500°C

360

9/1 wt, g-C3N4/CeO2

9/1

500°C

360

1/9 wt, g-C3N4/CeO2

1/9

500°C

360

2/8 wt, g-C3N4/CeO2

2/8

500°C

360

3/7 wt, g-C3N4/CeO2

3/7

500°C

360

4/6 wt, g-C3N4/CeO2

4/6

500°C

360

Photocatalytic Degradation Reactor

A 2 liter cylinder quartz glass reactor was used for the photodegradation experiments in the pharmaceutical industry wastewater at different operational conditions. 1000 ml pharmaceutical industry wastewater 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). Six 50 W UV-A lamps (Total: 300 W UV-A lamps) were used during experimental conditions for this study.

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 OFX antibiotic concentration in experimental samples.

Analytical Procedures

Chemical oxygen demand-total (CODtotal), chemical oxygen demand-dissolved (CODdissolved), total phosphorus (Total-P), phosphate phosphorus (PO4-3-P), total nitrogen (Total-N), ammonium nitrogen (NH4+-N), nitrate nitrogen (NO3-N), nitrite nitrogen (NO2-N), biological oxygen demand 5-days (BOD5), pH, Temperature [(°C)], total suspended solids (TSS), total volatile suspended solids (TVSS), total organic carbon (TOC), Oil, Chloride (Cl), total phenol, total volatile acids (TVA), disolved organic carbon (DOC), total alkalinity, turbidity, total dissolved solid (TDS), color, sulfide (SO3-2), sulfate (SO4-2), bicarbonate (HCO3), salinity, cobalt (Co+3), lead (Pb+2), potassium (K+), iron (Fe+2), chromium (Cr+2), Mercury (Hg+2) and zinc (Zn+2) were measured according to the Standard Methods (2017) 5220B, 5220D, 4500-P, 4500-PO4-3, 4500-N, 4500-NH4+, 4500-NO3, 4500-NO2, 5210B, 4500-H+, 2320, 2540D, 2540E, 5310, 5520, 4500-Cl, 5530, 5560B, 5310B, 2320, 2130, 2540E, 2120, 4500-SO3-2, 4500-SO4-2, 5320, 2520, 3500-Co+3, 3500-Pb+2, 3500-K+, 3500-Fe+2, 3500-Cr+2, 3500-Hg+2, 3500-Zn+2, respectively [158].

Total-N, NH4+-N, NO3-N, NO2-N, Total-P, PO4-3-P, total phenol, Co+3, Pb+2, K+, Fe+2, Cr+2, Hg+2, Zn+2, SO3-2, and SO4-2 were measured with cell test spectroquant kits (Merck, Germany) at a spectroquant NOVA 60 (Merck, Germany) spectrophotometer (2003).

The measurement of color was carried out following the methods described by Olthof and Eckenfelder [159] and Eckenfelder [160]. According these methods, the color content was determined by measuring the absorbance at three wavelengths (445 nm, 540 nm and 660 nm), and taking the sum of the absorbances at these wavelengths. In order to identify the color in pharmaceutical industry wastewater (25 ml) was acidified at pH=2.0 with a few drops of 6 N HCl and extracted three times with 25 ml of ethyl acetate. The pooled organic phases were dehydrated on sodium sulphate, filtered and dried under vacuum. The residue was sylilated with bis(trimethylsylil)trifluoroacetamide (BSTFA) in dimethylformamide and analyzed by gas chromatography–mass spectrometry (GC-MS) and gas chromatograph (GC) (Agilent Technology model 6890N) equipped with a mass selective detector (Agilent 5973 inert MSD). Mass spectra were recorded using a VGTS 250 spectrometer equipped with a capillary SE 52 column (HP5-MS 30 m, 0.25 mm ID, 0.25 μm) at 220°C with an isothermal program for 10 min. The initial oven temperature was kept at 50°C for 1 min, then raised to 220°C at 25°C/min and from 200 to 300°C at 8°C/min, and was 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 total phenol was monitored as follows: 40 ml of pharmaceutical industry wastewater was acidified to pH=2.0 by the addition of concentrated HCl. Total phenol was then extracted with ethyl acetate. The organic phase was concentrated at 40°C to about 1 ml and silylized by the addition of N,O-bis(trimethylsilyl) acetamide (BSA). The resulting trimethylsilyl derivatives were analysed by GC-MS (Hewlett-Packard 6980/HP5973MSD).

Methyl tertiary butyl ether (MTBE) was used to extract oil from the water and NPs. GC-MS analysis was performed on an Agilent gas chromatography (GC) system. Oil concentration was measured using a UV–vis spectroscopy fluorescence spectroscopy and a GC–MS (Hewlett-Packard 6980/HP5973MSD). UV–vis absorbance was measured on a UV–vis spectrophotometer and oil concentration was calculated using a calibration plot which was obtained with known oil concentration samples.

Acute Toxicity Assays

Microtox Acute Toxicity Test

Toxicity to the bioluminescent organism Aliivibrio fischeri (also called Vibrio fischeri or V. fischeri) was assayed using the Microtox measuring system according to DIN 38412L34, L341, (EPS 1/ RM/24 1992). Microtox testing was performed according to the standard procedure recommended by the manufacturer [161]. A specific strain of the marine bacterium, V. fischeri-Microtox LCK 491 kit was used for the Microtox acute toxicity assay. Dr. LANGE LUMIX-mini type luminometer was used for the microtox toxicity assay [162].

Daphnia magna Acute Toxicity Test

To test toxicity, 24-h born Daphnia magna were used as described in Standard Methods sections 8711A, 8711B, 8711C, 8711D and 8711E, respectively [163]. After preparing the test solution, experiments were carried out using 5 or 10 Daphnia magna introduced into the test vessels. These vessels had 100 ml of effective volume at 7.0– 8.0 pH, providing a minimum dissolved oxygen (DO) concentration of 6 mg/l at an ambient temperature of 20–25°C. Young Daphnia magna were used in the test (≤24 h old); 24–48 h exposure is generally accepted as standard for a Daphnia magna acute toxicity test. The results were expressed as mortality percentage of the Daphnia magna. Immobile animals were reported as dead Daphnia magna.

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, [164]. 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, [165]. 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 Dıscussıons

A Novel g-C3N4/CeO2 NCs Characteristics

The Results of X-Ray Diffraction (XRD) Analysis

The results of XRD analysis was observed to pure g-C3N4 NPs, pure CeO2 NPs and g-C3N4/CeO2 NCs, respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 1). The characterization peaks were observed at 2θ values of 14.21°, 20.12° and 28.24°, respectively, implying pure g-C3N4 NPs in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 1a). The characterization peaks were obtained at 2θ values of 29.41°, 34.22°, 48.45°, 57.62°, 59.27°, 70.18°, 77.17° and 79.31°, respectively, implying pure CeO2 NPs in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 1b). The characterization peaks were found at 2θ values of 13.20°, 28.72°, 33.67°, 48.15°, 58.39°, 60.16°, 71.17°, 75.35° and 79.53°, respectively, and which can also be indexed as (100), (002), (111), (200), (220), (311), (222), (400), (331) and (420), respectively, implying g-C3N4/CeO2 NCs in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 1c).

fig 1

Figure 1: The XRD patterns of (a) pure g-C3N4 NPs (black pattern), (b) pure CeO2 NPs (blue pattern) and (c) g-C3N4/CeO2 NCs (red pattern), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

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

The absorption spectra of OFX was observed in DRS Analysis (Figure 2). First, the absorption spectra of OFX were obtained at a maximum concentration of 40 mg/l in the wavelength range from 250 nm to 800 nm using diffuse reflectance UV-Vis spectra (Figure 2). Absorption peaks were observed at wavelengths of 400 nm for pure g-C3N4 NPs (black pattern) (Figure 2a), 310 nm for pure CeO2 NPs (green pattern) (Figure 2b), and 340 nm for g-C3N4/CoMoO4 NCs (blue pattern) (Figure 2c), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

fig 2

Figure 2: The DRS patterns of (a) pure g-C3N4 NPs (black pattern) (b) pure CeO2 NPs (green pattern) and (c) g-C3N4/CeO2 NCs (blue pattern), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

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

The morphological features of pure g-C3N4 NPs, pure CeO2 NPs and g-C3N4/CeO2 NCs were characterized through FE-SEM images (Figure 3). The FESEM images of pure g-C3N4 NPs were obtained in in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 3a). The FESEM images of pure CeO2 NPs were observed in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 3b). The FESEM images of g-C3N4/CeO2 NCs were characterized in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 3c).

fig 3

Figure 3: FESEM images of (a) pure g-C3N4 NPs, (b) pure CeO2 NPs and (c) g-C3N4/CeO2 NCs, respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

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

The EDX analysis was also performed to investigate the composition of g-C3N4/CeO2 NCs (Figure 4), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

fig 4

Figure 4: EDX spectrum of g-C3N4/CeO2 NCs, respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

The Results of Fourier Transform Infrared Spectroscopy (FTIR) Analysis

The FTIR spectrum of pure g-C3N4 NPs (black spectrum), pure CeO2 NPs (blue spectrum) and g-C3N4/CeO2 NCs (red spectrum), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 5). The main peaks of FTIR spectrum for pure g-C3N4 NPs (black spectrum) was observed at 1645 1/cm, 1564 1/cm, 1411 1/cm, 1321 1/cm, 1240 1/cm and 807 1/cm wavenumber, respectively (Figure 5a). The main peaks of FTIR spectrum for pure CeO2 NPs (blue spectrum) was obtained at 462 1/cm wavenumber, respectively (Figure 5b). The main peaks of FTIR spectrum for g-C3N4/CeO2 NCs (red spectrum) was determined at 462 1/cm wavenumber, respectively (Figure 5c).

fig 5

Figure 5: FTIR spectrum of (a) pure g-C3N4 NPs (black spectrum), (b) pure CeO2 NPs (blue spectrum) and (c) g-C3N4/CeO2 NCs (red spectrum), respectively, in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

The Results of Transmission Electron Microscopy (TEM) Analysis

The TEM images of g-C3N4/CeO2 NCs was observed in micromorphological structure level in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal (Figure 6).

fig 6

Figure 6: TEM images of g-C3N4/CeO2 NCs in micromorphological structure level in pharmaceutical industry wastewater with photocatalytic degradation process for OFX antibiotic removal.

The Reaction Kinetics of OFX Antibiotic

The reaction kinetics OFX were investigated using the Langmuir–Hinshelwood first-order kinetic model, expressed by Eddy et al. [166], as following Equation (1):

for 1

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 (2):

for 2

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

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 photocatalytic performance of the catalyst in the degradation of OFX is determined by photons. The degradation mechanism of OFX by hydroxyl radicals (OH) radicals concerning g-C3N4/CeO2 NCs as following equations (Equation 3, Equation 4, Equation 5, Equation 6, Equation 7, Equation 8, Equation 9 and Equation 10):

for 3-10

g-C3N4/CeO2 NCs absorbs photons with energies greater than the photocatalyst bandgap. As a result, the electron in the valence band (VB) jumps to the conduction band (CB), leaving a hole in the CB. The electrons present in the CB and VB will react with oxygen (O2) and water (H2O) molecules which are absorbed by the photocatalyst and lead to the formation of OH radicals which react with OFX. OH radicals are produced when the photocatalyst surface is illuminated with photons, and OH radicals are strong oxidising species, with an oxidation potential of approximately 2.8 V [as opposed to Normal hydrogen electrode (NHE)], which may increase total pollutant mineralisation. Normally, the higher the rate of formation of OH radicals, the greater the separation efficiency of electron-hole pairs. In this way, there is a correlation between the increased photocatalytic activity and the rate of formation of OHradicals. The OH radicals generation of g-C3N4/CeO2 NCs was extremely high, indicating that the sample has a high electron and hole separation rate.

CeO2 composites with g-C3N4 are also promising photocatalytic materials with a lower band gap energy [167-169] and significantly higher photocatalytic efficiency in degradation processes [170,171]. Considering the position of CB and VB in CeO2 and g-C3N4, the higher photocatalytic efficiency can be attributed to the transfer of photoexcited electrons and holes between CeO2 and g-C3N4, which suppresses the recombination of photogenerated h+/e pairs. During irradiation, photogenerated electrons on CB in g-C3N4 are transferred to CB in CeO2 and react with O2, while photogenerated holes on VB in CeO2 are transferred to VB in g-C3N4 and react with H2O according to the following reactions [172]:

The superoxide and hydroxyl radicals formed in the above-presented reactions take part in the degradation of pollutants. In the case of CeO2 composites with g-C3N4, two problems have still not been resolved. The first one is related to the lower rates of TOC or COD decrease in wastewater in comparison with the degradation rate of pollutants [173]. The second one is attributed to the immobilization of a composite photocatalyst, which could eliminate the post-treatment process of photocatalyst removal from the wastewater.

Effect of Increasing pH values for OFX Removal in Pharmaceutical Industry Wastewater during Photocatalytic Degradation Process

Increasing pH values (pH=3.0, pH=4.0, pH=6.0, pH=7.0, pH=9.0 and pH=11.0, respectively) was examined during photocatalytic degradation process in pharmaceutical industry wastewater for OFX removal (Figure 7). 67.2%, 85.7%, 96.4%, 56.5% and 44.8% OFX removal efficiencies was measured at pH=3.0, pH=4.0, pH=6.0, pH=7.0 and pH=11.0, respectively, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at 25°C (Figure 7). The maximum 99% OFX removal efficiency was obtained during photocatalytic degradation process in pharmaceutical industry wastewater, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 7).

fig 7

Figure 7: Effect of increasing pH values for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

Effect of Increasing OFX Concentrations for OFX Removal in Pharmaceutical Industry Wastewater during Photocatalytic Degradation Process

Increasing OFX concentrations (5 mg/l, 10 mg/l, 20 mg/l and 40 mg/l) were operated at 300 W UV-vis irradiation power, after 180 min photocatalytic degradation time, at pH=6.0, at 25°C, respectively (Figure 8). 85.3%, 94.1% and 77.2% OFX removal efficiencies were obtained to 5 mg/l, 10 mg/l and 40 mg/l OFX concentrations, respectively, at pH=6.0 and at 25°C (Figure 8). The maximum 99% OFX removal efficieny was found with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 8).

The percentage decrease (8%) in the concentration of OFX during the studies under the dark conditions was due to the contaminant adsorption onto the catalyst surface [174]. The formation of contaminant monolayer on the surface of the catalyst may have occupied all its active sites, and therefore no more adsorption was observed.

fig 8

Figure 8: Effect of increasing OFX concentrations for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

Effect of Increasing g-C3N4/CeO2 NCs Concentrations for OFX Removals in Pharmaceutical Industry Wastewater during Photocatalytic Degradation Process

Increasing g-C3N4/CeO2 NCs concentrations (1 mg/l, 2 mg/l, 4 mg/l, 6 mg/l, 8 mg/l and 10 mg/l) were operated at 20 mg/l OFX, at 150 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0, at 25°C, respectively (Figure 9). 54.5%, 68.1%, 75.8%, 87.3% and 92.1% OFX removal efficiencies were obtained to 1 mg/l, 2 mg/l, 4 mg/l, 6 mg/l and 10 mg/l g-C3N4/CeO2 NCs concentrations, respectively, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0, at 25°C, respectively (Figure 9). The maximum 99% OFX removal efficieny was measured to 8 mg/l g-C3N4/CeO2 NCs with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 9).

fig 9

Figure 9: Effect of increasing g-C3N4/CeO2 NCs concentrations for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

Effect of Different g-C3N4/CeO2 NCs Mass Ratios for OFX Removals in Pharmaceutical Industry Wastewater during Photocatalytic Degradation Process

Different g-C3N4/CeO2 mass ratios (5/5wt, 6/4wt, 7/3wt, 8/2wt, 9/1wt, 1/9wt, 2/8wt, 3/7wt and 4/6wt, respectively) were examined for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 10). 80.3%, 84.6%, 77.9%, 62.1%, 48.4%, 55.2%, 64.0% and 79.7% OFX removal efficiencies were measured at 5/5wt, 6/4 wt, 7/3wt, 8/2wt, 9/1wt, 1/9wt, 3/7wt and 4/6wt g-C3N4/CeO2 NCs mass ratios, respectively, at 20 mg/l OFX after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 10). The maximum 99% OFX removal efficiency was measured at 2/8wt g-C3N4/CeO2 NCs mass ratios at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 10).

fig 10

Figure 10: Effect of different g-C3N4/CeO2 NCs mass ratios for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

Effect of Different Recycle Times for OFX Removals in Pharmaceutical Industry Wastewater during Photocatalytic Degradation Process

Different recycle times (1., 2., 3., 4., 5., 6. and 7.) were operated for OFX removals in pharmaceutical industry wastewater during photocatalytic degradation process, at 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 11). 97.5%, 96.2%, 94%, 93.8%, 89.2%, 86.2% and 80.1% OFX 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 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 11). The maximum 99% OFX removal efficiency was measured in pharmaceutical industry wastewater during photocatalytic degradation process, after 1. recycle time, at 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively (Figure 11).

fig 11

Figure 11: Effect of recycle times for OFX removal in pharmaceutical industry wastewater during photocatalytic degradation process, at 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

Acute Toxicity Assays

Effect of Increasing OFX Concentrations on the Microtox (Aliivibrio fischeri or Vibrio fischeri) Acute Toxicity Removal Efficiencies in Pharmaceutical Industry Wastewater at Increasing Photocatalytic Degradation Time and Temperature

In Microtox with Aliivibrio fischeri (also called Vibrio fischeri) acute toxicity test, the initial EC90 values at pH=7.0 was found as 825 mg/l at 25°C (Table 3: SET 1). After 60 min, 120 min and 180 min photocatalytic degradation time, the EC90 values decreased to EC57=414 mg/l to EC22=236 mg/l and to EC12=165 mg/l in OFX=20 mg/l at 30°C (Table 3: SET 3). The Microtox (Aliivibrio fischeri) acute toxicity removal efficiencies were 40.86%, 79.75% and 90.86% after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l and at 30°C (Table 3: SET 3).

The EC90 values decreased to EC51, to EC16 and to EC6 after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l, at 60°C (Table 3: SET 3). The EC51, the EC11 and the EC7 values were measured as 550 mg/l, 540 mg/l and 500 mg/l, respectively, in OFX=20 mg/l at 60°C. The toxicity removal efficiencies were 46.41%, 85.30% and 96.41% after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l, at 60°C (Table 3: SET 3). 96.41% maximum Microtox (Aliivibrio fischeri) acute toxicity removal yield was found in OFX=20 mg/l after 180 min and at 60°C (Table 3: SET 3).

The EC90 values decreased to EC62=422 mg/l to EC21=241 mg/l and to EC17=168 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=5 mg/l at 30°C (Table 3: SET 3). The EC90 values decreased to EC62=421 mg/l to EC27=239 mg/l and to EC11=167 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=10 mg/l at 30°C. The EC90 values decreased to EC67=408 mg/l to EC32=230 mg/l and to EC22=162 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=40 mg/l at 30°C. The Microtox (Aliivibrio fischeri or Vibrio fischeri) acute toxicity removals were 85.30%, 85.28% and 79.75% in 5 mg/l, 10 mg/l and 40 mg/l OFX, respectively, after 180 min, at 30°C. It was obtained an inhibition effect of OFX=40 mg/l to Vibrio fischeri after 180 min and at 30°C (Table 3: SET 3).

The EC90 values decreased to EC57=419 mg/l to EC22=266 mg/l and to EC12=150 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=5 mg/l at 60°C (Table 3: SET 3). The EC90 values decreased to EC57=414 mg/l to EC22=232 mg/l and to EC12=161 mg/l after 60 min, 120 and 180 min, respectively, in OFX=10 mg/l at 60°C. The EC90 values decreased to EC62=403 mg/l to EC27=218 mg/l and to EC17=148 mg/l after 60 min, 120 and 180 min, respectively, in OFX=40 mg/l at 60°C. The Microtox (Aliivibrio fischeri or Vibrio fischeri) acute toxicity removals were 90.86%, 90.83% and 85.30% in 5 mg/l, 10 mg/l and 40 mg/l OFX, respectively, after 180 min, at 60°C. It was observed an inhibition effect of OFX=40 mg/l to Microtox with Vibrio fischeri after 180 min, and at 60°C (Table 3: SET 3).

Table 3: Effect of increasing OFX concentrations on Microtox (Aliivibrio fischeri) acute toxicity in pharmaceutical industry wastewater after photocatalytic degradation process, at 30°C and at 60°C, respectively.

No

Parameters

Microtox (Aliivibrio fischeri) Acute Toxicity Values, * EC (mg/l)

25°C

0 min

60 min

120 min

180 min

*EC90

*EC

*EC

*EC

1 Raw ww, Control

825

EC70=510

EC60=650

EC49=638

30°C

60°C

0. min

60 min

120. min

180. min

0 min

60 min

120 min

180 min

*EC90

*EC

*EC

*EC

*EC90

*EC

*EC

*EC

2 Raw ww, control

825

EC70=580

EC50=580

EC39=548

825

EC55=550

EC40=590

EC29=688

3 OFX=5 mg/l

825

EC62=422

EC27=242

EC17=168

825

EC57=419

EC22=266

EC12=150

OFX=10 mg/l

825

EC62=421

EC27=239

EC17=167

825

EC57=414

EC22=232

EC12=161

OFX=20 mg/l

825

EC57=414

EC22=236

EC12=165

825

EC52=550

EC17=540

EC7=500

OFX=40 mg/l

825

EC67=408

EC32=230

EC22=162

825

EC62=403

EC27=218

EC17=148

* EC values were calculated based on CODdis (mg/l).

Effect of Increasing OFX Concentrations on the Daphnia magna Acute Toxicity Removal Efficiencies in Pharmaceutical Industry Wastewater at Increasing Photocatalytic Degradation Time and Temperature

The initial EC50 values were observed as 850 mg/l at 25°C (Table 4: SET 1). After 60 min, 120 and 180 min photocatalytic degradation time, the EC50 values decreased to EC31=350 mg/l to EC17=240 mg/l and to EC12=90 mg/l in OFX=20 mg/l, at 30°C (Table 4: SET 3). The toxicity removal efficiencies were 42.96%, 72.87% and 82.65% after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l at 30°C (Table 4: SET 3).

The EC50 values decreased to EC27 to EC12 and to EC7 after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l at 60°C (Table 4: SET 3). The EC27, the EC12 and the EC7 values were measured as 150 mg/l, 60 mg/l and 375 mg/l, respectively, in OFX=20 mg/l at 60°C. The toxicity removal efficiencies were 52.94%, 82.62% and 92.36% after 60 min, 120 min and 180 min, respectively, in OFX=20 mg/l at 60°C (Table 4: SET 3). 92.38% maximum Daphnia magna acute toxicity removal was obtained in OFX=20 mg/l after 180 min and at 60°C, respectively (Table 4: SET 3).

The EC50 values decreased to EC37=450 mg/l to EC22=145 mg/l and to EC17=260 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=5 mg/l at 30°C (Table 4: SET 3). The EC50 values decreased to EC37=450 mg/l to EC22=175 mg/l and to EC17=100 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=10 mg/l and at 30°C. The EC50 values decreased to EC42=300 mg/l to EC27=170 mg/l and to EC22=52 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=40 mg/l and at 30°C. The Daphnia magna acute toxicity removals were 72.22%, 72.56% and 63.21% in 5 mg/l, 10 mg/l and 40 mg/l OFX, respectively, after 180 min and at 30°C. It was observed an inhibition effect of OFX=40 mg/l to Daphnia magna after 180 min and at 30°C (Table 4: SET 3).

The EC50 values decreased to EC32=130 mg/l to EC17=425 mg/l and to EC12=340 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=5 mg/l and at 60°C (Table 4: SET 3). The EC50 values decreased to EC32=425 mg/l to EC17=140 mg/l and to EC7=90 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=10 mg/l and at 60°C. The EC50 values decreased to EC37=250 mg/l to EC22=110 mg/l and to EC17=10 mg/l after 60 min, 120 min and 180 min, respectively, in OFX=40 mg/l and at 60°C. The Daphnia magna acute toxicity removals were 83.06%, 92.65% and 73.11% in 5 mg/l, 10 mg/l and 40 mg/l OFX, respectively, after 180 min and at 60°C. It was observed an inhibition effect of OFX=40 mg/l to Daphnia magna after 180 min and at 60°C (Table 4: SET 3).

Increasing the OFX concentrations from 5 mg/l to 40 mg/l did not have a positive effect on the decrease of EC50 values as shown in Table 4 at SET 3. OFX concentrations > 20 mg/l decreased the acute toxicity removals by hindering the photocatalytic degradation process. Similarly, a significant contribution of increasing OFX concentration to acute toxicity removal at 60°C after 180 min of photocatalytic degradation time was not observed. Low toxicity removals found at high OFX concentrations could be attributed to their detrimental effect on the Daphnia magna (Table 4: SET 3).

Table 4: Effect of increasing OFX concentrations on Daphnia magna acute toxicity in pharmaceutical industry wastewater after photocatalytic degradation process, at 30°C and at 60°C.

 

No

 

Parameters

Daphnia magna Acute Toxicity Values, * EC (mg/l)

25°C

0. min

60. min

120. min

180. min

*EC50

*EC

*EC

*EC

1 Raw ww, control

850

EC45=625

EC40=370

EC29=153

30°C

60°C

0 min

60 min

120 min

180. min

0. min

60. min

120. min

180. min

*EC50

*EC

*EC

*EC

*EC50

*EC

*EC

*EC

2 Raw ww, control

850

EC39=468

EC34=228

EC23=111

850

EC34=373

EC29=210

EC18=71

3 OFX=5 mg/l

850

EC32=450

EC22=145

EC17=260

850

EC32=130

EC17=425

EC12=340

OFX=10 mg/l

850

EC37=450

EC22=175

EC17=100

850

EC32=425

EC17=140

EC7=90

OFX=20 mg/l

850

EC32=350

EC17=240

EC12=90

850

EC27=150

EC12=60

EC7=375

OFX=40 mg/l

850

EC42=300

EC27=170

EC22=52

850

EC37=250

EC22=110

EC17=11

* EC values were calculated based on CODdis (mg/l).

Direct Effects of OFX Concentrations on the Acute Toxicity of Microtox (Aliivibrio fischeri or Vibrio fischeri) and Daphnia magna without Pharmaceutical Industry Wastewater after Photocatalytic Degradation Process

The acute toxicity test was performed in the samples containing 5 mg/l, 10 mg/l, 20 mg/l and 40 mg/l OFX concentrations, at 25°C room temperature. In order to detect the direct responses of Microtox (Aliivibrio fischeri or Vibrio fischeri) and Daphnia magna to the increasing OFX concentrations the toxicity test were performed without pharmaceutical industry wastewater after photocatalytic degradation process, at 25°C room temperature. The initial EC values and the the EC50 values were measured in the samples containing increasing OFX concentrations after 180 min photocatalytic degradation time. Table 5 showed the responses of Microtox (Aliivibrio fischeri or Vibrio fischeri) and Daphnia magna to increasing OFX concentrations.

The acute toxicity originating only from 5 mg/l, 10 mg/l, 20 mg/l and 40 mg/l OFX were found to be low (Table 5). 5 mg/l OFX did not exhibited toxicity to Aliivibrio fischeri (or Vibrio fischeri) and Daphnia magna before and after 180 min photocatalytic degradation time. The toxicity atributed to the 10 mg/l, 20 mg/l and 40 mg/l OFX were found to be low in the samples without pharmaceutical industry wastewater after photocatalytic degradation process for the test organisms mentioned above. The acute toxicity originated from the OFX decreased significantly to EC2, EC4 and EC6 after 180 min photocatalytic degradation time. Therefore, it can be concluded that the toxicity originating from the OFX is not significant and the real acute toxicity throughout photocatalytic degradation process was attributed to the pharmaceutical industry wastewater, to their metabolites and to the photocatalytic degradation by-products (Table 5).

Table 5: The responses of Microtox (Aliivibrio fischeri or Vibrio fischeri) and Daphnia magna acute toxicity tests in addition of increasing OFX concentrations without phamaceutical industry wastewater during photocatalytic degradation process after 180 min photocatalytic degradation time, at 25°C room temperature.

 

 

OFX Conc. (mg/l)

Microtox (Aliivibrio fischeri or Vibrio fischeri)

Acute Toxicity Test

Daphnia magna

Acute Toxicity Test

Initial Acute Toxicity EC50 Value (mg/l)

Inhibitions after 180 min photocatalytic degradation time

EC Values (mg/l)

Initial Acute Toxicity EC50 Value (mg/l)

Inhibitions after 180 min photocatalytic degradation time

EC Values (mg/l)

5

EC10=24

EC10=39

10

EC15=79

3

EC2=3

EC20=99

5

EC3=5

20

EC20=149

5

EC4=6

EC30=199

6

EC6=11

40

EC25=219

7

EC6=9

EC40=299

9

EC8=15

The Comparison with Other Scientific Studies in the Literature

Comparison of our study “The use of a novel graphitic carbon nitride/cerium dioxide (g-C3N4/CeO2) nanocomposites for the ofloxacin removal by photocatalytic degradation in pharmaceutical industry wastewaters and the evaluation of microtox (Aliivibrio fischeri) and Daphnia magna acute toxicity assays” with other scientific studies in the literature is summaried at Table 6 [175-182].

Table 6: The Comparison with other Scientific Studies in the Literature

Photocatalyst

Experimental Conditions (for maximum removal efficiencies)

Experimental Results

References

a-Bi2O3/g-C3N4 [DOX]=10 mg/l, [Material]=500 mg/l, [H2O2]=10 mM, Unadjusted pH, Xe lamp (150 W). 79.1% DOX (30 min) (Liu et al., 2021a)
Ag/AgCl@ZIF-8/g-C3N4 150 W, Xe, λ > 420 nm, 50 mg/l, [LVFX]=10 mg/l, V=50 ml, 87.3% LVFX (60 min) (Zhou et al., 2019)
Ag@ZIF-8/g-C3N4 300 W, Xe, λ > 420 nm, [Ten antibiotics] =10 mg/l, V=50 ml 90% (60 min) (Guo et al., 2022)
Peroxymonosulfate/ZnFe2O4 Waters e2695 HPLC instrument (Milford, USA), UV-Vis detector λ=294 nm [OFX]=1000 mg/l, pH=6.0 80.9% OFX (30 min), pH 6.0 (Sun et al., 2021b)
Bi2WO6 and g-C3N4 nanosheets [CRO]=16.5-66 µM, KrCl excilamp, λ=222 nm, 23 W, incident irradiance 0.74 mW/cm2, 60 min 91% Ceftriaxone (60 min) (Sizykh et al., 2023)
Bi2WO6/g-C3N4 [CRO]=100 mg/l 300 W Xe lamp, 94.5% Ceftriaxone (120 min) (Zhao et al., 2018)
CeO2-ZnO hetero photocatalyst [TCN]=100 mg/l, 300 W Xenon lamp, 87.25% Tetracycline (60 min) (Ye et al., 2016)
g-C3N4/CeO2 core-shell structure Hydrothermal method, [DOX]=1000 mg/l, HCl=10 mg/l, H2O2=100 µl, 150 W Xe lamp (λ > 400 nm), g-C3N4=2.82 eV, CeO2=2.76 eV 66.7%g-C3N4, 71.7%CeO2,

84% g-C3N4/CeO2 (60 min)

(Liu et al., 2019)
CeO2/ATP/g-C3N4 ATP—attapulgite Electrostatic-induced self-assembly method, Dibenzothiophene (DBT), m(catal)/m(DBT)=1/10, SO₂=200 mg/l, 30% H2O2, 300 W Xe lamp (λ > 420 nm) Desulfurization 42% g-C3N4,

83% CeO2/g-C3N4, 98% CeO2/ATP/g-C3N4 (180 min)

(Li et al., 2017b)
g-C3N4/CeO2 NCs g-C3N4/CeO2 NCs was prepared to hydrothermal calcination method, CeO2 was prepared sol-gel method, g-C3N4 was prepared to calcination method, pH=6.0,

[OFX]=20 mg/l,

[g-C3N4/CeO2 NCs]=8 mg/l, g-C3N4/CeO2 mass ratio=2/8,

300 W UV-vis A lamp λ=350-400 nm range (λmax=368 nm; FWHM=17 nm; Actinic BL TL-D 18W, Philips)

Recycle time=7, at 25°C Microtox (Aliivibrio fischeri) and Daphnia magna acute toxicity assays

99% OFX (180 min, at 25°C)

96.41% maximum Microtox (Aliivibrio fischeri) acute toxicity removal (180 min, at 60°C)

92.38% maximum Daphnia magna acute toxicity removal (180 min, at 60°C),

99% OFX after 1. recycle time

This study
DOX: doxycycline; LVFX: Levofloxacin; CRO: ceftriaxone; TCN: Tetracycline; OFX: ofloxacin

Conclusıons

The maximum 99% OFX removal efficiency was obtained during photocatalytic degradation process in pharmaceutical industry wastewater, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

The maximum 99% OFX removal efficieny was found with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

The maximum 99% OFX removal efficieny was measured to 8 mg/l g-C3N4/CeO2 NCs with photocatalytic degradation process in pharmaceutical industry wastewater, at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

The maximum 99% OFX removal efficiency was measured at 2/8wt g-C3N4/CeO2 NCs mass ratios at 20 mg/l OFX, at 300 W UV-vis light irradiation power, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

The maximum 99% OFX removal efficiency was measured in pharmaceutical industry wastewater during photocatalytic degradation process, after 1. recycle time, at 20 mg/l OFX, 8 mg/l g-C3N4/CeO2 NCs, at 2/8wt g-C3N4/CeO2 NCs mass ratio, after 180 min photocatalytic degradation time, at pH=6.0 and at 25°C, respectively.

96.41% maximum Microtox (Aliivibrio fischeri) acute toxicity removal yield was found in OFX=20 mg/l after 180 min and at 60°C. It was observed an inhibition effect of OFX=40 mg/l to Microtox with Vibrio fischeri after 180 min photocatalytic degradation time and at 60°C. 92.38% maximum Daphnia magna acute toxicity removal was obtained in OFX=20 mg/l after 180 min photocatalytic degradation time and at 60°C, respectively. It was observed an inhibition effect of OFX=40 mg/l to Daphnia magna after 180 min photocatalytic degradation time and at 60°C. OFX concentrations > 20 mg/l decreased the acute toxicity removals by hindering the photocatalytic degradation process. Similarly, a significant contribution of increasing OFX concentrations to acute toxicity removal at 60°C after 180 min photocatalytic degradation time was not observed. Finally, it can be concluded that the toxicity originating from the OFX is not significant and the real acute toxicity throughout photocatalytic degradation process was attributed to the pharmaceutical industry wastewater, to their metabolites and to the photocatalytic degradation process by-products.

As a result, the a novel g-C3N4/CeO2 NCs photocatalyst during photocatalytic degradation process in pharmaceutical industry wastewater 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 g-C3N4/CeO2 NCs photocatalys during photocatalytic degradation process performance was still considerable. The synthesis and optimization of g-C3N4/CeO2 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 antibiotics, which can potentially be deployed for purifying wastewater, especially pharmaceutical wastewater. Finally, the combination of a simple, easy operation preparation process, excellent performance and cost effective, makes this a novel g-C3N4/CeO2 NCs a promising option during photocatalytic degradation process in pharmaceutical 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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Stock Effect of Bio-Economic Indicators in an Over- exploited Fishery of the Gulf of Mexico

DOI: 10.31038/AFS.2023513

Abstract

The main bio-economic indicators of a pelagic fishery of the Northern Gulf of México (the Gulf Menhaden Brevoortia patronus Goode), was examined to understand their 8 performance as a result of simulated trials of the age of first catch and the fishing mortality. First, the validity of simulation was tested rebuilding numerically the performance of biological data and catch over time. A simple approach was made assigning economic value to the catch per-kg and the cost of fishing, so the output of biological variables could be linked to their corresponding economic performance, under the dynamics of the exploited stock, before adding value to the catch. As a part of results, the historical trend of a declining yield, suggests that the fishery has been over exploiting the juveniles, and even tough this condition has been sustained for more than forty years, this process produces nearly 400 thousand t, while it could yield more than one million t if it exploits only adult fish. On testing the economic indicators of the stock response as effect of the age of first catch, it is evident that the current yield is well below the Maximum Sustainable Yield, which might be higher if only adult fish are the targets of the fishery. The same occurs with the Maximum Economic Yield. The Benefit/Cost displays an inverse relationship with the Cost per t. It was found that the fishery could profit more than three hundred million USD if the age of first catch is re-addressed to get only adults as fisheries target. It is clear that this approach could be adopted as useful tool for decision-making and fisheries management.

Keywords

Stock assessment, Maximum sustainable yield, Maximum economic yield, Overexploited fishery, Gulf menhaden

Introduction

One of the problems of fisheries management deals with use of formal procedures of evaluation of exploited stocks in order to derive quantitative regulations able to foresee accurate consequences after the application of certain management actions [1-5]. However, a few years ago, it was stated that fisheries overexploitation and unsustainability are still not widely understood [6], despite cascade effects have been reported [7,8]. Fortunately, after twenty years, with much scientific research work done on this problem, it is much better understood. Therefore, there are multiple examples of mismanagement of fisheries resources, with regrettable consequences leading to the over exploitation of many fish resources and their consequences in their environment [9-12]. In the present paper, populations are evaluated by reconstructing the age structure of each of the years analyzed. The potential catch, benefits, direct jobs, and earnings per fisher can be estimated in several scenarios by changing the fishing mortality F, and the age of first catch, tc. In this way it is possible to test the response of the biologic and socio-economic variables of each fishery with reference to the maximum sustainable yield MSY, and the maximum economic yield MEY.

Many Fisheries at a worldwide level, have been declared chronically overexploited [13]. However, stock assessments and management regulations are usually addressed towards limitations of access, reduction of fishing seasons, reduction of fishing effort, establishment of closed areas, etc., but fisheries scientists as advisers and managers do not usually pay attention in the effects of mesh openings as means to control the age of first catch (tc), allowing to catch only adults of the fish stock and giving to juveniles usually caught, the opportunity to survive to the adult age and having the chance to breed at least only once in their lifetime. An examination of the population parameter values of several fisheries shows that tc value is at least one year lower than the age of first maturity ™. This is a circumstance that unavoidably leads these fisheries towards a condition of overexploitation, which in the case of the Gulf Menhaden and other cases, becomes a chronical condition that often leads to a biological and economic crisis. It is remarkable to find out that management regulations usually ignore the need to increase mesh openings to allow juvenile fish being released from the nets and capturing only adults [14].

Methods

The assessment of the Menhaden stock was made by using a simulation model [15,16]; is based on the general principles of the assessment of exploited fish stocks and is conducted with usually fifteen years of catch data. Thus, with the purpose of formulating better management options, a meta-analysis of data was conducted  to evaluate the performance of the fisheries with reference to the output of this model. In each of these options, catch data and the values of the population parameters are used, from the references    or estimated directly [17-20] and are indicated in Table 1. The associated costs and economic benefits of the fishery are taken as a reference for the bio-economic analysis. The model proposed allows testing of as many exploitation possibilities as fishing data allow, in a dynamic programming exercise that can provide answers to logical questions such as: What will happen to the biomass of the stock and the economic yield if the size of first capture is increased? What will be the biological and economic consequences if fishing effort is doubled? What is the maximum effort that the fishery can sustain and fail to deliver benefits of at least 10 percent above costs? And what are the economic expectations for the next season if the cost of fuel increases in a certain proportion? Population parameter values used as input of the simulation and the corresponding equations are in Table 1.

Table 1: Population parameter values, units, equations and source or comments used for the evaluation of the Gulf Menhaden fishery are indicated.

tab 1

Among the results obtained with the use of this model, the evaluations carried out indicate that for a combination of tc and F values, the estimated performance describes a dome-shaped response surface; if a single value of tc is taken and the response of the stock is observed, the yield is shown as a curve that at certain F level attains a maximum value and declines after this point. The output also describes the number of jobs as a function of F as a line with the same trend as that of potential capture; the benefit/cost ratio is a curve that declines as F increases. In general, the MSY level is at a higher value of F than in the case of the economic yield (MEY). In high-value fisheries, such as lobster, this value coincides with MSY at the same F. In addition, it is remarkable to find out that the cost of fishing increases with higher F intensity, making the activity unprofitable with higher values.

For the economic analysis of the resource, it is necessary to feed the model with data such as the number of fishing days that each season lasts on average, the number of boats and the number of fishers per boat. The total costs are obtained by multiplying the costs/ship/ day by the total number of ships in operation. Ideally, estimates of economic data are made after examining the fishing log from a trading trip [21]. The maximum social value can be determined in two ways, the first is the level of maximum employment (the maximum number of fishers). The second is the maximum profit per fisher. The economic and social values as input data were the value per kilogram landed and the number of fishers during the last fishing season. It is desirable to use a long series of economic data, but these variables though exist, they are not easily available nor collected in a systematic way like those of the catch and effort and for now the estimate that is made by the model roughly reconstructs the economic history of the fishery, with the risk of incurring in certain errors. This problem will cease when a diagnosis of the current situation be made as a basis for the rationale and future management of the resource.

Benefits are determined by subtracting total costs from the total value of the catch. Costs and value are linked to the catch and the other variables in the model. The populations are evaluated by reconstructing the age structure of each one during the series of years of the analyzed data. The potential catch, benefits, direct jobs, and profits per fisher are estimated under the scenarios sought, changing the F and the tc. In this way, it is possible to test the response of the socio-economic variables of the fishery with reference to MSY and MEY. In this context, benefits are obtained by subtracting total costs from the total value of the catch; costs and value are linked to the catch and the other variables in the model.

It is amazing to find out that more than six decades ago Beverton & Holt [22] stated the principle that yield tends to increase with higher values of the age of first catch and displayed this in the well-known figure of yield per recruit. In addition, with the advent of computers and profuse modelling, it is not understood why this problem has not been tackled by fisheries scientists in the following years after that paper. Therefore, this essay was written with the purpose of showing evidence that for any exploited stock, there is a MSY value which is the maximum catch that can be extracted from an exploited stock in the long term, as one of the many equilibrium values that any fishery can have. It is pertinent to mention that in some cases there are huge differences between the MSY and the optimum yield (OY), which is the maximum harvest producing the highest benefit indefinitely. OY is a particular case of the equilibrium MSY values, corresponding to the highest yield that an exploited stock can produce. In addition, when economic values are explicitly considered, it is possible to talk about the MEY, which is closely equivalent to the MSY, but values  of these variables do not coincide at the same F value. Fishing effort was not explicitly considered in this paper, based on the amount of noise usually implicit in it; instead, the spread sheet allowed that catch equation was fitted backwards and most of the significant amount of uncertainty disappeared in the stock assessment process.

The Gulf Menhaden

Despite the distribution range of the Gulf menhaden  spreads over the Gulf of Mexico, and beyond, the fishery takes place in the brackish-waters of the Mississippi river delta, where the coastal areas contain high Cla values, in contrast with the low Cla content along the southern Gulf, where there is much lower productivity (an order of magnitude lower than along the northern Gulf) [23], which does not allow the high stock biomass of this fish as along the vicinity of the Mississippi river delta.

It is pertinent to mention that the catch trend shows an even decline since 1987 (data after Gedar 03 2021) [24], with 640 thousand t in 1987 to 414 thousand t in 2020, as shown in Figure 1, which was drawn to display the fitting process of catch and reconstructed data as a part of the model calibration. No fishing effort data were used to avoid the noise implicit in its use. Population structure was rebuilt in the simulation by applying backwards the stock assessment equations.

fig 1

Figure 1: Model fitting of the catch and assessment of the biomass of the Gulf menhaden for the years 1977-2020

Once the population structure was rebuilt with the current parameters of the fishery, successive trials were applied to each age of first catch of the simulated stock, and this way the stock response could be measured. With the purpose of having an economic output, explicit consideration of the catch value before landing, the number of boats, the catch per trip, and the cost per trip were taken into consideration. The analysis presented in this paper deals within the scope of the so- called stock effect [25,26], it refers to the idea that unit operating costs are sensitive to the size of the exploited fish stocks; in other words, the analysis is referred to the performance of bio-economic indicators inside the fishery, before landing the catch.

With this information in the model, and by knowing the stock response as consequence of different values of the F, it was possible to determine the potential catch, the profits, the benefit/cost ratio,  the MSY, the MEY, the best tc, and other bio-economic variables useful for fisheries management,  produced  as  model  outputs.  As it was stated before, population parameter values were  obtained from FishBase, and Gedar 03 2021. Estimation of some population parameter values were obtained with the aid of Froese 2006; Froese & Binohlan 2000 [27].

Results

Profits and Benefit/Cost Ratio

Despite its declining trend, the Gulf menhaden is a very productive economic activity, displaying profits above 160 M USD in 1987 to around 70 M USD in the year 2020 (Figure 2). The same statement is valid for the Benefit/Cost, whose values (times the cost of fishing) range from 86 in 1986 to 47 in 2011. During the last five years of the series, the economic activity displayed a significant increase up to 116 in 2020 (Figure 2).

fig 2

Figure 2: Trend of profits, in USD and B/C ratio of the Gulf menhaden fishery since 1977

Optimum Yield

The MSY use to be the target of many fisheries; however, it is not usually mentioned that it is not a fixed parameter, it is a variable which depends on the age  of  first  catch  and  therefore  there  are as many MSY values as age groups are in a given stock, being the optimum that one which is at or near the oldest age class in the fishery; in this case it would be the catch of 3.3 M t at the age of eight years profiting 527 M USD at the same age. For obvious reasons, it would be no practical the application of tc = 8 years and the most convenient option could be choosing seven years instead. Any other values are sustainable and are maximum for each age class before the last one. Under the MSY (Figure 3A) and the MEY (Figure 3B), the stock responds the same way and both variables display in an analogous way as a function of tc.

fig 3

Figure 3: Maximum sustainable yield (MSY), 3A, and Maximum economic yield (MEY), 3B, of the Gulf menhaden fishery as a function of tc. In the first case the units are metric tons (t) and in the second case the units are Million USD.

Economic Variables

As a result of the analysis, it was found that there is an inverse relationship between the costs of exploitation and the B/C ratio (Figure 4). This is an evident condition, because it is logical to expect that the exploitation of the fishery is subject to higher costs when the stock is less abundant and vice versa.

fig 4

Figure 4: Relationship between the Benefit/Cost ratio (B/C) and the Costs of exploitation per t (C/t, USD) in the Gulf menhaden fishery. Each dot represents a tc value, being the first two overlapped on the right end of line trend, corresponding to tc ages of 1 and 2 years. The horizontal axis indicates the cost per t.

Under-Exploited or Over-Exploited?

The main reason why the consideration that the Gulf menhaden is overfished, as stated in the title of the present paper, is because from the viewpoint of the author, based on this and previous analysis, the stock is exploited as overexploited of recruits in a condition such that is shared by many fisheries around the world [28-32] and there are countless examples evidencing this problem. The analysis of this and other fisheries lead to the conclusion that the main reason for the over exploitation of recruits may be economic, because often occurs in pelagic stocks which are very productive and display high turnover rate. They are often linked to high economic value, product of high catch volumes, as it is the case of the Gulf menhaden; this fishery is very productive for its high landings and for its high profits. Then, it has been exploited for long time and the yield shows a declining trend to the point of capturing near 400 thousand t per season in the last few years, as compared to the landings of near one million t per season recorded in the middle eighties. It is amazing to realize that nobody has pointed this situation before, despite that the historical decline of catch is an evident fact and the teams in charge of evaluations refuse to accept this condition of the fishery, stating that “the Gulf of Mexico menhaden stock is not experiencing overfishing and is not overfished” (Gedar 03 2021). The authors of the present paper believe that the main reason why nobody has called the attention on the condition   of an overexploited fishery is because the menhaden has been very profitable for many decades, confirming what was stated above. Then if nobody pays attention on this problem, the condition will continue until the turnover rate of recruits becomes critical, the stock biomass to be not enough to replace the stock and the fishery to become unprofitable [33]. This is evidence confirming that the Gulf menhaden is under a condition of overexploitation of recruits [34], a problem common to many other fisheries [35-39].

As result of the analysis, it was found that a nearly four times higher catch could be obtained by applying F = 0.4, as shown in Figure 5, where the exploitation rate (E) and the F estimated for the years 1977-2020 are displayed. It is pertinent to mention that it is  not desirable to increase the F in an overexploited stock because the number of recruits would get exhausted in a few more fishing seasons and the whole fishery would fall into a collapse in brief time.

fig 5

Figure 5: Historic trend of the F (bars) and the E (dotted line) in the menhaden fishery for the period 1977 – 2020.

Numerical analysis and simulation of fisheries systems allow estimating potential yields, amongst other options; one of them deals with the possibility of doing a long-term forecast of the expected performance of the stock under different exploitation policies, with a very reasonable accuracy. In this case, after rebuilding the structure of the population, it is possible to estimate the expected potential yield by application as many feasible management options of F and the tc in a modern and flexible approach of the Beverton- Holt (1957) yield per recruit method. In this study case, three age classes, one, three- and five-years old fish were used as an example to demonstrate in first place, that the current fishery is overexploited of recruitment by applying a tc = 1, as shown in Figure 6. The trend line of each one of the three age classes selected here for demonstration display the outputs of the expected yield as a function of F. In the last few years of catch records, the F value estimated is F = 0.11 and the yield is Y = 414,730 t; then by looking at the expected potential yield by exploiting only adults (tc = 3 and tc = 5), would allow a much higher stock biomass to catch, and the F could be three times the current one being able to yield more than 1.1 M t, without the risk of depleting the fishery.

Horizontal lines showing the FMSY and the EMSY values are indicated as reference, showing that the fishery is exploited below the limit reference points since 1988. This is an apparent situation, because by increasing the F above the current values, the yield would decrease instead of increasing (Figure 6).

fig 6

Figure 6: A. Expected yield of the Gulf menhaden fishery under three scenarios, as a function of fishing mortality. The lowermost line corresponds to the current condition with tc=1, whose maximum yield could hardly produce 670 thousand t at the maximum at F=0.4. By contrast, after applying the same F, with tc=3, the fishery would yield 904 thousand t; with tc=5, the fishery would harvest 1.3 M t. In the last two cases, only adult fish would be exploited. B. Economic performance of the fishery by expressing the profits in Million USD as a dependent variable. In the current condition (tc=1) the maximum profit is $104 M. By applying the same F, with tc=3 the fishery would produce $142 M; with tc=5, the fishery would profit $218 M. Other variables are the same as in Figure 6A.

Discussion

By examining the causes of over exploitation of the most productive world fisheries, it is generally aknowledged that the most common problems of overexploitation of a fishery may occur after the application of excessive fishing effort, by overexploitation of recruits or both, leading to an excess of fishing capacity [40-43], despite clear recommendations and reference points are defined [44,45]. This is the case of the Gulf menhaden, exploited in the northern Gulf of Mexico, and whose huge biomass makes it one of the most productive fish stocks at world level (Myers & Worm 2003).

Production of the Gulf menhaden fishery was briefly examined because of the Deep-Sea Horizon oil spill in 2010 awakened the interest on it by the authors, but an impact of the oil spill on its stock biomass immediately after that event was not evident. A ban was temporarily imposed to the fishery during this disaster, but the fishery continued shortly afterwards. However, no evidence of depletion could be observed in the stock biomass if there was any, as it is not shown in Figure 1.

Overexploitation of fish stocks is a major concern in many world fisheries. It is the case for not just the Gulf menhaden, but it occurs in many others and it has been pointed as one of the reasons why   the world fisheries production display decreasing trends since more than fifty years ago [40,41], claiming for urgent rebuilding of stocks, Despite reference points and statements on the management have been provided (Caddy 1999; Caddy & Mahon 1995).

It has been stated that close to 90% of the world’s marine fish stocks are fully exploited, overexploited or depleted, threatening the chance of renewal of stock biomass, because the gradual reduction  of production capacity of the stocks to the point that a stock may be exhausted becoming incapable to restore its biomass as consequence of the lack of enough reproducers, compromising the sustainability of a fishery [42-44]. There are several causes leading fisheries to    an overexploited condition, like illegal fishing, subsidies, fishing overcapacity and degradation of environment, as the more common ones. The effects of overexploitation are often expressed as social and economic crises on the harbours and ports where the reduced catches are landed, and where much infrastructure and services stop being  in use leaving many people out of jobs. Contrary to what has been expressed in most of stock assessments [45], in this paper the use of fishing effort data was deliberately ignored, but once the model was fitted, it was possible to do an estimation of the number of fishing days, without the noise that is usually implicit in the current stock assessment procedures.

An undesirable perspective of the current condition of the Gulf menhaden, is maybe the worst case of a more general problem, biomass overexploitation not necessarily expresses the more critical consequence of this fishery, which has been gradually overexploiting its juveniles for decades. In this activity, the age groups caught by the fishery include since the age class of one year of age, but the stock reaches the age of sexual maturity at the age of two years; this implies that the fishing gears are catching all age classes. By consequence, the portion of the stock caught by the fishing gears include juveniles that otherwise would have the chance of reaching the adulthood   and contributing to replace the stock with the products of their reproduction. In the Gulf menhaden fishery, catch trend over time displays a slight but consistent decline, evidencing the effect of a gradual reduction of the population turnover rate, which as far as it persists without change, eventually would lead the fishing activity into a crisis, becoming unprofitable, because the cost of fishing would make the fishery unviable. A reduction of the stock biomass would lead to an increase of fishing because it will make the fishery more expensive, to the point of reaching the economic equilibrium limit, this is when the fishing stops being profitable.

In order to conclude this paper, it is considered that despite the Gulf menhaden still is a productive fishery, with profits near to one hundred million USD, it could profit more than three hundred million USD if the owners of the fishing fleet decide to open the meshes of fishing gears, and the age of first catch is re-addressed to get only adults as target of the fishery. Evidently, the adoption of this fishing strategy would imply some previous trials of selectivity using several mesh openings, and results could allow choosing the most suitable one [46-52]. However, in order to achieve the expected goals in the desired size-frequency of the new catch, the adoption of the new mesh size should be applied to the whole fishing fleet, so the new selectivity can have impact on the whole exploited stock; otherwise it would not have the expected effect. It is considered that the use of the new mesh sizes, may take a couple of years to achieve the expected results.

Author Credit Statement

EC and ACH developed the paper concept; EC created the draft and structure of the paper; both authors contributed to writing and editing.

Declaration of Competing Interest

The authors declare that they have not known competing financial interests or personal relationships that could have appeared to to influence the work reported in this paper.

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Prevalance and Risk Factors of Hypogonadism in Male Patients with Type 2 Diabetes in El Minya, Egypt

DOI: 10.31038/EDMJ.2023711

Abstract

Background: Hypogonadism in adult men is a clinical and biochemical syndrome associated with low level of testosterone, which may adversely affect multiple organ functions and quality of life. It is closely related to the development of diabetes. This study was designed to determine the incidence of hypogonadism and related risk factors among men with type 2 diabetes (T2D).

Patients and Methods: A total of 300 male patients diagnosed with T2D age from 30-70 years were enrolled in the study. Arabic version of the Androgen Deficiency in Aging Male (ADAM) questionnaire was employed to assess the androgen insufficiency in men. Hemoglobin A1c, FSH, LH, total and free testosterone, levels were measured by enzyme immunoassay.

Results: T2D patients were divided into two groups: 48 (16%) patients with hypogonadism and 252 (84%) patients without hypogonadism. Multiple logistic regression analysis for factors affecting Hypogonadism among patients according to (total testosterone + ADAM +ve) versus those without hypogonadism it was found that age, random blood sugar, body mass index (BMI), Hb A1c are independent risk factors for the development of hypogonadism with odds ratio (0.95, 1, 1.1, 1.37) with p value (0.02, 0.03, 0. 03, 0.008) respectively. The ROC analysis of the accuracy of indices and cut off values for the studied total testosterone for predicting the hypogonadism according to total testosterone + ADAM score positive: The AUC was 0.98 “p-value <0.0001” with sensitivity 100% and specificity of 96.4% at Cut off value ≤ 12.

Conclusion: Several risk factors of diabetes are associated closely with hypogonadism. Age, BMI, blood sugar, and Hb A1c are independent risk factors for the development of hypogonadism in male patients with T2D.

Introduction

Diabetes mellitus is a metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, defective insulin action or both. The chronic hyperglycemia of diabetes is associated with relatively specific Long-term complications from high blood sugar can include macrovascular complications as coronary artery disease, cerebrovascular strokes and chronic limb ischemia and there is microvascular complication as diabetic retinopathy, chronic kidney disease which may require regular dialysis, and diabetic neuropathy [1].

Type 2 diabetes (T2D) is ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance. This form of diabetes, which accounts for 90-95% of those with diabetes, previously referred as non-insulin dependent diabetes, type 2 diabetes, or adult onset diabetes, encompasses individuals who have insulin resistance and usually have relative (rather than absolute) insulin deficiency. This is probably many different causes of this form of diabetes although the specific etiologies are not known. Most patients with this form of diabetes are obese, and obesity itself causes some degree of insulin resistance [2].

Hypogonadism (testosterone deficiency) in adult men is a clinical and biochemical syndrome associated with low level of testosterone, which may adversely affect multiple organ functions and quality of life [3]. Overt hypogonadism was defined as the presence of clinical symptoms of hypogonadism and low testosterone level (total testosterone <8 nmol/l and/or bioavailable testosterone <2.5 nmol/l). Borderline hypogonadism was defined as the presence of symptoms and total testosterone of 8-12 nmol/l or bioavailable testosterone of 2.5-4 nmol/l [4].

From the cross-sectional studies done, it is clear that between 20% and 64% of men with diabetes have hypogonadism; generally, there is a slow and continuous decrease in testosterone production among older population. Furthermore, the prevalence of hypogonadism varies between racial, ethnic groups [5]. A high incidence of hypogonadism in men with (T2D) has been globally reported. This study was designed to determine the incidence of hypogonadism and related risk factors among men with T2D in Minia governorate, Egypt.

Patients and Methods

This prospective cross sectional study included a total of 300 T2D patients; all patients gave verbal consent to participate in the study. Patients were selected from those coming for follow up at different Minia University and Ministry of Health hospitals in the period between January 2018 and June 2019. Patients are known to have type 2 diabetes mellitus according to criteria of American diabetic association [6].

The criteria of diagnosis of hypogonadism in our work is low level of testosterone (12 nmol/L total testosterone 3.5 ng/mL) represents a reliable threshold to diagnose late onset hypogonadism (LOH) or free testosterone <5.7 pg/ml) and positive result of screening of ADAM questionnaire [3,7]. Hypogonadism was classified as primary hypogonadism (total testosterone >12 nmol/L and LH<10 IU\L) and secondary hypogonadism ( total testosterone >12 nmol/L and LH >10 IU/L).

Inclusion Criteria

Male patients, diagnosed with diabetes mellitus type 2, age from 30-70 years and on oral therapy or insulin or both.

Exclusion Criteria

Any patient with any of the following criteria: a history of hypopituitarism, type 1 diabetes mellitus, chronic debilitating diseases, chronic inflammatory diseases, or connective tissue disorders, take any medications affecting glucose metabolism as (steroids, anti-psychotic medications), malignancy, autonomic neuropathy, or patients on testosterone replacement therapy.

All subjects were subjected to full history taking and thorough clinical examination. All the patients were required to complete an Arabic version of the Androgen Deficiency in Aging Male (ADAM) questionnaire designed by the Saint Louis University, MO, USA, 2007. This 10-item screening questionnaire was employed to assess the androgen insufficiency in aging men, including morning erection to exclude psychogenic erectile dysfunction. A positive response denoted the presence of clinical hypogonadism based on a decrease in libido, strength of erections, or any three nonspecific questions that may include a decrease in muscle strength, fatigability, mood changes, and loss of height.

The following laboratory investigations were performed: blood glucose level, renal and liver function tests, complete lipogram using fully automated clinical chemistry auto-analyzer system Konelab 20i (Thermo-Electron Incorporation, Finland). Hemoglobin A1c (glycated hemoglobin), FSH, LH, total and free testosterone, levels were measured by enzyme immunoassay.

Study sample size: the number of study participants was calculated using EPI – Info (statistical; software for epidemiology) depend on population number (diabetic patients) and percentage of disease (prevalence of hypogonadism).

Statistical Analysis

Normality of data distribution was done by using Shapiro-wilk test. Descriptive statistics, such as percentages, frequencies, mean, and standard deviations, were used to measure the demographic variables, clinical and laboratory data. Analytical statistics were applied to investigate the association of the demographic variables, clinical and laboratory data and hypogonadism. Quantitative data were presented by mean (standard deviation), while qualitative data were presented by frequency distribution. The independent sample t-test used for comparison of means and the Chi-square test was used to compare between proportions.

Logestic regression analyses were performed to identify the significant predictors (independent risk factors) for hypogonadism (target dependent factor) The probability of less than 0.05 was used as a cut off point for all significant tests and all statistical tests were 2 tailed. The receiver operating characteristic (ROC) curve is the plot that displays the full picture of trade-off between the sensitivity (true positive rate) and (1-specificity) (false positive rate) across a series of cut-off points. Total area under ROC curve is a single index for measuring the performance a test. The larger the AUC, the better is overall performance of the medical test to correctly identify diseased and non-diseased subjects. All analyses were done using the statistical Package of social Science (SPSS, version 22).

Results

This study included a total of 300 men with T2D. Their socio-demographic characteristics are shown in Table 1. T2D patients were divided into two groups: 48 (16%) patients with hypogonadism and 252 (84%) patients without hypogonadism. 68.8% of the hypogonadal group were in age group 41-60 years with p value 0.009 , 43.3% of hypogonadal group were smokers with p value 0.05, and 25% sere Ex-smoker, 68.8% of the hypogonadal group were on oral treatment of diabetes mellitus (p=0.05), 18.8% were on insulin, 56.3% of hypogonadal group were diabetic 6-10 years with (p=0.0001), 81.3% of hypogonadal group were obese with (p=0.001). The group of hypogonadism show higher BMI, waist circumference grades, waist/hip ratio and waist/height ratio with (p=0.001, =0.008, >0.0001, =0.03) respectively (Table 2).

Table 1: Sociodemographic data of whole patient with type 2 diabetes mellitus

Socio-demographic characteristics

Mean ± SD or N (%)

Age (years)

54.46 ± 9.46 (31-70)

Age groups

30-40 (years)

41-50 (years)

51-60 (years)

61-70 (years)

 

33 (11%)

60 (20%)

126 (42%)

81 (27%)

Smoking

Non smoker

Smoker

Ex-smoker

 

141 (47%)

96 (32%)

63 (21%)

Type of treatment of DM

Lifestyle

Insulin

Oral antidiabetic

Mixed (Insulin + oral)

 

21 (7%)

60 (20%)

180 (60%)

39 (13%)

Complication of DM

No

Yes

 

198 (66%)

102 (34%)

Classification of complication :

Neuropathy

Stroke

IHD

Retinopathy

Nephropathy

 

39 (13% )

12 (4%)

27 (9%)

21 (7%)

3 (1%)

Hypertension

No

Yes

 

204 (68%)

96 (32%)

Duration of diabetes (years)

7.73 ± 6.76 (0.1-27)

Duration of diabetes ranges

≤ 5 (years)

6-10 (years)

11-15 (years)

< 15(years)

 

156 (52%)

66 (22%)

51 (17%)

27 (9%)

BMI (KGm/M2)

31.22 ± 6.56 (21.1-40.8)

BMI grades (KGm/M2)

≤ 24.9 (KGm/M2) average

25-29.9 (KGm/M2) overweight

≥ 30 (KGm/M2) obesity

 

27 (9%)

102 (34%)

171 (57%)

Waist circumference (Cm)

101.62 ± 13.67 (69-135)

Waist circumference grades (Cm)

< 102 (Cm)

≥ 102 (Cm)

 

84 (28%)

216 (72%)

Waist/hip ratio

0.97 ± 0.06 (0.81-1.15)

Waist/height ratio

60.53 ± 7.71 (43-79)

BMI: Body mass index, KGm: Kilogram, M: Meter, CM: Centimeter

Table 2: Sociodemographic characteristics in type 2 DM patients with hypogonadism according to (Total Testosterone + ADAM +ve) versus those without hypogonadism.

Socio-demographic characteristics

Hypogonadism
N=48

No hypogonadism
N=252

p-value

Age (years)

52.87 ± 9.03

54.76 ± 9.52

0.2

Age groups

31-40 (years)

 41-50 (years)

 51-60 (years)

 61-70 (years)

 

3 (6.3%)

18 (37.5%)

15 (31.3%)

12 (25%)

 

30 (11.9%)

42 (16.7%)

111 (44%)

69 (27.4%)

 

0.009*

Smoking

Non smoker

Smoker

Ex-smoker

 

15 (31.3%)

21 (43.8%)

12 (25%)

 

126 (50%)

75 (29.8%)

51 (20.2%)

 

0.05

Type of treatment of DM

Lifestyle

Insulin

Oral

Mixed

 

0 (0%)

6 (12.5%)

33 (68.8%)

9 (18.8%)

 

21 (8.3%)

54 (21.4%)

147 (58.3%)

30 (11.9%)

 

0.05

Complications of DM

No

Yes

 

33 (68.75%)

15 (31.25%)

 

165 (65.5%)

87 (34.5%)

 

0.01*

Hypertension

No

Yes

 

33 (68.8%)

15 (31.2%)

 

171 (67.9%)

81 (32.1%)

 

0.9

Duration of diabetes (years)

7.15± 3.73

7.84± 7.20

0.5

Duration of diabetes ranges

≤ 5 (years)

6-10 (years)

11-15 (years)

< 15(years)

 

15 (31.2%)

27 (56.3%)

6 (12.5%)

0 (0%)

 

141 (56%)

39 (15.5%)

45 (17.9%)

27 (10.6%)

 

 

>0.0001*

BMI (KGm/M2)

32.97 ± 7.88

30.89 ± 6.24

0.04*

BMI grades (KGm/M2)

≤ 24.9 Average

25-29.9 Overweight

≥ 30 Obesity

 

0 (0%)

9 (18.8%)

39 (81.3%)

 

27 (10.7%)

93 (36.9%)

132 (52.4%)

 

0.001*

Waist circumference grades (cm)

< 102

≥ 102

 

6 (12.5%)

42 (87.5%)

 

78 (31%)

174 (69%)

 

 

0.008*

Waist/hip ratio

1.01 ± 0.07

0.96 ± 0.05

<0.0001*

Waist/height ratio

62.70 ± 4.68

60.11± 8.10

0.03*

*Significant level of p-value is < 0.05.
* p value of frequency was calculated by using chi-square test.
* p value of means was calculated by using independent sample t-test.

In term of complications of diabetes mellitus, our results demonstrated no significant differences between the two studied groups (Table 3). Table 4 shows the comparison between routine investigations and hypogonadism of hypogonadism according to (Total Testosterone + ADAM +ve) versus those without hypogonadism: It was significant in urea, creatinine, eGFR, SGPT with p value (0.01, >0.0001, 0.02, >0.0001). As regard glycemic control non of our hypogonadal patients have HbA1c >7%, but in the non hypogonadal group 33.3% have HbA1c >7 and 66.7% have HbA1c <7%, with p value 0.0001. Regarding the relation between specific investigations and hypogonadism according to total testosterone it was significance in free testosterone, total testosterone, FSH, ADAM score with p value of 0.001, > 0.0001, 0.003, > 0.0001 respectively (Table 5).

Table 3: The classification of complications between the hypogonadism according to (Total Testosterone + ADAM +ve) versus those without hypogonadism.

Diabetic complications

Hypogonadism
N=48

No hypogonadism
N=252

p-value

All number of patients complaint of complications

15(31.25%)

87 (34.5%)

Neuropathy

6 (12.5%)

33 (13.09%)

0.9

Stroke

3 (6.25%)

9 (3.57%)

0.4

Ischemic heart disease

3 (6.25%)

24 (9.52%)

0.6

Retinopathy

3 (6.25%)

18 (7.14%)

0.8

Nephropathy

0 (0%)

3(1.19%)

0.4

Table 4: Comparison of Routine investigations in hypogonadism group according to (Total Testosterone + ADAM +ve) versus those without hypogonadism.

Routine investigations

Hypogonadism
N=48

No hypogonadism
N=252

p-value

Urea (mg/dL)

36.87 ± 9.71

32.42 ± 11.28

0.01*

Creatinine(mg/dL)

1.08 ± 0.19

0.95 ± 0.22

<0.0001*

eGFR(ml/min/1.73 M2)

82.96 ± 19.95

89.79 ± 18.57

0.02*

SGOT(Iu/L)

23.56 ± 11.95

24.20 ± 15.73

0.7

SGPT (Iu/L)

27.68 ± 13.24

20.01 ± 8

<0.0001*

HbA1C (%)

10.01 ± 1.60

8.39 ± 2.17

<0.0001*

HbA1C ranges (%)

< 7

≥ 7

 

0 (0%)

48 (100%)

 

84 (33.3%)

168 (66.7%)

 

<0.0001*

HDL (mg/dL)

35.37 ± 6.40

37.34 ± 9.57

0.2

LDL (mg/dL)

149.43 ± 41.47

142.27 ± 42.69

0.3

TGS (mg/dL)

180.93 ± 51.75

202.05 ± 85.64

0.1

Cholesterol (mg/dL)

223.43 ± 41.01

224.96 ± 45.70

0.8

*Significant level of p- value is < 0.05.
*p value of means was calculated by using independent sample t-test.

Table 5: Relation between specific investigations and hypogonadism according to Total testosterone of the studied group.

Specific investigations

Hypogonadism
N=48

No hypogonadism
N=252

p-value

Free testosterone (pg/mL)

5.58 ± 3.25

7.42 ± 3.62

0.001*

Total testosterone (nmol/L)

9.09 ± 2.87

26.68 ± 12.63

<0.0001*

FSH(IU/L)

8.42 ± 4.26

9.25 ± 4.68

0.003*

LH(IU/L)

11 ± 5.45

12.72 ± 6.06

0.06

ADAM score

Positive

Negative

 

48 (100%)

0(0%)

 

150 (59.5%)

102 (40.5%)

 

<0.0001*

Total Testosterone level

Normal

Low

 

0 (0%)

48 (100%)

 

243 (96.4%)

9 (3.6%)

<0.0001*

*Significant level of p- value is < 0.05.
*p value of frequency was calculated by using chi-square test.
*p value of means was calculated by using independent sample t-test.

Table 6 shows multiple logistic regression analysis for factors affecting Hypogonadism among patients according to (Total Testosterone + ADAM +ve) versus those without hypogonadism it was found that age, random blood sugar, body mass index, HbA1c are independent risk factors for the development of hypogonadism with odds ratio (0.95, 1, 1.1, 1.37) with p value (0.02, 0.03, 0. 03, 0.008) respectively.

Table 6: Multiple logistic regression analysis for factors affecting Hypogonadism among patients according to (Total Testosterone + ADAM +ve) versus those without hypogonadism.

Independent variables

Adjusted odds for multivariate (95% CI)

P-value

Age (years)

0.95 (0.91-0.99)

0.02*

Random blood sugar (mg/dL)

1 (1-1.01)

0.03*

BMI(KGm/M2)

1.1 (1-1.19)

0.03*

Waist circumference (Cm)

1 (0.96-1.05)

0.8

HbA1c (%)

1.37 (1.08-1.74)

0.008*

HDL(mg/dL)

0.95 (0.91-1)

0.06

TGS (mg/dL)

0.99 (0.99-1)

0.2

FSH (IU/L)

0.94 (0.88-1)

0.08

LH (IU/L)

0.99 (0.91-1.08)

0.8

Figure 1 shows the receiver operating characteristic (ROC) analysis of demonstration of the accuracy of indices and cut off values for the studied total testosterone for predicting the hypogonadism according to total testosterone + ADAM score positive: The area under the curve (AUC) was 0.98 ” p-value <0.0001″ with sensitivity 100% and specificity of 96.4% at Cut off value ≤ 12. Figure 2 shows the ROC analysis of demonstration of the accuracy of indices and cut off values for the ADAM score for predicting the hypogonadism according to total testosterone + ADAM score positive: The AUC was 0.70 ” p-value <0.0001″ with sensitivity 100% and specificity of 40.5% at Cut off value<0.

fig 1

Figure 1: Roc curve analysis of total testosterone level in hypogonadism according to Total testosterone

fig 2

Figure 2: Roc curve analysis of ADAM score in hypogonadism according to Total testosterone

Figure 3 shows the ROC analysis of demonstration of the accuracy of indices and cut off values for the studied HbA1c for predicting the hypogonadism according to total testosterone + ADAM score positive: The AUC was 0.72 ” p-value <0.0001″ with sensitivity 87.5% and specificity of 58.3% at Cut off value < 8.7. Figure 4 shows the ROC analysis of demonstration of the accuracy of indices and cut off values for the studied FSH for predicting the hypogonadism according to total testosterone + ADAM score positive: The AUC was 0.60 ” p-value=0.02″ with sensitivity 75% and specificity of 48.8% at Cut off value < 17.

fig 3

Figure 3: Roc curve analysis of HbA1c level in hypogonadism according to Total testosterone

fig 4

Figure 4: Roc curve analysis of FSH level in hypogonadism according to Total Testosterone

Figure 5 shows the ROC analysis of demonstration of the accuracy of indices and cut off values for the studied eGFR for predicting the hypogonadism according to free testosterone + ADAM score positive: The AUC was 0.39 ” p-value 0.003″ with sensitivity 53.6% and specificity of 37% at Cut off value < 82.5.

fig 5

Figure 5: Roc curve analysis of e GFR in hypogonadism according to Free Testosterone

Discussion

Male hypogonadism is a common disease characterized by certain clinical features and low levels of serum testosterone. Its typical clinical manifestations include physical decline, memory loss, difficulty paying attention, depression, loss of libido, and erectile dysfunction. It significantly impacts patients’ quality of life [8]. Recently, studies have shown that hypogonadism is closely related to the development of diabetes [9]. It has been confirmed that male patients with T2D are significantly more likely to develop hypogonadism: the proportions of diabetes patients with low total testosterone levels are 36.5% [10]. Male hypogonadism seriously affects the quality of life in patients with diabetes [11,12]. So far, it is unclear which correlates of diabetes are associated with hypogonadism. Therefore, it is especially important to explore the risk factors for hypogonadism to facilitate prevention, diagnosis, and early treatment.

The current study was designed to evaluate the prevalence and risk factors o hypogonadism in patients with T2D among the egyptian population by using an ADAM questionnaire with the use both total and free testosterone level (≤ 12nmol, ≤5.7). We studied 300 male diabetic, according total testosterone level it showed that the prevalence of hypogonadism was 24.2% with of whom 56.3% was secondary hypogonadism and 43.7% was primary hypogonadism, according to free testosterone level it was found that the prevalence of hypogonadism was 42.42%, and secondary hypogonadism and 42.9% was primary hypogonadism. Similar to our results, the study of Dhindsa et al. [13] which was conducted in 103 patients by hypogonadism (33% in patients aged 28e80 years) and they reported that their high prevalence might be attributed to a higher mean BMI, Multicentre study was done in India reported a hypogonadism prevalence of 20.7% among patients with diabetes mellitus [4].

In our study we found that the prevalence of hypogonadism was higher with free testosterone cut of level (≤5.7 pg/mL) in comparison to total testosterone (≤12 nmol/L), similar to our findings the study of Rhoden et al. [14] which was cross-sectional study from Brazil who reported that that free and total testosterone levels were subnormal in 46% and 34% of diabetics respectively. In the present study hypogonadotropic hypogonadism is the predominant type of hypogonadism in our diabetic subjects. As, 43.7% had primary hypogonadism (LH > 10 MIU/ML) and 56.3% had secondary hypogonadism (LH < 10 MIU/ML); Similar to our finding, the study of Chandel et al. [15] found that LH and FSH concentrations in type 2 diabetic patients with low free testosterone concentrations were in the normal range. Tenover et al. [16] found that the majority of hypogonadal men over the age of 60 had low, or inappropriately normal LH levels. In contrary to our results the study of Ali et al. [17] who found high serum and urinary FSH and LH among diabetics with low serum total and serum free testosterone levels and Kapoor et al. [18] who found that 7% had hypogonadotropic hypogonadism.

Regarding to risk factors for development of hypogonadism, the present study should that age is important risk for development of hypogonadism. A higher prevalence of low total testosterone (69%) was seen in men aged between 60 and 70 years. This finding in agreement Grossmann et al. [19] who reported that 43% of men of the same age had low total testosterone. Many studies reported that the fraction of diabetic men with a subnormal level of total testosterone increased with age [20-22]. Although we found that lower testosterone level was found in older age groups but univariant relationship between total tesosterone and age is not there in similar studies conducted in South Africa and New York [13,23]. In contrast to this study, a study conducted in Jordan reported a significant positive correlation of age with TT [24]. Studies in England and Nigeria reported the presence of a significant negative correlation between age and TT level [25,26]. The most possible explanation for these inconsistencies is that serum hormone binding globulin (SHBG), which accounts for 60-80% of testosterone binding, increases with age. Yet low levels of SHBG may occur in the presence of insulin resistance, thus resulting in a decrease in TT levels. Therefore, in the absence of the assessment of bioavailable testosterone levels, the degree to which this confounder (SHBG) affected our results if at all is difficult to speculate on [27]. In the present study, there was significant association between the serum testosterone level and HbA1c concentration. This finding is consistent with the results obtained by other study Kapoor et al. [25], Our findings also contradict the finding of the study undertaken by Fukui et al. [22], who found that total testosterone concentrations correlated positively with HbA1c concentrations while opposing what was found by Grossmann et al. [21], and Dandona et al. [28].

In the present study, we observed negative association of serum testosterone levels with blood glucose markers including HbA1c values, which is in consistent with the studies of Fukui et al. [22], Rabia et al. [29], and Laaksonen et al. [30] where serum testosterone levels were shown to have negative association with glucose markers, Not only HbA1c levels but Insulin resistance indicators as BMI, waist/hip ratio and waist/height ratio among males have also been found to be related with lower levels of testosterone levels. Many such studies have confirmed that insulin resistance is found to be associated with low serum testosterone levels. The reason would be that the testosterone regulates GLUT-4 gene expression and other genes important for insulin signaling. Lower testosterone levels leads to decrease in the expression of GLUT-4 levels in muscles so reduction in the glycolytic enzyme activity in muscle, liver and abdominal adipose tissues [31,32]. Testosterone reduction also causes dysregulation of lipid metabolism which also increases the risk of developing diabetes [33,34].

Conclusion

Several risk factors of diabetes are associated closely with hypogonadism. Age, BMI, blood sugar, and Hb A1c are independent risk factors for the development of hypogonadism in male patients with T2D.

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