Monthly Archives: July 2024

Knowledge and Practices Regarding Antenatal Care and Care After Elective Caesarean Section Among Pregnant Mothers

DOI: 10.31038/IJNM.2024531

Abstract

Introduction: Pregnancy gives joy and new feelings to the mothers but along with that, there are different issues and problems faced by the mothers in the antenatal period and postnatal period. These problems can put the mother in danger. Worldwide, approximately 830 women died every single day due to complications during pregnancy or childbirth (2015) [1]. It is very important for the mothers to have knowledge regarding antenatal and postnatal care after caesarean section. So, the present study was conducted to find the knowledge and practices regarding antenatal care and care of self and newborn after caesarean section.

Objective: The study was conducted with the objectives of “to assess the effectiveness of ‘Health Promotion Interventions’ for women undergoing elective caesarean in PGIMER, Chandigarh on knowledge and practices related to antenatal care.

Method: A quasi experimental study was done in OBG unit of Nehru hospital PGIMER, Chandigarh during the month of July-Aug 2019. Total 80 pregnant mothers admitted for elective caesarean section were enrolled as per inclusion criteria by using purposive sampling technique. Pregnant mothers were interviewed by using interview schedule to assess knowledge and practices. The tool was validated by experts of National Institute of Nursing College, Obstetrics and Gynecology Department and department of Physiotherapy PGIMER, Chandigarh. Each interview took 25-30 minutes to complete.

Results: The mean age of the subjects was 29.32 ± 4.4 years. Majority of subjects (37%) had placenta previa as the indication of elective caesarean. More than half of the mothers were aware about diet (53%) and importance of personal hygiene (100%) in antenatal period. Less than half of the mothers were had knowledge regarding other aspects of antenatal care like rest and sleep (45.8%), body mechanics (44.6%), less than half of the mothers were practicing antenatal exercises i.e. deep breathing exercises (12%), foot and ankle exercises (2.4%) and maintaining daily fetal movement count (25.3%). Majority of the mothers were knew about breastfeeding (initiation, duration, position) (65.1%), condom and oral pills as contraceptive methods (78.3% and 61.4% respectively) but less than half of the mothers were had knowledge about breastfeeding complications and their management (38.6%), warning signs of postpartum complications (19.3%), about lochia (38.6%), postnatal exercises (4.8%), benefits of early ambulation (13.3%), about another contraceptive methods and newborn care after caesarean section.

Conclusion: Hence, has been concluded that there was a need to plan a health intervention program or protocol aiming to improve the maternal health knowledge and practices which eventually improve the health status of the mothers as well as baby.

Keywords

Antenatal care, Self-care after caesarean section, Newborn care

Introduction

Pregnancy is the period of transition which would nearly disturbed the every aspect of a woman’s life. The postoperative course of a mother having a caesarean section is different for each mother. The issues related to the postpartum period can be managed by providing efficient, effective, quality nursing care to postnatal mothers and their neonates. Mothers have to face different problems during pregnancy, immediately after childbirth and in the postnatal period. During pregnancy the problems faced by the mothers are lower back pain, swelling of the lower legs, heartburn, breathing difficulties which are most common complaints amongst women during the antenatal period, have a great impact on their quality of life. Certain interventions like education on body mechanics for back pain, range of motion exercises for leg swelling, deep breathing exercises, and advising mother to lie in left lateral position and diet modifications including small and frequent meal can reduce these problems to some extent. If the mothers have knowledge regarding these problems and their interventions she will be able to deal with the problems early and can prevent arising of complications. Health knowledge is an important element to enable mothers to be aware about their health status and any abnormal signs which required further investigations. Only on the basis of knowledge assessment we are able to finds the gaps and interventions to fulfill these gaps in improving maternal and newborn health. So, this study was conducted to determine the level of knowledge and practices regarding antenatal care and knowledge regarding postnatal care and newborn care after caesarean section. This will be used as baseline data and will help the future planning of Health Intervention Program. Various literatures had proved that the knowledge gaps, cultural beliefs and behavioral pattern of which mothers had an impact on neonatal skin-care. Health education needs to change wrong practices [2]. The studies were also suggested that educations provided in antenatal period will results in better maternal and neonatal outcomes. The quality of the health care for mothers and newborns is supported with education; their health status will be affected positively in future [3] Education can be provided by using different methods like self-instructional module and information booklet. Similar findings were found in the another study that self- instructional module was effective in improving the knowledge of mothers on postoperative self-care after caesarean section [4].

Objective

To assess the eff ectiveness of ‘Health Promotion Interventions’ for women undergoing elective caesarean in PGIMER, Chandigarh on knowledge and practices related to antenatal care.

Material and Method

A quasi experimental study study was done in OBG unit including clean labor room, maternity ward, Gynae ward and CLR extension of Nehru hospital PGIMER, Chandigarh during the month of July-Aug 2019. Total 80 pregnant mothers were enrolled as per inclusion criteria i.e. pregnant mothers admitted for elective caesarean section with ≥ 32 weeks of gestation period and who were willing to participate. The women with known mental illness were excluded. Purposive sampling technique was used for data collection. Ethical clearance was obtained from the Institute Ethics Committee PGIMER, Chandigarh with reference number (NK/5167/MSc/10). Written permission was taken from the Head of the Department of Obstetrics and Gynaecology, PGIMER Chandigarh. Patient information sheet was given the pregnant mothers which contains all the information regarding the study. Informed Written Consent was obtained from the pregnant mothers enrolled in the study. Anonymity and confidentiality of the study subjects were maintained. The investigator was introduced her to the pregnant mothers and gradually moved to the interview by asking questions, data was also taken from hospital records. Pregnant mothers were interviewed by using interview schedule which included a) Socio-demographic profile b) Obstetrical profile c) Self-developed questionnaire included questions regarding knowledge and practices of pregnant mothers on antenatal care and care after caesarean section. The tool was validated by experts of National Institute of Nursing College, Obstetrics and Gynecology Department and department of Physiotherapy PGIMER, Each interview took 25-30 minutes to complete.

Results

Socio-Demographic Profile of the Subjects

As shown in Table 1 the mean age of the subjects was 29.32 ± 4.4 years. More than half of the mothers (60.2%) of the subjects were Hindu. Majority of the pregnant mothers and their spouse (54.2% and 62.7%) had education up to senior secondary and above level respectively. More than half of the pregnant mothers (85.5%) were homemaker and more than half of the spouse were doing private job. Most of the subjects (75.9%) were having joint family. The mean monthly per capita income of the subjects was 4795 ± 4913.2rupee symbol.

Table 1: Socio-demographic profile of the subjects (n=80)

Variables

f (%)

Age* (years)
20-25

13 (15.7)

26-30

40 (48.2)

>30

27 (32.5)

Religion

Hindu

50 (60.2)

Sikh

25 (30.1)

Others

5 (6.0)

Educational qualification of mother
Primary

13 (15.7)

Secondary

22 (26.5)

Senior secondary and above

45 (54.2)

Occupation status of mother
Homemaker

71 (85.5)

Working

10 (12.0)

Educational qualification of spouse
Primary

7 (8.4)

Secondary

21 (25.3)

Senior secondary and above

52 (62.7)

Occupation status of spouse
Private job

69 (83.1)

Govt. job

11 (13.3)

Family type
Nuclear

17 (20.5)

Joint

63 (75.9)

Monthly per capita income (rupee symbol)#
7008 and above

20 (24.1)

3504-7007

21 (25.30)

2102-3503

13 (15.7)

1051-2101

14 (16.90)

Below 1050

12 (14.5)

*Mean ± SD=29.32 ± 4.4
#Mean ± SD=4795 ± 7012.1

Obstetrical Profile of the Subjects

As shown in Table 2 that more than half of the subjects (67.5%) were multigravida and 28.9% and of subjects were primigravida. Majority of the subjects (79.5%) were having a period of gestation between 33 weeks to 37 weeks.

Table 2: Obstetrical Profile of the subjects admitted for elective caesarean (n =80)

Variables

f (%)

Gravida
Primi

24 (28.9)

Multi

56 (67.5)

Period of gestation (in weeks)
33-37

66 (79.5)

>38

14 (16.9)

Pre-interventional comparison of knowledge regarding antenatal self-care among subjects shown in Table 3a, mean baseline knowledge about nutrition among subjects was 14.8 ± 1.39 and 3.7 ± 0.72) in the subjects of control and experimental group respectively (p=<0.01). Mean baseline knowledge about the rest and sleep of the mother in control and experimental groupwas 2.95 ± 1.71 and 3 ± 0.81 respectively (p=0.77). Mean baseline knowledge about body mechanics was 1.62 ± 0.49 and 1.45 ± 0.50 respectively (p=0.11). Mean baseline knowledge about preparation for elective caesarean was 1.80 ± 0.4 and 1.75 ± 0.43 respectively (p=<0.01). The total Mean baseline knowledge amongst subjects about antenatal self- care in control and experimental group was 15.6 ± 1.28 and 14.8 ± 1.39 respectively (p=0.06).

Table 3a: Pre-interventional comparison of knowledge regarding antenatal self care among subjects of Control group and Experimental group in antenatal period (n=80)

Knowledge domain (maximum attainable score)

Control group (n1=40) Mean ± SD Experimental group (n 2=40) Mean ± SD

χ2/Fisher*/t value (df) p value

Nutrition (6)

14.8 ± 1.39

3.7 ± 0.72

-3.59

(78) 0.001*

Rest and sleep (4)

2.95 ± 1.71

3 ± 0.81

0.29

(78) 0.77

Hygiene (10)

5 ± 0

5 ± 0

Body mechanics (2)

1.62 ± 0.49

1.45 ± 0.50

-1.57

(78) 0.11

Pre-preparation for elective caesarean (2)

1.80 ± 0.4

1.75 ± 0.43

-0.53

(78) 0.59

Total (24)

15.6 ± 1.28

14.8 ± 1.39

-2.8

(78) 0.06

*p value significant at <0.05

Pre-interventional comparison of antenatal care practices among subjects shown in Table 3b that deep breathing exercises were performed by only 20% and 5% subjects in the control and experimental group respectively. Majority of the subjects in the experimental group (55%) and in the control group (22.5%) performed walking after each meal. In the control group (32.5%) and in the experimental group (20%) of subjects were keeping a record of daily fetal movements count.

Table 3b: Pre-interventional comparison of antenatal care practices among subjects of Control group and Experimental group (n=80).

Variables

Control group (n 1=40) f (%) Experimental group (n2=40) f (%)

χ2/Fisher$/value (df) p value

Antenatal Exercises
Deep breathing exercises Foot and ankle exercises. Kegel exercises
Walking 10-15 min after each meal

8 (20)
1 (2.5)
0 (0)
18 (22.5)

2 (5)
1 (2.5)
1 (2.5)
22 (55)

1.11  (1) 0.09#
1.0 (1) 1.0
1.01$
0.80 (1) 0.37

Daily fatal movements count chart

13 (32.5)

8 (20)

1.61 (1) 0.20

#Yates correction

Post-interventions comparison of knowledge regarding antenatal self-care among subjects as shown in Table 4, Mean knowledge about rest and sleep of the mother in control and experimental group was 2.9 ± 1.01 and 2.2 ± 0.40 respectively (p=<0.01). Mean knowledge about body mechanics was 1.62 ± 0.45 and 1 ± 0 respectively (p=<0.05). Mean knowledge about preparation for elective caesarean was 1.72 ± 0.45 and 1 ± 0 respectively (p=<0.01). The total Mean knowledge amongst subjects about self-care in the antenatal period was 15.6 ± 1.43 and 12.1 ± 0.36 respectively (p=<0.001). Hence, post- interventional knowledge score of subjects regarding antenatal self- care in the experimental group was significantly higher as compared to the control group.

Table 4: Post-interventions comparison of knowledge regarding antenatal self care among subjects of Control group and Experimental group in antenatal period (n=80).

 

Variables

Control group (n 1=40)

Means/

f (%)

Experimental group (n 2=40) Mean ± SD/f (%)

χ2/t value (df) p value

Nutrition (6)

4.3 ± 0.82

3 ± 0

-10.11

(78) <0.001*

Rest and sleep (4)

2.9 ± 1.01

2.2 ± 0.40

-4.35

(78) <0.001*

Hygiene (10)

40 (100)

40 (100)

Body mechanics (2)

1.62 ± 0.45

1 ± 0

-9.0

(78) <0.001*

Pre-preparation for elective caesarean(2)

1.72 ± 0.45

1 ± 0

-10.14

(78) <0.001*

Total (24)

15.67 ± 1.43

12.1 ± 0.36

-15.02

(78) <0.001*

*p value significant at <0.05.

Post-interventional comparison of antenatal care practices among subjects as shown in Table 5, that a significantly higher percentage of subjects in the experimental group was adherent to antenatal exercises, deep breathing exercises (100%), foot and ankle exercises (100%), walking after each meal (100%), Kegel exercises (97.5%) and daily fetal movement count (100%) whereas in the control group lower percentage of subjects were doing deep breathing (15%), foot and ankle exercises (2.5%), walking (42.5%), daily fetal movement count (32.5%) and no one had performed kegel exercises. Findings revealed that post-intervention almost 100% of the subjects in the experimental group performed antenatal exercises and maintained a daily fetal movement count chart as compared to the control group.

Table 5: Post-interventional comparison of antenatal care practices among subjects of Control group and Experimental group (n=80).

Variables

Control group (n1=40) Mean ± SD/f (%) Experimental group (n2=40) Mean ± SD/f (%)

χ2/t value (df) p value

Antenatal Exercises
Deep breathing exercises Foot and ankle exercises. Kegel exercises
Walking 10-15 min after each meal.

6 (15)
1 (2.5)
0
17 (42.5)

40 (100)
40 (100)
39 (97.5)
40 (100)

59.13 (1) 0.001*
76.09 (1)<0.001*
76.09 (1) 0.001*
32.28 (1)<0.001*

Daily fatal movements count chart

13 (32.5)

40 (100)

45.49
(1) <0.001*

*p value significant at <0.05.

Discussion

Pregnancy is the one of the most important event in the life for all mothers. From the conception until postpartum it may be a critical time for the mother and baby. The postnatal period becomes much difficult when it is after caesarean section. At this time consistent care is required by the mother. Previous knowledge about post caesarean period plays an important role in the recovery and the mother is also motivated for breastfeeding and newborn care. The health care personals are obliged to educate the mothers in antenatal period. It is said that by educating a mother we educate a family, a community and whole nation. So, knowledge plays an important role in lowering the maternal and infant mortality and morbidity. The present study was conducted with the objective of assessment of assess knowledge and practices regarding antenatal care and knowledge regarding self-care and newborn care after caesarean section. The mean age of the subjects was 29.32 ± 4.4 years. In the present study pregnant mothers with ≥32 weeks of gestation admitted for elective caesarean section were selected. In the current study more than half of the subjects (67.5%) were multigravida and 28.9% and of subjects in were primigravida. Majority of the subjects (79.5%) were having a period of gestation between 33 weeks to 37 weeks. In the present study is has found that the majority of subjects (37%) had placenta previa as the indication of elective caesarean. In the present study it has been found that more than half of the pregnant mothers (53%) were had knowledge about nutrition to be taken in antenatal period. 45.8% of the pregnant were know about rest and sleep as an important aspect in antenatal period. 44.6% of the pregnant mothers had knowledge regarding body mechanics and only 21.7% of the pregnant mothers were aware of preparation for elective caesarean section. The present study was supported by study done by V Yashodha (2014). Study results showed that majority of mothers (82%) were had inadequate knowledge and 18% had moderately adequate knowledge, 54% had moderate and only 10 had adequate knowledge regarding antenatal care. The study concluded that by providing information guide sheet, knowledge can be improved [5]. The present study concluded that lower percentages of the mothers were practicing antenatal exercises i.e. only 12% of the mothers were performed deep breathing exercises. Majority of the subjects (48.2%) were performed walking after each meal. Only 2.4% of the pregnant mothers were performed foot and ankle exercises. These findings were consistent with the findings of Elamurugan Sujindra et al. who reported that knowledge and practices of antenatal exercises was less than average and a very few mothers were practicing exercises in pregnancy [6].

Current study found that more than half of the pregnant mothers (65.1%) had knowledge regarding breastfeeding (initiation of breastfeeding, correct positioning and burping and exclusive breastfeeding upto 6 months) but they don’t know the correct duration, position and attachment. A similar study done by Dr. Deepanjan Ray et al. concluded that benefits of breastfeeding was known to majority but correct duration, intervals, initiation were lacking [7]. Less than half of the pregnant mothers were having knowledge about breastfeeding complications and their management (breast engorgement, cracked and sore nipples) (38.6%), hunger signs of the newborn (32.5%) and about spoon and katori feed (28.9%) respectively. Majority of the pregnant mothers (49.4%) were known about incisional site care. Only 4.8% of the pregnant mothers were known about postnatal exercises and its benefits. The present study resulted that more than half of the mothers (81.9%) were had knowledge about maintenance of temperature of the newborn. Less than half of the mothers were have knowledge regarding normal weight of newborn (41%), changes in weight of the newborn with days of life (3.6%), umbilical cord care (27.7%), not to apply kajal (21.7%), sponge bath after 24 hours of the birth (27.55%), eye care ( inner canthus to outer canthus) (16.9%), skin care (32.5%), warning signs of newborn (33.7%) and immunization respectively (12%) . The present study was supported by similar study done by Ali BCT et.al. which was resulted that the awareness about postnatal care and breastfeeding was good among participants while lacking in a few aspects like vaccination. Hence, the study concluded that there is a need to educate the antenatal mothers about various aspects of vaccination and postnatal care [8]. More than half of the pregnant mothers were known about condom (78.3%,) and oral pills (61.4%) as contraceptive methods respectively. Less than half of the mothers were known about permanent methods (43.4%) and PPIUCD (33.7%). The study was supported by the similar study done by Radha Sangavi et. al. which was concluded that 78% of the subjects were aware about barrier method of contraception [9]. Hence, the study was concluded that pregnant mothers were having adequate knowledge about diet and importance of personal hygiene in antenatal period, about breastfeeding, about temperature maintenance in newborn. More than half of the mothers were known about condom and oral pills as methods of contraception. But less than half of the mothers had knowledge about antenatal exercises, about DFMC, post caesarean care, about alternative methods of contraception and about newborn care.

References

  1. International Journal of Community Medicine and Public Health Kaur A et al. Int J Community Med Public Health. 2018 Oct; 5.
  2. Srinivasa S, Bhavya G, Patel S, Harish S, Anjum SK (2018) Knowledge, attitude and practice of mothers in infantile skin care. Int J Contemp Pediatr 5: 536-541.
  3. Esin Çeber, Neriman Sogukpinar, Birsen Karaca Saydam, Rabia Ekti Genç Hafize Öztürk Can, et al. (2013) Mother and Newborn Home Care Education Program The Effects of “Mother and Newborn Home Care Education Program (MNHCEP)” on Mother and Persons Providing Care of Mother/Newborn.
  4. Rajan E, Nayak S (2014) Effectiveness of self instructional module on knowledge of post operative self care for mothers undergoing elective caesarean section in selected hospitals, Nitte Univ J Heal Sci 4: 39-41.
  5. YashodhaV, Hemavathy V (2020) The knowledge of primigravida mother regarding antenatal care in selected rural and urban areas. International Journal of Innovative Research in Science, Engineering and Technology 3.
  6. Sujindra E, Bupathy A, Suganya A, Praveena R (2015) Knowledge, attitude and practice of exercise during pregnancy among antenatal mothers. Int J Educ Psychol Res 1: 234-237. [crossref]
  7. Deepanjan Ray, Abdur Rahman, Aprajita Dasgupta (2015) A cross-sectional study to assess breastfeeding knowledge among antenatal mothers. IOSR journal of Dental and Medical Science 14.
  8. Ali BCT, Fysal N, Asha Saleema CV, et al. (2019) Study about the knowledge and attitude of anatnatal women on postnatal care and immunization. Int J Contemp Pediatr 6: 1003-1007.
  9. Sangavi R, Hantoor S (2018) Knowledge, attitude and practice of contraception among antenatal care Int. J Repord Contracept Obstet Gynecol 7: 3065- 3068.

Monocrystalline lonsdaleite in REE-Rich Fluorite from Sadisdorf and Zinnwald/E-Erzgebirge, Germany

DOI: 10.31038/GEMS.2024643

Abstract

We present the results of our Raman studies on natural lonsdaleite crystals in fluorite of the two tin deposits Sadisdorf and Zinnwald in the E-Erzgebirge/Germany. The Raman spectra,  specially from Zinnwald, can deconvoluted into three Raman-active vibrational modes: E2g, A1g, and E1g. For the origin, transport via supercritical fluid or melting from the mantle region into the crust is necessary.

Keywords

Lonsdaleite, REE-rich fluorite, Raman spectroscopy, Sadisdorf and Zinnwald tin-tungsten deposits, Supercritical fluid

Introduction

The Variscan Erzgebirge (German side) and Krušné hory (Czech side) contain many tin-tungsten deposits of vein and greisen type. Famous deposits are that from Zinnwald, Cinnovec, Krupka, Sadisdorf, Ehrenfriedersdorf, and Geyer. For the regional geology and description of single deposits, extensive literature is present [1-5] and references in these). From a repetition of that, we will abstain because our described observations are new and do not fit into the old genetic view, forcing us to adopt a new approach for the whole region. In the abandoned Sadisdorf Sn-W-(Cu) deposits, there are vein and greisen- type mineralizations (Figures 1a and 1b).

The frequently present breccia pipes here are analogous to the famous Schneckenstein breccia in the W-Erzgebirge, which is very characteristic of this mineralization type [6]. During the study of thin sections from the Sadisdorf deposit, peculiar violet fluorite aggregates attract attention. These aggregates contain many black, sometimes bent needles, as well as also spherical to elliptical carbon solids. A similarity to the other described new findings of spheric high-pressure minerals is very obvious (see, for example, Thomas et al., 2023) [7]. This publication also contains a schematic geological map of the Erzgebirge-Vogland Zone with the Variscan granites, etc.

fig 1a

Figure 1a: Location and simplified geological map of the Sadisdorf and Zinnwald deposit/ E-Erzgebirge.

fig 1b

Figure 1b: Schematic cross-section through the Sadisdorf deposit with the approximate origin place of the studied sample. The green color marks the origin of the Sadisdof sample.

Sample Material

Sadisdorf

The rock material is from the endocontact of the tin-tungsten- copper deposit Sadisdorf in eastern Erzgebirge/Germany [1,8]. The sample thin section (SD-H01B) is from a fine-granular white quartz-topaz rock with violet fluorite, taken during the exploration campaign Sc-ore 2012/2013 – the violet fluorite is, according to Raman spectroscopy, very REE-rich. Besides the primary mineral quartz and rarer topaz, there are many small, mostly opaque mineral grains of wolframite, cassiterite, columbite, and others. The large fluorite aggregates are not isomorphic but more in tube or irregular form. Smaller fluorite crystals are isometrically. These large tubular fluorite aggregates contain many black and transparent needles, grains, and curved crystals (Figure 2) and are generally fluid inclusion-free. If present, then they are secondary late formations.

The curved black crystal (Figure 2) contains many nano-diamonds. The straight black needles are prevailing graphite-like material. Graphite is very often present in the Variscan tin mineralization, and it is also often present in cassiterite. Graphite has mostly not been paid attention to in the past.

fig 2

Figure 2: Curved graphite aggregate with nano-diamonds in REE-rich fluorite. All black points are graphite-like stuff and contain nano-diamonds.

Zinnwald

For comparison, we used fluorite grains included in tabular zinnwaldite crystals from the Zinnwald deposit (deep Bünau gallery) in the E-Erzgebirge/Germany, which is not far from the Sadisdorf deposit (taken by the first author in 1984). This violet fluorite sample contains numerous sharp black disk-like bodies of lonsdaleite-diamond-graphite (Figure 3). Some of these form half- moon-like bodies (Figure 4) where the sharp edges lie parallel to the crystallographic{100} planes.

It follows from Figures 3 and 4 that the black bodies obviously form hemispheres on the fluorite surfaces. The general impression is that this fluorite is an early formation and has a more plastic behavior at the formation time. That spoke for a high-temperature and high- pressure formation from a fluorine-rich melt containing such C-aggregates.

fig 3

Figure 3: Small disk-like bodies of lonsdaleite in fluorite from Zinnwald/E-Erzgebirge (top view).

fig 4

Figure 4: Side view of such bodies, as shown in Figure 3, arranged to the growth zones of the fluorite host.

Methodology: Microscopy and Raman Spectroscopy

For the study of the lonsdaleite-diamond-graphite-bearing samples and their paragenetic main minerals, we use the Zeiss JENALAB pol as well as the Raman spectrometer EnSpectr R532 combined with the Olympus BX43 microscope both for transmitted and reflected light and equipped with a rotating stage. Note here that the incident laser light is always polarized – in our case, N – S (see Tuschel, 2012) [9]. Generally, we used an Olympus long-distance LMPLFL100x objective lens. For the identification of different minerals, we used the RRUFF and the Hurai et al. Raman mineral databases [10,11]. As references, we applied a water-clear diamond crystal from Brazil (1331.63 ± 0.60 cm-1 and a semiconductor-grade silicon single-crystal (520.70 ± 0.15 cm-1). For this study, we used laser energies from 0.9 to 50 mW on the sample. Because the minerals lonsdaleite, diamond, and nano- diamond contain black graphite particles and are metastable in the new upper crust surrounding, heating by the laser energy can partially destroy these minerals in the extreme case or shift the characteristic peak position of Raman bands [12,13] to lower values.

Results

Sadisdorf

The sizeable bent carbon crystal (Figure 2) contains many small nano-diamonds. The diamond main band lies at 1331.8 ± cm-1 (11 different crystals). The FWHM (Full Width at Half Maximum) is 83.1 ± 13.9 cm-1. Needle-formed diamonds, generally black, give the prominent diamond peak a value of 1333.6 ± 5 cm-1 (5 needles). In violet REE-rich fluorite of the rock, there are a lot of black needles and sphäric or elliptic crystals. Some needles are twisted or bent. Most of them contain graphite or carbonaceous material (see Beyssac et al., 2002) as well as nano-diamonds. There are also whisker-like transparent and some thick, short, transparent prismatic crystals. As a total surprise, the rare whiskers and these short prismatic crystals are, according to Raman spectroscopy, lonsdaleite (Lon). Such crystals are present exclusively only in fluorite. Figure 5 shows two such prismatic lonsdaleite crystals, and Figure 6 depicts a lonsdaleite whisker. The lonsdaleite crystal (Lon) in the center of Figure 5 is 14 x 2 µm large.

fig 5

Figure 5: Lonsdaleite (Lon) crystals in REE-rich fluorite

By the Raman spectrum (band at 1325 cm-1), these transparent crystals are monocrystalline lonsdaleite (see Shumilova et al., 2011) [14] and, according to Bhargava et al. (1995) [15], hexagonal diamond. By the form (long-prismatic), the hexagonal diamond has a high probability of being lonsdaleite (Figure 6).

With Raman spectroscopy, we obtained the following data for the five lonsdaleite crystals: 1318 ± 3.8 cm-1. Opposite to fluorite, the black points (mainly carbon) in quartz are ore minerals like wolframite, columbite, and different sulfides. Obviously, bulk rocks (quartz and topaz) are the result of varying evolutions. Fluorite looks like remnants of a high-temperature melt. According to Seiranian et al. (1974), the eutectic points in the CaF2– YF3 system occur at 60 and 91 % (mol/mol) and 1120 and 1106 °C. Similar systems (CaF2-BaF2) have analog high temperatures (Figure 8) [16].

Zinnwald

In the violet fluorite from Zinnwald, there are a lot of black bodies (Figures 3 and 4). Some are large enough to perform systematic Raman studies. In the beginning, we used 20 mW on the sample. The corresponding Raman spectrum (Figure 9) resembles the monophase lonsdaleite (Figure 3 in Shumilova et al., 2011) [14]. To prevent heating of the lonsdaleite sample by always presenting black carbon, we used low laser energy on the sample (0.9 mW of the 532 nm laser). The authors Goryainov et al., 2018 [17] used the excitation of a UV laser with a wavelength of 325 nm and low intensity of 1 mW on the sample.

Interpretation

The synthesis of hexagonal lonsdaleite succeeded in 1966 by Bundy and Kasper (1967) – [18] at 1000°C and 130 kbar. In nature, lonsdaleite was found first (1967) in the Canyon Diablo meteorite by Frondel and Marvin (cited in Shumilova et al., 2011) [14] and in the Kumdykol diamond deposit (North Kazakhstan) by Shumilova et al., 2011) [14]. The Raman bands at 1318 to 1324 cm-1 are evident and characteristic of the hexagonal diamond phase in the Sadisdorf material (see also Misra et al., 2006) [19]. Lonsdaleite in the fluorite shows a certain metastability due to laser irradiation, perceptible by the increase of the G bands at about 1580 to 1600 cm-1 (Figures 6 and 8) and the black coloring of the nearly colorless lonsdaleite crystals during the Raman measuring. The metastability of high-pressure minerals coming from mantle deeps and staying at high temperatures for a long time in low- pressure regions (upper crust) is very characteristically [13,20-22]. One exception is moissanite here, which is very stable. Because lonsdaleite is a high-pressure and high-temperature mineral, its formation in the deposit level (≤ 3km; see Thomas and Klemm, 1997) [23] is usually not possible. Therefore, the formation of the lonsdaleite-bearing fluorite occurred at significantly greater depths and came from mantle depths via supercritical fluids or melts into the crustal level. However, the formation of lonsdaleite whisker is, at the moment, a mystery.

fig 6

Figure 6: Raman spectrum of both lonsdaleite crystals in Figure 5. The broad Raman band at about 1325 cm-1 results from a small component of diamond (a two-phase crystal of lonsdaleite-diamond [14].

fig 7

Figure 7: Lonsdaleite (Lon) whisker in fluorite. The whisker has a length of 45 µm and a thick of 0.9 µm.

fig 8

Figure 8: Raman spectrum of the whisker-like (Figure 7) monophase lonsdaleite crystal (characteristic band at 1319 cm-1). The bands at 321 cm-1 and lower values come from the matrix fluorite.

fig 9

Figure 9: Raman spectrum of lonsdaleite in fluorite from Zinnwald/E-Erzgebirge taken at 20 mW on the sample.

Discussion

According to Németh et al., 2014 [24] lonsdaleite does not exist as a discrete material. That is in contradiction to our observations. Figures 5 and 7 clearly show prismatic crystals with a Raman spectrum corresponding, according to Shumilova et al. (2011) [14], to natural lonsdaleite. Of course, the formation of lonsdaleite is unclear. However, this material is existent as prismatic crystals. The lonsdaleite whisker (Figure 7) shows the same Raman spectrum. Although it is well-known that cubic crystals can also form whiskers (for example, GaP-whiskers grown from a non-stochiometric Sn-melt produced by the first author in 1970 (unpublished results). Shiell et al. (2016) [25] report the synthesis of almost pure nanocrystalline lonsdaleite in a diamond anvil cell at 100 GPa and 400°C from glassy carbon. That means lonsdaleite is, in contrast to Németh et al. (2014) [24], a discrete material. Our findings of macroscopic lonsdaleite in fluorite from Sadisdorf underline this statement. That means at least that at the formation of lonsdaleite, an enormous pressure has worked. Conceivable is the transport from mantle regions via supercritical fluids or melts or a tremendous pressure impact during the breccia formation. The lonsdaleite crystals in violet fluorite from Zinnwald/E- Erzgebirge are more frequent and more stable than the lonsdaleite from Sadisdorf. Therefore, we could perform more Raman measurements under different conditions. At the high intensity of the laser (about 20 mW on the sample), a very strong graphite line at 1581 cm-1 appears. The clear differentiation between diamond and lonsdaleite is uncertain (line at 1328 cm-1). To avoid heating the lonsdaleite sample using the laser, we used a low-intensity laser excitation (0.9 mW on the sample) in analogy to Goryainov et al., 2018) [17], which used a 325 nm UV laser with 1 mW on the sample. Figure 10 shows the results of our measurements. We see clearly three Gaussian components at (1251.3 ± 9.4 cm-1), (1310.6 ± 3.9), and (1350.4 ± 9.9 cm-1), with the FWHMs of 57.4, 58,8, and 67.0 cm-1, respectively – 10 measurements each. These three experimental lines, according to Goryainov et al., 2018 [17], can be assigned to the theoretical Raman lines E2g, A1g, and E1g obtained through ab initio calculations [17]. Independent of the interpretation of our described carbon phases as lonsdaleite or hexagonal diamonds as inclusions in upper crustal minerals, transport via supercritical phases from the mantle region to the crust is necessary. Our here-presented results increase the number of high- pressure and high-temperature minerals (diamond, nano-diamonds, moissanite, stishovite, coesite, kumdykolite, beryl-II, cristobalite-II, cristobalite X-I, and CaCl2-type cassiterite) in the Variscan granites and tin mineralizations in the crustal Erzgebirge region [26].

fig 10

Figure 10: Raman spectrum of a lonsdaleite crystal (diameter ~ 24 µm, thickness ~14 µm) in fluorite from Zinnwald/E-Erzgebirge, taken with 0.9 mW on the sample and a measuring time of 1000 s.

Acknowledgment

For the longstanding and often controversial discussions of the interaction between mantle and crust, the first author thanks Otto Leeder (1933-2014) from the Mining Academy Freiberg.

References

  1. Baumann L, Kuschka E, Seifert T (2000) Lagerstätten des Enke. Pg: 300.
  2. Hösel G (1994) DasZinnerz-Lagerstättengebiet Ehrenfriedersdorf/Erzgebirge. Bergbau in Sachsen. Bd.1, Pg: 195.
  3. Leopardi D, Gutzmer J, Lehmann B, Burisch M (2024) The spatial and temporal evolution of the Sadisdorf Li-Sn-(W,Cu) magmatic-hydrothermal greisen and vein system, Eastern Erzgebirge, Germany Economic Geology 110: 771-803.
  4. Seltmann R, Kampf H, Möller P (eds) (1994) Metallogeny of Collisional Orogens focused on the Erzgebirge and comparable metallogenetic settings. Czech Geological Survey, Prague 1994, Pg: 448.
  5. Weinhold G (2002) die Zinnerz-Lagerstätte Altenberg/Osterzgebirge. Bergbau in Bd. 9, 283 p.
  6. Rösler HJ, Baumann L, Jung W (1968) Postmagmatic mineral deposits of the northern edge of the Bohemian Massif (Erzgebirge-Harz). International Geological Congress, XXIII Session, guide to Excursion 22 AC, ZGI: 57 p.
  7. Thomas R, Davidson P, Rericha A, Recknagel U (2023) Ultrahigh-pressure mineral inclusions in a crustal granite: Evidence for a novel transcrustal transport mechanism. Geosciences 13: 1-13.
  8. Schröcke H (1954) Zur Paragenese erzgebirgischer Zinnlagerstätten. Neues Jb Mineral Abh 87: 33-109.
  9. Tuschel D (2012) Raman crystallography, in theory and in Spectroscopy 27: 2-6.
  10. Lafuente B, Downs, RT, Yang H, Stone N (2015) The power of database: the RRUFF project. In: Armbruster T, Danisi RM (eds.). Highlights in mineralogical Berlin, 1-30.
  11. Hurai V, Huraiova M, Slobodnik M, Thomas R (2015) Geofluids – Developments in Microthermometry, Spectroscopy, Thermodynamics, and Stable Isotopes. Elsevier, Pg:489.
  12. Tuschel D (2016) Raman Spectroscopy 31: 8-13.
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  14. Shumilova TG, Mayer E, Isaenko SI (2011) Natural monocrystalline Doklady Earth Sciences, 441: 1552-1554.
  15. Bhargava S, Bist HD, Sahli, S, Aslam M, Tripathi HB (1995) Diamond polytypes in the chemical vapor deposited diamond films. Appl Phys Lett 67: 17061708.
  16. Seiranian KB, Fedorov P, Garashina LS, Molev GV, Karelin VV (1974) Phase diagram of the system CaF2-YF3. Journal of Crystal Growth 26: 61-64.
  17. Goryainov SV, Likhacheva Y, Ovsyuk NN (2018) Raman scattering in Journal of Experimental and Theoretical Physics 127: 20-24.
  18. Bundy FP, Kasper JS (1967) Hexagonal diamond – a new form of carbon. The J of Chemical Physics 46: 3437-3446.
  19. Misra A, Tyagi PK, Yadav BS, Rai P, Misra DS (2006) Hexagonal diamond synthesis on h-GaN strained Applied Physics Letters 89: 071911-171911-3.
  20. Gigl PD, Dachille F (1968) Effect of pressure and temperature on the reversal transitions of stishovite. Meteoritics 4: 123-136.
  21. Thomas R (2023a) Growth of SiC whiskers in beryl by a natural supercritical VLS Aspects in Mining and Mineral Science 11: 1292-1297.
  22. Thomas R, Davidson P, Rericha A, Recknagel U (2022) Discovery of stishovite in the prismatine-bearing granulite from Waldheim, Germany: A possible role of supercritical fluids of ultrahigh-pressure origin. Geosciences 196: 1-13.
  23. Thomas R, Klemm W (1997) Microthermometric study of silicate melt inclusions in Variscan granites from SE Germany: Volatile content and entrapment Journal of Petrology 38: 1753-1765.
  24. Németh P, Garvie LAJ, Aoki T, Dubrovinskaia N, Dubrovinsky, Buseck, PR (2014) Lonsdaleite is faulted and twinned cubic diamond and does not exist as a discrete Nature Communications 5: 1-5.
  25. Shiel TB, McCulloch DG, Bradby JE, Habed B, Boehler R, McKenzoe DR ((2016) Nanocrystalline hexagonal diamond formed from glassy carbon. Scientific Reports 6: 1-8.
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  27. Beyssac O, Goffé B, Chopin C, Rouzaud, JN (2002) Raman spectra of carbonaceous material in metasediments: a new J metamorphic Geol 20: 859-871.

Commentary on “The Clinical Syndromes Produced by the Offensive Biological Agents”

DOI: 10.31038/IDT.2024515

Commentary

This presentation was due to cover a wide range of clinical syndromes, induced by microorganisms that could be used as biological threats. This was issued for the European Training in Infectious Disease Emergencies (ETIDE), held at the Lazzaro Spallanzani Institute of Infectious Diseases in Rome, Italy, where I participated as lecturer during 2008-2009.

The presentation has a general part that was reviewing the main European Programs concerning the highly infectious diseases, then defining the clinical microorganisms which to be concerned off, and reviewing the main clinical syndromes produced by such microorganisms, then the main syndromic presentations: respiratory, influenza-like, digestive, neurologic, cutaneous, sepsis.

The isolation precautions basics were discussed, then I focused on the general means of laboratory diagnosis (sample collection for isolate, immunological testing, toxin detection, molecular biology).

On the special part of presentation I focused on each syndrome and the microrganisms that induced it, discussing the etiology, modes of transmission, clinical presentation, the definite diagnosis, the treatment and the preventive measures.

Thus as respiratory syndromes I discussed the: anthrax, plague, tularemia, melioidosis, glanders, SARS, for the influenza like syndromes (influenza), for the neurological syndromes (botulism, anthrax), cutaneous syndromes ( anthrax, plague, tularemia, melioidosis, glanders, smallpox), for sepsis (plague, melioidosis, glanders, hemorrhagic fevers), as for the digestive syndromes (gastrointestinal anthrax, tularemia, the hemolytic uremic syndrome).

Towards the end of my presentation I discussed the coordinated response against those biological threats (e.g for paramedics, triage nurses, nurses), and the conclusions: that bioweapon proliferation is a contemporary reality, the potentially use of the genetically modified microorganisms.

The reality was that the syndromic approach represents a ready and efficient answer to bioweapon threats, and a practical and efficacious way to biodefense. The proper strategically approach includes: the coordinated response (medical and social) where co-operation is necessary.

Thus, my presentation represents a synthesis of the syndromes produced by the offensive microbiological agents, and the proper preparing for those conditions is a realistic way to protect the population for the eventuality of these unwanted events.

“A Spirit Encroachment”: Hysterical Possession, Case Study from Kerala

DOI: 10.31038/AWHC.2024724

Abstract

The Present case of a 45-year-old female with a 10th-grade education who presented with a history of episodes where she would display extraordinary strength while becoming aggressive towards her family members and displaying bizarre behavior. The period was short. She was diagnosed with hysterical based on possession. She would always claim amnesia for the event. She claimed a hidden treasure that was in her dream in her backyard and seemed to be also possessed with spirit as she said. The family tried black magic to cure it. But the black magician tries to physically assault her. Later she starts showing physical symptoms of hysterical possession. She always tries to avoid her family husband and children. The suggestions of a close family member brought the patient for consultation in the hypnotherapy and counseling clinic. The present case illustrates how sexual harassment can lead to possession. Visualization hypnotherapy and counseling were the treatments given to the client. Finally, the client completely cured.

Keywords

Hysterical possession, Hypnotherapy, Counseling, spirit

Introduction

The word “hysteria” is frequently used to define highly charged, seemingly uncontrollably emotional behavior. During the Victorian era, the term hysteria was a common medical diagnosis, especially for women. Hysteria was viewed as a psychological disorder as far back as 1900 BCE. The word hysteria comes from the Greek “hystera”, which means “uterus”. This is when ancient Egyptians first described the condition, adding that it was caused by “spontaneous uterus movement.” This was also sometimes referred to as having a wandering uterus. In the early 1600s, the focus switched, such as when anatomist Thomas Willis concluded that hysteria did not originate in the uterus, but in the brain. This understanding opened the possibility that hysteria could affect men as well. In the 1800s, for instance, French neurologist Jean-Martin Charcot utilized hypnosis to treat women suffering from hysteria. It was Freud’s work with colleague Josef Breuer on the case of Anna O, a young woman experiencing symptoms of hysteria. that helped lead to the development of psychoanalytic therapy.Carl Jung, a colleague of Freud’s, treated a young woman named Sabina Spielrein who was also thought to suffer from hysteria. The term “hysterical neurosis” was first mentioned in the second edition of the DSM (DSM-II), published in 1968, but has since been abandoned in favor of a diagnosis of somatic symptom disorder, dissociative disorder, or conversion disorder [1-8].

Sensory Disturbances

These disturbances include paresthesia, hypersensitivity, and complete or partial loss of sensation. In severe cases, hysteria may also cause damage to other sensory organs and cause blindness, hearing loss, and loss of taste or smell.

Motor Symptoms

Motor symptoms include complete paralysis, tremors, or convulsions. When the disease progresses, it may even cause loss of speech, vomiting, hiccuping, etc. However, when undergoing a neurological examination of the affected site, these individuals present intact neuromuscular apparatus with normal electrical activity, response, and stimulation.

Psychic Symptoms

These symptoms are generally called dissociative reactions, where a person presents with attacks of amnesia and sleepwalking and can also present with multiple personalities. For example, a person with a dissociative reaction sometimes forgets his name or house address or has a split personality. Females with hysterical behaviors can behave emotionally charged, and out of control [9].

Discussion

Case Presentation

The case on the current study was took place in March 2016. The client was a 45-year-old woman and had a 10th-grade education. She had a husband and two daughters in the family. The beginning was that she showed some special unusual symptoms like strange behavior, extreme unrest, change of voice, seizures and acquiring tremendous strength shown to the children and the husband, especially to the husband. In Kerala, associated with the Hindu belief system, a spirit (called “Yakshi -A female spirit”) enters the body in myths and old texts. That belief is still being followed to some extent in Kerala, the majority of the parts. The client grew up amide such beliefs. Once one night she dreamed that a treasure was hidden in her backyard. Even then and before that, she was experiencing symptoms like unusual psychomotor agitation. Her husband brought the information to a black magician. He summoned everyone at night two 2 am and cast a spell. Finally, the black magician was relieved to let the woman sit in the room and asked the other relatives to go out. Then he closed the door and tried to rape her. She screamed. Everyone ran to her. After that incident, she has unusual psychomotor agitation when she sees her husband. She assumes that the spirit has entered her body. Sometimes swearing at someone who resembles her husband also causes symptoms.

Patient History in Their Words

As soon as the client came, unusual behavior was visible to therapist. They asked to stop the red light coming from the computer monitor on the table.

“That red light should be turned off,” she strictly said

When asked if she believed she was infected, she gave the therapist strange wordings with expression.

“I will kill you and drink your blood”

When asked to her, she did not remember anything that happened at that time of possession, she spoke in such a way that she had the knowledge that others had told to her.

The information given by the client confirmed what the bystanders. They also believed that there was treasure in the back yard and she is possessed by the spirit.

Medical History

Her whole family members believed in superstitious things. After the appearance of the black magician they again visited many other several faith healers and swamis with no improvement in her condition. They had no idea that she was mentally ill and this mental illness should need to be treated. They visit the therapist for consultation only after when one of their educated close family members suggests. The client was not at all interested in that particular decision. She never visits a doctor or psychologist or takes any other medication for this illness.

Treatment History

Visualization hypnotherapy and Counseling were the treatments given to the client.

Visualization Hypnotherapy

Visualization is just about the most powerful form of suggestion imaginable. The more senses that are stimulated, the more realistic the image to the brain, and the easier it is to establish that all-important process of selective thought within the hypnotic state. Just about any sort of hypnotic suggestion we might wish to give somebody can be enhanced by the use of the “four-sense” method of creative visualization. It means we include sounds, feelings, and even smells — in addition to any visual imagery [10].

Counseling

Counseling is a talking therapy that involves a trained therapist listening to you and helping you find ways to deal with emotional issues. Sometimes the term “counseling” is used to refer to talking therapies in general, but counseling is also a type of therapy in its own right [11].

Clinical Findings General Examination

She was not properly tied his hair. She had an average mode of dressing. Other than that on examination, all general parameters were normal.

Differential Diagnosis

  1. Possession syndrome (most likely diagnosis for discussion).
  2. Schizo-Hysteria (not in the diagnostic classification system).
  3. Schizophrenia (not meeting the criteria).
  4. Organic brain syndrome (ruled out).

Diagnostic Findings

  • Cannot control themself: She didn’t know what she was doing. She was unable controlhimself. She used to be violent towards family members especially, her husband and children.
  • New personality: New personality, introduced to her- the victim becomes a different person and acts and speaks as one who is controlled by another personality
  • Different voice: A slight change and tone in her voice identifies
  • Supernatural knowledge: She repeatedly says that a treasure in the backyard
  • New abilities: She, those possessed by can demonstrate superhuman strength, the family reported

Her family was a lower class one. Finances have overwhelmed them to spend their days constantly. Being a family that strongly followed the superstitious belief, she believed that they would get a way out of that one day. That may be the reason she believes there is treasure in their backyard, her family must have believed it too. It is also a reason to introduce the black magician. There is a common belief in Kerala that only a person with supernatural powers can take the treasure.

What made this client the most difficult was the insecure feeling that came to her. The fact that the black magician tried to physically harm the client after letting her husband, children and relatives out and closing the door while they were outside, caused a great impact on them. The reason for their anger towards her husband is that, it was her husband who brought the man there. She hated everyone who had left her alone in front of the man and guarded her. It was that hatred that later came out as possession symptoms.

Therapeutic Intervention

Hypnotherapy and counseling methods were used for the client.

Hypnotherapy

In getting the true basic information about the client, the therapist talked to the client, the bystanders that arer her husband, children, and the two elder brothers of the client. The therapist did not have to use any form of hypnotic techniques for information gathering, because it was clearly understood that the information given by them was accurate and the necessary information was already available. But here hypnotherapy was used as a treatment modality later. The visualization technique was used. Being a hysteric patient, the suggestibility of the client was high. So that it was also possible to bring the client into deep hypnosis very quickly. Through suggestions, she went to “Aluva Manappuram” (the place where the Aluva Manappuram temple is located, Ernakulam), which is a very important sacred place according to the Hindu faith and “Periyar” (the largest river in Kerala) flows nearby it. Curative suggestions are that when you immerse yourself in the river, the spirit goes away with the very strong flow of the river and the spirit is unable to swim back to her. The client was following the suggestion exactly. The situation was explained in detail. So it was easy for her to follow it. After the procedure, let her sleep and when awakened visible difference started to be seen. It was with just one trial. She was that much cooperative. As a follow-up, she was subjected to hypnotherapy for three consecutive days to make counseling in her subconscious mind. Both of those times they were subjected to light hypnosis and after that time she seems to be almost completely free.

Counseling

The suggestions given in light hypnosis convinced her even when she was awake. She understood what her problem was and said that she would never have that problem again. Therapist gave satisfactory answers to her questions. Client gave counseling three times more every each week.

Conclusion

Possession syndrome is important diagnostic category that should be considered especially in cross culture contexts. Because most of the times it’s deeply connected with culture. If it is in India or especially in Kerala is has another dimension too. The religion Psychotic illnesses can manifest in various forms. We can’t predict it anyway. It depends on so many psycho -socio- cultural factors. Cultural consultation is important in treatment.

Foot note

Informed consent: Yes

Competing interests: None

Patient consent: Obtained

References

  1. Baloh RW (2021) Early Ideas on Hysteria. In: Medically Unexplained Symptoms. Copernicus,
  2. Britannica (2020) Conversion disorder.
  3. C, Rapetti M, Carta MG, Fadda B (2012) Women and hysteria in the history of mental health. Clin Pract Epidemiol Ment Health 8: 110-119. [crossref]
  4. Arraez-Aybar L, Navia-Alvarez P, Fuentes-Redondo T, Bueno-Lopez J (2015) Thomas Willis, a pioneer in translational research in anatomy (on the 350th anniversary of Cerebri anatome) J Anat 226(3). [crossref]
  5. Carota A, Calabrese P (2014) Hysteria around the world. Front Neurol Neurosci 35. [crossref]
  6. Tsuman L Anna O. (2020) Encycloped Personal Indiv Diff.
  7. Balbuena F (2020) Sabina Spielrein: From being a psychiatric patient to becoming an analyst Am J Psychoanal 80(3). [crossref]
  8. North C (2015) The classification of hysteria and related disorders: Historical and phenomenological considerations. Behav Sci 5(4). [crossref]
  9. Gandhi VA (2022) Hysteria – Types, Causes, Diagnosis, and The virtual  hospital.
  10. com (2022) Creative Visualization and Self Hypnosis Available from: https://www.selfhypnosis.com/creative-visualization/
  11. NHS (2021) Counselling.

The CaCl2-to-Rutile Phase Transition in SnO2 from High to Low Pressure in Nature

DOI: 10.31038/GEMS.2024642

Abstract

Raman studies on cassiterite from the Sauberg mine near Ehrenfriedersdorf showed that besides the tetragonal rutile-type phase in the root zone of a cassiterite vein, there is also present orthorhombic cassiterite with the CaCl2 structure. According to Raman measurements, a maximal pressure of 18.9 GPa results. Such pressure implies the origin of that cassiterite from great depths, brought with supercritical fluids into the lower crustal level. The results show a reverse transition from high-pressure to low-pressure polymorphs of SnO2 in nature.

Keywords

Raman spectroscopy, Tetragonal and orthorhombic Cassiterite, CaCl2-to-rutile transition, Supercritical fluids

Introduction

The naturally occurring form of cassiterite is usually tetragonal, with the point group 4/m 2/m 2/m (point group number 128), and crystallizes as a rutile type phase. The paper by Thomas [1] described unusual cassiterite crystals from the tin deposit Ehrenfriedersdorf, Erzgebirge/Germany, as orthorhombic ones.

However, in the Balakrishnan et al. [2], only the bands at 446 (444 and 448 cm-1) are present for the stable SnO2 polymorphs. The data for the metastable phases are not given. All in all, the authors mentioned 20 relatively stable polymorphs. Seven stable polymorphs are tabulated. The band at 832 cm-1 is missing for all stable newly identified orthorhombic cassiterites. However, in the case of Ehrenfriedersdorf, at azimuthal rotation under the Raman microscope, some crystals show two unusual Raman bands at about 446 and 832 cm-1, which are very strong at specific azimuthal positions and room temperature and room pressure. These authors (Balakrishnan et al., [2] have also stated that one polymorph can easily transformed into another by varying temperature or pressure. That must be true also for a combination of both variables. However, the transformation is sluggish enough to conserve precede phase states. In the case of the specific cassiterite from Ehrenfriedersdorf, we assume that the cassiterite came very fast from mantle deeps via supercritical fluids indicated by minerals like diamond, graphite, moissanite, OH-rich topaz, and the high-temperature feldspar kumdykolite [NaAlSi3O8] in the closer paragenesis [1]. Therefore, it is quite possible that at room temperature and pressure, “abnormal” cassiterite contains quenched remnants of high-temperature and high-pressure indications in the form of unusual Raman bands. This paper serves as a starting point for more systematic studies of cassiterite as a natural pressure sensor.

Sample Material

All sample material for this study came from a specimen, about 10 x 7 x 3 cm large, taken from the Prinzler counter vein in the Sauberg mine near Ehrenfriedersdorf by Puffe in 1936. The main minerals are quartz (~6 cm long), cassiterite (2 cm in diameter), and violet to green, sometimes pink fluorite (up to 1 cm in diameter). In the root zone, there are inclusions in different minerals (topaz, quartz, muscovite), which are generally tiny crystals of albite, kumdykolite, plagioclase, trilithionite, calcite, colorless high-temperature fluorite, OH-rich topaz, rynersonite, cassiterite, mangancolumbite, uraninite, monazite, xenotime, graphite, diamond, moissanite, and Ti-carbides [1]. Figures 1-3 show the studied cassiterite crystals, which are very different in appearance. In muscovite, there are smaller crystals beside the crystal shown in Figure 1, which are spherical or elliptical. The cassiterite crystal in Figure 2 is 500 µm thick as the tick section is. Figure 3 is a sizeable orthorhombic cassiterite crystal in spherical muscovite inclusion surrounded by dark tetragonal cassiterites. All cassiterites with the untypical Raman bands at 445 and 832 cm-1 are inclusion- free, and the trace element concentration is low (about at the detection limit of the microprobe). Tiny crystals are colorless.

FIG 1

Figure 1: Cassiterite crystal I with rhombohedral cross-section in muscovite. The Raman bands of muscovite are entirely suppressed.

FIG 2

Figure 2: Cassiterite (Cst) crystall (crystal-II), about 250 x 390 µm large, beside tetragonal cassiterite (black), OH-rich topaz (OH-Toz) and calcite (Cal).

FIG 3

Figure 3: Large orthorhombic cassiterite crystal (o-Cst) in a muscovite inclusion (white) between normal tetragonal cassiterite (Cst). That is the sample cassiterite III.

The differentiation between tetragonal and orthorhombic cassiterite is under the Raman microscope with a rotating stage simple. Rutile-type cassiterite shows at room temperature only one strong Raman band at about 633 cm-1 during azimuthal rotation under the polarized Raman light. Strong Raman bands at about 76, 448, 635, and 834 cm-1 are characteristically for orthorhombic cassiterite. The symmetry of the CaCl2-type structure is orthorhombic and has the space group P42/mnm.

Microscopy and Raman Spectroscopy: Methodology

For the study of the cassiterite sample and the paragenetic minerals, we use the Zeiss JENALAB pol as well as the Raman spectrometer EnSpectr R532 combined with the Olympus BX43 microscope both for transmitted and reflected light and equipped with a rotating stage. For the identification of minerals and slight mineral inclusions, we used an Olympus long-distance LMPLFL100x objective lens. For the identification of different minerals, we used the RRUFF and the Hurai et al. [3] Raman mineral databases [3-4]. As references, we applied a water-clear diamond crystal from Brazil and a semiconductor-grade silicon single-crystal.

Results

In contrast to the typical tetragonal cassiterite of the Erzgebirge with the usual bands at 474, 633, and 775 cm-1 (both bands at 474 and 775 cm-1 are generally weak), the here-discussed cassiterite shows additional azimuthal-depending strong bands at 446, 832 cm-11, beside the 633 cm-1 band [1]. In the compilation [2] of the Raman modes of stable SnO2 polymorphs, only the orthorhombic cassiterite Pbcn (point group 2/m 2/m 2/m (number 60 in the room group list) contains a Raman active band at about 446 cm-1. The 832 cm-1 band is completely missing in the list of polymorphs. Figure 4 shows a typical Raman spectrum of cassiterite crystal III. Conspicuous are the strong bands at 76, 448, 635, and 834 cm-1.

FIG 4

Figure 4: Raman spectrum (a choice of 46 spectra) of SnO2 (sample III).

According to the measurements of the Raman intensity of both bands (446 and 832 cm-1), there is a good correlation shown in Figure 5. That means that both Raman bands belong together.

FIG 5

Figure 5: Correlation between the Raman intensity of the 446 and 832 cm-1 bands; I832cm-1=-89.829 + 0.609 * I446 cm-1, r2=0.989.

Because mineral inclusions in all the studied cassiterite crystals here are missing, the Raman bands are clearly components of the orthorhombic cassiterite, and both are strongly correlated. Also, the other crystals show a correlation between the two bands with near the same incline. That also will be clear from the following diagram (Figure 6). This figure shows the intensity ratio between the 633 and 832 cm-1 bands in dependence on the azimuth position. The figure (Figure 6) shows, in principle, the results for all three studied cassiterite crystals (I to III), which only show a peaks’ position dependence on the crystal orientation (a synchronous shift of the maxima to right or left).

FIG 6

Figure 6: Intensity ratio between the 633 and the 832 cm-1 bands versus the azimuth position for crystal I. Similar figures resulted for the cassiterite crystals II and III.

Figure 7 shows the azimuthal Raman intensity distribution for the orthorhombic cassiterite main band at 633 cm-1. The position of the points depends on the orientation of the studied sample. The points for the 446 and 832 Raman bands lie almost perpendicular to the 150° – 330° line. In the case of tetragonal cassiterite, the open red points would form a circle.

FIG 7

Figure 7: Cassiterite, crystal-III: Raman intensity distribution for the 633 cm-1 band in dependence on the azimuth position of the crystal. The numbers on the left are intensities.

Interpretation

The Raman bands at 446, 633, and 832 cm-1 are strongly polarized, and the bands at 446 and 832 have a different symmetry – they are almost perpendicular to the 633 cm-1 band. The explanation is not simple. Have we, in this case, a different polymorph phase of SnO2 not described in Balakrishnan et al., [2]? Or are the unusual Raman bands of SnO2 frozen high-temperature and high-pressure remnants of the rutile-type, orthorhombic, or the CaCl2 phase of cassiterite?. Note that in Figure 8, the points for the 832 cm-1 Raman band show a twisted form. From 38 measurements of the 832 cm-1 band on the cassiterite crystal-III, we obtain a mean of 833.9 ± 0.4 cm-1. This value corresponds to Hellwig et al. [5] for the B2g mode to a pressure of 10.5 GPa and falls into the rutile-type cassiterite. According to Girao [6], we can assume that the high-temperature and high-pressure cassiterite are well-crystallized (indicated by the intense and sharp Raman bands), are nano-particles in high concentrations, or contain larger domains. According to Girao [6] [Table 4, p.105], it results from the mean of 833.9 cm-1, a pressure of about 15 GPa. This pressure marks the rutile- to CaCl2-type transition. The rutile polymorph of SnO2 underwent a phase transition to a CaCl2 polymorph at 11.8 GPa under hydrostatic conditions [2]. Sometimes, we observe on the 833.9 band a shoulder at 849.7 ± 1.1 cm-1 (n = 10). Using Table 4 in Girao [6], it results in a pressure of 18.9 GPa and is, obviously, a high-pressure remnant of the CaCl2-type cassiterite.

FIG 8

Figure 8: Cassiterite, crystal-III: Raman intensity distribution for the 633 cm-1 (red) and the 832 cm-1 (green) bands in dependence on the azimuth position of the crystal. The other orientation of the 832 cm-1 band is good to see. The measured intensities are the numbers on the right side of the diagram.

Generally, besides the 633 cm-1 prominent bands, small bands at 695.9 ± 2.1 cm-1 are present. After Figure 7 and Table 4 in Hellwig et al. [5], results for this A1g mode band a pressure of 12.2 GPa and, according to Girao [6] [Figure 54 and Table 4], a pressure of 13.7 GPa. For the cassiterite crystal-III, we could also determine for the B1g mode a mean of 76.1 ± 0.5 cm-1 (n = 46). The intensity of this Raman band is very high. Using Figure 8 in Hellwig et al. [5] results in a pressure of 10.8 GPa. By some uncertainties (strong asymmetry of this band) of the soft mode in the CaCl2 phase [5], the 76.1 cm-1 band can also represent the CaCl2-type phase. The symmetry is similar to the 446 and 832 cm-1 bands.

The band at 448.2 ± 0.4 cm-1 strongly correlated with the 833 cm-1 band (n = 38) (see Figure 5), resulting after Girao [6] only a pressure of 5.7 GPa. That means the freezing behavior for the different Raman bands of different SnO2 polytypes is not regular.

Discussion

The exceptional Raman band at 832 cm-1, shown at first by Thomas [1], can explained, according to Hellwig et al. [5] and Girao [6], as frozen remnants of high-pressure phases of rutile- and CaCl2-type cassiterite structures.

Because together with the orthorhombic cassiterite at room temperature, there are also present high-pressure and high-temperature indicator minerals, like diamond, moissanite, Ti-carbides, and kumdykolite [1], the interpretation of the extreme Raman bands finds his explanation. That means that a part of the cassiterite of the Ehrenfriedersdorf Sauberg mine comes directly from the mantle regions. Schütze et al., [7] came after careful studies to the result that the Ehrenfriedersdorf granite presents the differentiation products of subducted altered ocean crust. The proof of high-pressure cassiterite (with signs up to 18.9 GPa) underlines this interpretation. After a couple of studies (for example, Thomas and Rericha, 2023) [8], the transport of high-pressure cassiterite (suspended as solid phases) happens via supercritical fluids from mantle regions to the crust. We have not considered the influence of the temperature on the band shift [9].

We found many deposits in the Erzgebirge (Germany) and the Slavkovsky les (Czech Republic), which prove the presence of orthorhombic cassiterites. More sophisticated studies on the natural cassiterite samples are necessary.

Acknowledgments

For the sample, we are grateful to Professor Ludwig Baumann (1929-2008) from the Mining Academy Freiberg. We thank Pierre Bouvier, Grenoble, France, and Jörg Acker, Cottbus, Germany, for the courtesy of critical references and for starting the discussion on the unusual cassiterite from Ehrenfriedersdorf.

References

  1. Thomas R (2023) Unusual cassiterite mineralization, related to the Variscan tin- mineralization of the Ehrenfriedersdorf deposit, Germany. Aspects in Mining & Mineral Science 11 : 1233-1236.
  2. Balakrishnan K, Veerapandy V, Fjellvåg H, Vajeeston P (2022) First-principles exploration into the physical and chemical properties of certain newly identified SnO2 ACS Omega 7 : 10382-10393. [crossref]
  3. Hurai V, Huraiova M, Slobodnik M, Thomas R (2015) Geofluids – Developments in Microthermometry, Spectroscopy, Thermodynamics, and Stable Isotopes. Elsevier, 489 pp.
  4. Lafuente B, Downs RT, Yang H, Stone N (2015) The power of database: s RRUFF In: Armbruster T, Danisi RM (eds.). Highlights in mineralogical crystallography. Berlin 1-30.
  5. Hellwig H, Goncharov AF, Gregoryanz E, Mao H, Hemley RJ (2003) Brillouin and Raman spectroscopy of the ferroelastic rutile-to CaCl2 transition in SnO2 at high Physical Review 67 : 174110-1174110-7
  6. Girao HT (2018) Pressure-induced disorder in bulk and nanometric SnO2. Material Chemistry, Theses, Université de Lyon, 139 pp.
  7. Schütze H, Stiehl G, Wetzel K, Beuge P, Haberland R, et al. (1983) Isotopen-und elementgeochemische sowie radiogeochronologische Aussagen zur Herkunft des Ehrenfriedersdorfer Granits-Ableitung erster Modellvorstellungen. ZFI-Mitteilungen 76 : 232-254.
  8. Thomas R, Rericha A (2023) The function of supercritical fluids for the solvus formation and enrichment of critical elements. Geology, Earth and Marine Science 5 : 1-4.
  9. Diéguez A, Romano-Rodríguez A, Vilà A, Morante JR (2001) The complete Raman spectrum of nanometric SnO2 Journal of Applied Physics 90 s: 1550-1557.

Applications of Ezrin Peptide Therapy to Long COVID, Drug Resistant Infections, Chronic Inflammation and in the Support of Healthy Aging

DOI: 10.31038/MIP.2024512

Introduction

Ezrin peptides amplify adaptive immunity through the RANTES/CCL5 pathways that lead to cures of drug resistant infections due to bacteria, viruses, fungi and protozoans. Ezrin peptides simultaneously suppress chronic pro-inflammatory cytokine and chemokine signalling, leading to cures for chronic inflammatory disease of the muscular-skeletal system (for example; Ankylosing Spondylitis): inflammatory gut diseases (for example; ulcerative colitis): inflammatory liver diseases (for example; HCV induced hepatitis) and inflammatory heart disease (for example; myocarditis).

Ezrin peptide pharmaceutical technology evolved from a prototype HIV peptide vaccine program in London UK and San Antonio TX, USA, established by Dr Rupert Holms in the mid-1980s. In the early 1990s, Dr Holms discovered that the amino-acid sequence at the C-terminus of HIV gp120 mimics part of the Alpha domain of human ezrin, a protein that builds multi-protein cell signalling complexes of adhesion molecules and receptors on the cell surface; with adaptor proteins, kinases and cytoskeletal components attached to the sub-surface of the cell-membrane. Aqueous solutions of Ezrin peptides are active on mucosal membrane surfaces and seem to behave as a ligand for a surface-exposed “receptor” transition conformation of human ezrin, which causes allosteric changes in the submembrane multi-protein complex that triggers intra-cellular signaling [1].

Dr Holms organised development of Human Ezrin Peptide One (HEP1) which was a synthetic peptide copy of the protein sequence between amino-acids 324 and 337 of human ezrin, at The Gamaleya Institute and Institute of Immunology in Moscow. Safety and efficacy of HEP1 was first demonstrated in HIV and AIDS opportunistic infections, and later in drug resistant sex infections. The first ezrin peptide product (HEP1) was launched on the Russian market in 2001 (brand name “Gepon”) as an adaptive immune amplifier that simultaneously down-regulated inflammation for treatment of AIDS and other defective immune responses to infection.

A normal course of treatment is 2mg ezrin peptide per day for 5 days. Ezrin peptides have been clinically demonstrated as safe: no adverse reactions, nor adverse drug interactions, nor allergic responses, have been reported. Human Ezrin Peptide One (HEP1) and Regulatory Ezrin Peptide Glycine 3 (RepG3) are closely related fourteen amino acid synthetic peptides, which are highly charged, highly soluble, 4-turn alpha helical peptides, mimicking the Alpha domain of human ezrin. Ezrin peptides are cheap and simple to manufacture and the active substance costs less than one pound per milligram (mg). Ezrin peptides are stable at room temperature in solid form for at least 2 years. In aqueous solution, ezrin peptides degrade at about 1% per month.

Treatment of Drug Resistant Infections

After the registration of HEP1 in the Russian Federation, a large number of clinical trials were performed with ezrin peptide HEP1 in the treatment of drug resistant chronic sex infections. Generally the clinical trials of HEP1 treatment of chronic viral, bacterial, fungal or protozoan infection, demonstrated approximately ninety per cent success rates, either in combination with existing therapy or as monotherapy, and there were no reports of any adverse reactions. Clinical use of ezrin peptide therapy in Russia to treat and prevent Candida, Chlamydia, Trichomonas vaginalis, Syphilis, HPV and Herpes (HSV-1 & 2) revealed a broad clinical potential for this adaptive immunity amplification technology. HEP1 was also used to successfully treat HCV hepatitis in HIV patients and as an adjuvant to increase antibody titres during hepatitis B vaccination of children [2,3].

Treatment of Acute COVID

Between 2020 and 2022, experimental ezrin peptide therapy using generation one ezrin peptide HEP1 or generation three ezrin peptide RepG3, was used to successfully treat acute COVID, based on earlier clinical successes using ezrin peptides to treat acute viral respiratory infections with inflammatory complications [4]. Investigation of the pro-inflammatory cell-signalling problem triggered by spike protein of SARS-CoV-2, identified RAGE, PKC, p38, NFkB & IL-6 hyper-expression as important components of the problem. The understanding of a possible disease mechanism, suggested both ezrin peptide therapy and also vaso active intestinal peptide (VIP) therapy as potential solutions in which suppression of NFkB mediated chronic expression of pro-inflammatory cytokine expression could be achieved by the induction of PKA>CREB signaling [5].

Treatment of Long COVID and mRNA Vaccine Injury

Long COVID, also referred to as Post-Acute Sequelae of COVID (PASC), is probably triggered during acute SARS-CoV-2 infection by Spike protein binding and hyper-activating the cell-membrane expressed Receptor for Advance Glycation End-products (mRAGE) and Toll-Like Receptor 4 (TLR4). SARS-CoV-2 infects lung monocytes by Spike binding to mRAGE (not ACE2). During acute COVID-19, high levels of IL-6 hyper-stimulate S100A8/A9 expression and secretion. Although no viral protein nor mRNA can be detected in half of long COVID (PASC) patients, there is a significant elevation of serum levels of IL-1b, IL-6, TNFa, and S100A8/A9. It appears that a pathological pro-inflammatory feedback loop (the TLR4/RAGE-loop) is established during acute COVID-19, which is maintained by S100A8/A9 > RAGE/TLR4 chronic inflammatory signalling, even after SARS-CoV-2 has been cleared from the body [6].

However, more evidence has emerged of chronic spike expression over long periods of time, both as a result of SARS-CoV-2 infection and the use of mRNA COVID vaccines. NewalR&D established a volunteer experimental ezrin peptide treatment program for Long COVID and COVID vaccine injury in which more than sixty volunteers have been treated on an individual unmet medical need basis (this data is anecdotal and is not a clinical trial). However the general observation is that ezrin peptide therapy is safe in Long COVID and COVID vaccine injury patients, about half report symptom improvement and about ten per cent report a significant benefit. The most common symptomatic improvements suggest reduction of inflammation in the gut, brain and heart. Ezrin peptides have already been shown to be clinically effective as anti-inflammatory therapy for any ulceration or inflammation in the gut, including the treatment and prevention of stomach & duodenal ulcers, and ulcerative colitis [7-9].

During the treatment of a vaccine injury patient, blood results provided new information that ezrin peptide RepG3 was inducing enhanced RANTES/CCL5 expression, providing an explanation for the amplification of adaptive immunity which has been observed with ezrin peptide treatment over the previous thirty years. In addition a second control pathway was identified that had a dominant suppressive effect on pro-inflammatory cytokine expression [10]. Results from individual Long COVID patients with other co-morbidities, also revealed a potent ezrin peptide cure for the inflammatory spine disease Ankylosing Spondylitis, and relief from myocarditis chest pains experienced by COVID vaccine injury patients, in addition to the reduction of symptoms of gut inflammation and “brain fog” due to CNS inflammation.

Current Developments

Research and clinical use of ezrin peptides over three decades has revealed the unusually broad beneficial biological activities of ezrin peptides, in the absence of adverse reactions. The scientific endeavour is to develop an integrated theory to explain these diverse results.

Ezrin peptides induce RANTES/CCL5 amplification of adaptive immunity while simultaneously suppressing pro-inflammatory cytokines and chemokines. Ezrin peptides are effective therapy for drug resistant infection whether viral, bacterial, fungal or protozoan, and are effective as monotherapy or in combination with existing therapy, to over-come Anti-Microbial Resistance (AMR). 17 clinical trials have been performed that showed clinical efficacy in a variety of sexually transmitted infections that failed to respond to existing therapy.

Ezrin peptides amplify adaptive B-cell and T-cell programmed immune responses, mediated via RANTES/CCL5 secondary signalling. Ezrin peptides also suppress pro-inflammatory cytokines (IL1b, IL6, IL8, IL13 & TNFa) and chemokines (MIP1a & MIP1b). Ezrin peptides amplify programmed B-cell responses, increase antibody titres and have vaccine adjuvant effects. Ezrin peptides also induce leukocyte migration and fibroblast activation. They stimulate tissue repair, wound healing, ionization radiation recovery and ulcer healing. Ezrin peptides stimulate NK-cell responses and have anti-solid tumour activity in animal models.

Ezrin peptides activate various cell signalling pathways: such as the Ras>Raf>MEK>ERK growth signalling and PI3K>AKT anti-apoptotic signalling, and possibly the JNK stress response pathway, and “Hippo” cell proliferation control pathway. Observations of anti-solid tumour activity, recovery from ionizing radiation damage and tissue regeneration suggest “Hippo” signalling and JNK signalling may be modulated by ezrin peptides.

Over the thirty years ezrin peptide technology has evolved, the evidence has grown that these peptides are operating at a deep level of living systems. For example, in chronic toxicity-safety studies mice displayed features of a slow-down of the rate of aging (healthier hair and higher fecundity). Ezrin peptides may enhance activity of transcription factor FOXO3: it is already known that some FOXO3 SNPs that enhance its activity are associated with extreme human longevity. Ezrin peptides have potential applications in the treatment of radiation sickness and in the enhancement of healthy aging but much more research needs to be done.

References

  1. Holms RD, Ataullakhanov RI (2021) Ezrin Peptide Therapy from HIV to COVID: Inhibition of Inflammation and Amplification of Adaptive Anti-Viral Immunity. Int J Mol Sci 22: 11688. [crossref]
  2. Holms RD (2023) Pandemics of Sexually Transmitted Infections (STIs): Clinical Use of Ezrin Peptide Therapy in Russia to Treat and Prevent Candida, Chlamydia, Trichomonas vaginalis, Syphilis, HPV and Herpes (HSV-1 & 2) Microbiology & Infectious Diseases. Microbiol Infect Dis 7.
  3. Salamov G, Rupert Holms RD, Wolfgang G, Bessler WG, Ataullakhanov RI (2007) Treatment of Hepatitis C Virus Infection with Human Ezrin Peptide One (HEP1) in HIV Infected Patients. Arzneimittel-Forschung (Drug Research) 57: 497-504. [crossref]
  4. Holms RD, Ataullakhanov RI (2021) Ezrin Peptide Therapy: A Potential Treatment for COVID. J Bioprocess Biotech 12: 3. [crossref]
  5. Holms RD (2022) The COVID-19 Cell Signalling Problem: Spike, RAGE, PKC, p38, NFkB & IL-6 Hyper-Expression and the Human Ezrin Peptide, VIP, PKA-CREB Solution. Immuno 2: 260-282.
  6. Holms RD (2022) Long COVID (PASC) Is Maintained by a Self-Sustaining Pro-Inflammatory TLR4/RAGE-Loop of S100A8/A9 >TLR4/RAGE Signalling, Inducing Chronic Expression of IL-1b, IL-6 and TNFa: Anti-Inflammatory Ezrin Peptides as Potential Therapy Immuno 2: 512-533.
  7. Chulkina M, Negmadjanov U, Lebedeva E, Pichugin A, Mazurova D, et al. (2017) Synthetic peptide TEKKRRETVEREKE derived from ezrin induces differentiation of NIH/3T3 fibroblasts. European Journal of Pharmacology 811: 249-259. [crossref]
  8. Malakhova NS, Pichugin AV, Khaliph IL, Ataullakhanov RI (2005) Use of Immuno-Enhancer Gepon For The Treatment Of Ulcerative Colitis. [crossref]
  9. Chulkina MM, Pichugin AV, Ataullakhanov RI (2020) Pharmaceutical grade synthetic peptide Thr-Glu-Lys-Lys-Arg-Arg-Glu-Thr-Val-Glu-Arg-Glu-Lys-Glu ameliorates DSS-induced murine colitis by reducing the number and pro-inflammatory activity of colon tissue-infiltrating Ly6G+ granulocytes and Ly6C+ monocytes Peptides 132. [crossref]
  10. Holms R (2024) The therapeutic potential of RANTES/CCL5 across diverse infections and its synergistic enhancement by ezrin peptide RepG3 for long COVID. Microbes & Immunity 1: 2474.

Pattern of Presentation of Newly Diagnosed Diabetes Mellitus Among Sudanese Patients

DOI: 10.31038/EDMJ.2024824

Abstract

The objectives of this study is to know the pattern of presentation of newly diagnosed diabetic patients among Sudanese, and how late they present, after developing micro and macro vascular complications. Among 620 diabetic patients attending a medical clinic for ten month duration, 44 patient were newly diagnosed diabetes mellitus patients. 54.5% were male and 45.5% female, with the mean age of 49.6 year, hemoglobin A1c% (Hb A1c) ranging from 7.1 to 15.9 mean of (11.02%). Most of them have positive family history of diabetes 75%, other risk factors include obesity 47.7, and hypertension31.8%. 7 patients out of 44 patients (15%). presented with micro and macro vascular complications which was not related to the level of HbA1c at presentation. These results make the need for screening for diabetes mellitus in those with risk factors is important for early diagnosis to prevent or delay the development of these complications.

Main Objective

To study the pattern of presentation of newly diagnosed diabetic patients among Sudanese population.

Specific Objective

  1. To study the risk factors for diabetes
  2. To know how late is the presentation, after the development of the acute and chronic diabetic complication.
  3. To study the relation between the complication at presentation and the risk

Keywords

Type2 diabetes mellitus (T2DM), Hemoglobin A1c (Hb A1c), Hypertension (HTN)

Introduction

Diabetes mellitus is a growing health problem, leading to morbidity and mortality. Type 2 diabetes mellitus (T2DM) is increasing and the prevalence and number of adults affected, have risen faster in lower income than in high-income countries. Sudan is one of the lower income country, with poor income and resources. Diabetes Mellitus is common in Sudan, with some studies showing the prevalence is 19% of the adult population. Type 2 diabetes mellitus is sometimes diagnosed when chronic complications have already developed and one third of all people with type 2 diabetes mellitus may be undiagnosed until late. this make the screening for diabetes mellitus for those at high risk of developing diabetes is crucial [1]. Early diagnosis and control of blood sugar will delay if not prevent the development of micro and macro vascular complications.

Methodology

This is a retrospective study for the patients attending a medical clinic in the period from April 2022 to February 2023 (about 10 months duration), from 620 diabetic patients attending the clinic, 44 patients were newly diagnosed diabetes mellitus. 24 male patients (54.5%) and 20 female (45.5%) out of them 7 patients (15%) presented with micro and macro vascular complication.

The risk factor for most of them was the family history of diabetes 75.0%, followed by obesity 47.7%, hypertension 31.8%, and a single case with past history of gestational diabetes.

The study showed that males have significantly more obese than females (62.5% compared to 30.0%) p value <.032.

The mean age at presentation was 49.6 year. Hemoglobin A1c (HbA1c) at presentation was varying from 7.1 to 15.9 mean of (11.02%) (Table 1).

Table 1: Mean age

Mean

Std. Deviation

N

AGE

49.68

13.194

44

A1c%

11.018

2.2152

44

7 out of 44 patients (15%) have obvious diabetic complication at presentation including peripheral neuropathy 4.6%, diabetic septic foot, chronic kidney injury, ischemic heart disease, diabetic ketoacidosis and diabetic retinopathy 2.3% for each (Table 2).

Table 2: Diabetic complication

Frequency

Percent

Valid Percent

Valid CHRONIC KID INJ

1

2.3

2.3

DIAB KETO ACIDOS

1

2.3

2.3

DIAB SEP FOOT

1

2.3

2.3

IHD CHF

1

2.3

2.3

NO

37

84.1

84.1

PERIPH NEUROPATH

2

4.5

4.5

RETINOPATHY

1 2.3

2.3

Total

44

100.0

100.0

There was no relation between the presentation with diabetic complication and A1c% at presentation (Table 3).

Table 3: Relation between the presentation with diabetic complication and A1c% at presentation

A1c% COMPL

Mean

N

Std. Deviation

CHRONIC KID INJ

8.300

1 .

DIAB KETO ACIDOS

7.800 1

.

DIAB SEP FOOT

7.100

1 .

IHD CHF

10.500 1

.

NO

11.508

37 1.9916

PERIPH NEUROPATH

8.150 2

2.3335

RETINOPATHY

9.000

1 .

Total

11.018 44

2.2152

Discussion

This study describes the pattern of newly diagnosed diabetes mellitus in Sudan, and the risk factors and how late they present, after the appearance of micro and vascular complication. Similar to other studies in Africa, the age of presentation of newly diagnosed diabetes in our study was in younger age group (the mean is 49.6 year), in contrast to with that from higher income countries where diabetes incidence peak is between 60 and 70 years [2] The risk factor for developing diabetes in our study was mainly the non- modifiable risk factor, the familial predisposition, and family history of DM similar to that in Saudi Arabia, in addition to the other modifiable risk factors like obesity, hypertension and sedentary lifestyle [3]. The risk factors for developing type 2 diabetes mellitus in Sudan is high, according to the study done in North of Sudan, using Finnish score as a risk assessment for predicting type 2 diabetes mellitus, more than half of the population of the study group were at risk of developing type 2 diabetes mellitus, and if not discovered early are prone of developing diabetic complications [4]. The development of complications was not related to the level of HbA1c at presentation, diabetic complications may be related to the chronicity of the disease, rather than the blood sugar at the time of diagnosis Peripheral neuropathy was the most common diabetic complication at presentation, 28.5% of cases with micro and macro vascular complication at initial presentation similar to study done in Pakistan [5]. Peripheral neuropathy patients present with symptoms of numbness and paraethesia, with impaired sensation [6]. Patients with diabetic nephropathy present with proteinuria, renal impairment or chronic kidney injury. Diabetic retinopathy patients present with symptoms of blurring of vision, headache, pain in the eyes and impairment of vision. Final examination will show background diabetic retinopathy, new vascularization and intra retinal hemorrhage leading to loss of vision and blindness [6].

Notice: Formal visual examination wasn’t done in all patients.

Recommendation

We recommend screening for those who are at risk of developing diabetes mellitus, specifically those with family history of DM and other modifiable risk factors like obesity or sedentary lifestyle, so we can avoid the late presentation after developing micro and macro vascular complications.

References

  1. Clinical Practice Guidelines and Standards of Care of Diabetes Mellitus in Sudan 2020.
  2. Roy William Mayega et (2018) Clinical presentation of newly diagnosed diabetes patients in a rural district hospital in Eastern Uganda. Afr Health Sci. 18(3): 707-719 [crossref]
  3. Saudi Diabetes Clinical Practice Guidelines (SDCPG) 2021.
  4. Sufian et al. (2024) benefit of Finnish Score as a Risk Assessment Tool for predicting type 2 DM among Sudanese population in North Sudan, Sudan Journal of Medical Science.
  5. Nalia Naeem et al. (2014) Frequency of peripheral neuropathy in newly diagnosed patients of diabetes mellitus 2 on clinical and electrophysiological Pakistan Journal of Neurological Science vol 9 issue 4.
  6. A P Nambuya et The presentation of newly diagnosed diabetic patients in Uganda, Q J Med. [crossref]

Sex Differences in Anti-Obesity Drugs: Is it Time to be More Proactive in Engaging Men?

DOI: 10.31038/JCRM.2024721

Introduction

The paper “Sex-differences in response to treatment with liraglutide 3.0 mg” provides a critical analysis of how responses to obesity treatments can vary by sex, with a particular focus on the efficacy of liraglutide 3.0 mg in patients with obesity (BMI ≥ 30 kg/m2), but without type 2 diabetes (T2D) [1].

The emphasis on sex-specific responses in obesity places this study within a trend of increasing recognition, among clinicians and researchers, of the critical role of sex and gender at all levels of medical research [2]. Despite this growing awareness, sexual biology is often relegated to a specialized discipline rather than being integrated as a fundamental aspect [3], underscoring the need for integration of this analysis.

The authors provide a clear picture of the increasing rates of obesity in recent decades, and of the apparent sex differences in obesity prevalence, attitudes and behaviors [4].

While it is generally accepted that the prevalence of obesity appears to be slightly higher in women than in men, it is increasing in both sexes worldwide [5]. Interestingly, the authors report that recently in Italy, obesity appears to be higher in men than in women [6,7].

This discrepancy may explain why the authors chose to emphasize that, despite the overall higher prevalence of obesity in men, women are more likely to be included in obesity clinical trials, and to seek and to be prescribed anti-obesity pharmacotherapy [8].

In addition, although previous studies have suggested a sexually dimorphic response to GLP-1RAs, with greater weight loss in women than in men, as the authors note, most of these studies were conducted in people with T2D and, in any case, sex-specific analysis remains underexplored [2].

Overall, the study highlights the importance of better understanding sex-specific responses to obesity treatments, such as liraglutide, the first GLP-1 receptor agonist approved for weight management in Italy, in a real-world setting.

Results

The authors conducted a single-center, real-world, retrospective study at the Santa Maria Goretti Hospital in Italy, focusing on a specific cohort of patients with obesity, but without T2D. The study design includes criteria that help minimize confounding variables such as previous anti-obesity treatments or significant metabolic comorbidities or treatments, ensuring a more homogeneous sample. By including only patients who reached and maintained the maximum dose of liraglutide (3.0 mg) for at least 6 months, the study strengthens the validity of its findings regarding the effects of liraglutide on weight loss and improvements in metabolic parameters.

The results show significant sex differences in response to liraglutide. Men experienced significantly greater reductions in weight and BMI at both 3 (-10.7 vs -7.1 kg, -3.6 vs -2.6 kg/m2), and 6 months (-17.9 vs -11.9 kg, -6.0 vs -4.4 kg/m2) compared with women. In addition, the authors decided to include in the analysis the assessment of percentage weight loss (%WL) and the achievement of weight loss of >5% (WL>5%) and >10% (WL>10%), which are considered meaningful for clinicians, public health, and for anti-obesity drug targets [9,10]. A higher percentage of men achieved significant WL >5% (93.7% vs. 58.0%) and %WL (-9.2% vs. -6.5%) at 3 months than women, and this trend was maintained at 6 months, with WL >10% (87.5% vs. 29.0%) and %WL (-15.2% vs. -10.5%).

The inclusion of metabolic parameters adds depth to the study and has shown that men also experienced significantly greater improvements in total (-14.0 mg/dL vs. 9.5 mg/dL) and LDL cholesterol (-19.0 mg/dL vs. 6.8 mg/dL) and the fibrosis-4 index FIB-4 (-0.25 vs. -0.003) as an indicator of liver function than women. However, no significant sex-differences were observed in glucose metabolism or renal function [1].

Discussion

One of the key considerations in this study is the higher representation of women (65.9%) compared to men (34.0%) in the sample. This is consistent with other analyses in the literature suggesting that women are more likely than men to be enrolled in clinical trials of anti-obesity drugs [11], and may confirm that in the real world, women may also be more proactive in seeking weight management treatments in a clinical setting, possibly due to different attitudes and awareness of body weight than men [12].

In terms of results, while some previous studies have suggested superior weight loss in women with GLP-1 receptor agonists (GLP-1 RAs), this study found the opposite, confirming the complexity of sex-specific pharmacodynamics and pharmacokinetics.

The authors discuss possible explanations for these conflicting results, emphasizing that the majority of results have been obtained in people with T2D using other classes of GLP1-Ras [13-15]. Consistent with this, it has been suggested that the different molecules may have different pharmacokinetics and pharmacodynamics [13], and it is also known that diabetes is a known factor that can influence pharmacotherapy weight loss or changes in metabolic parameters in people with increased adiposity [16].

In addition, the authors noted that most studies reported different baseline body weights, and BMIs between the sex groups, describing a non-homogeneous sample. Despite in some studies researchers have hypothesized that the greater weight loss in women may be related to their greater exposure to the drug due to their lower body weight [13,15,17], while others have observed an association between women’s greater weight loss and their higher baseline BMI [15,18], these hypotheses remain contradictory.

Overall, the absence of baseline differences in weight, BMI, and comparison of percent body weight loss may have helped to attenuate any differences in the authors’ results, in addition to the absence of T2D and other metabolic treatments in a real-world setting, may potentially explain the different results from those reported in the literature.

Given the mean age of the cohort (50.8 years), the authors have also suggested that the contribution to the observed differences may be due to differences in body composition and hormonal changes experienced by women during the menopausal transition [19,20], which could also influence the pharmacokinetics and pharmacodynamics of the drugs [21]. Indeed, in a study conducted only in patients with obesity treated with liraglutide 3.0 mg, greater weight loss was observed in women than in men, but the mean age was 43.6 years [22], which may have influenced the results.

In line with the latter, it can be added that recent evidence suggests that central estrogen receptor (ER)α signaling is necessary for the effects of GLP-1 on food reward behavior [23,24], and that in ovariectomized animal models, lower estradiol (E2) levels were associated with hyperfagia and weight gain [25].

To date, weight loss interventions are not tailored to women’s menopausal status, nor to sex differences, and studies based on sex in response to liraglutide in people with obesity only remain very limited. This context allows to highlight the significance of these findings for clinical practice implications as a major strength of this paper. Given the recent increase in the prevalence of obesity in men and their underrepresentation in weight management programs, the findings of greater efficacy of liraglutide in men are particularly significant, and underscore the need for clinicians to be more proactive in engaging men in obesity treatment programs. In addition, given the higher cardiovascular risk in men, the notable improvements in total and LDL cholesterol and liver fibrosis in men raise important questions about the cardiometabolic benefits of liraglutide.

Conclusion

This paper makes a significant contribution to the field of obesity treatment by highlighting the importance of considering sex differences in clinical settings where, similar to lifestyle intervention trials, most pharmacological trials do not analyze weight loss separately for men and women due to the higher representation of women in pharmacological weight loss trials [11].

The potential for sex-specific tailoring of obesity treatments is in line with the need to develop more personalized treatment in the medical field, including dose adjustment where appropriate [24], with significant public health benefits.

Strengths of the study include its real-world setting, comprehensive data collection, and focus on a homogeneous cohort. However, the authors acknowledge several limitations, including the small sample size, retrospective design, and lack of data on changes in body composition, dietary habits, and physical activity levels.

Despite these limitations, the study provides valuable insights into the sex-specific effects of liraglutide and calls for further research into sex-specific responses to anti-obesity drugs to better understand the mechanisms behind these differences. In doing so, it paves the way for more effective, personalized obesity treatments that take into account the unique physiological and hormonal factors that influence treatment outcomes in men and women, and may increase men’s engagement in obesity treatment programs.

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Addressing Global Inequities in Poxvirus Vaccination: Strategies for a More Equitable Future

DOI: 10.31038/IJVB.2024812

Abstract

There has been persistent vaccine inequity between high-income and low-income nations, resulting in the prevalence of infectious disease epidemics in Sub-Saharan African countries. While the global surge in poxvirus cases peaked in 2022, western and central African countries have struggled with this virus since the 1970s [1]. These nations face numerous barriers to accessing adequate vaccination. Wealthy nations acquire vaccines at higher rates due to their ability to bear the high costs, forcing poorer nations to rely on donations and low-cost subsidies. This situation is further complicated by inadequate healthcare infrastructure and socioeconomic, cultural, and geographical obstacles. To address these challenges, comprehensive, inclusive, and integrated approaches are essential, incorporating preventive measures, surveillance systems, low-cost vaccines, vaccine subsidies, the expansion of vaccine manufacturers, and vaccine education through multi-sectoral collaborations in both the public and private sectors.

Keywords

Poxvirus vaccination, Monkeypox, Disease surveillance, Vaccine awareness, Vaccine inequity

Preventive Measures and Community Involvement

Similar to other infectious diseases, preventive measures for the poxvirus include maintaining diligent sanitation, such as thoroughly washing hands with clean water and regularly cleaning and disinfecting spaces. However, these measures face significant obstacles in Africa due to limited access to clean water and inadequate water and sewage treatment facilities [2]. Resources need to be mobilized to develop water treatment plants, sanitation infrastructure, and waste management systems. Implementing preventive measures requires community involvement, with local village leaders playing a crucial role in educating residents about prevention and early treatment. To enhance prevention efforts, recruited local trainees can be mobilized.

Surveillance Systems

Since Mpox has both animal and human reservoirs, it is theoretically difficult to control and eradicate, necessitating the maintenance of active surveillance systems [3]. However, effective surveillance is challenging in most African countries due to a lack of diagnostic capacity to detect monkeypox [4]. Logistical barriers further contribute to the underreporting of cases, but this can be partially overcome by mobile phone apps, which allow for quick information delivery from remote areas to central health information systems. Effective surveillance relies on strengthening diagnostic capacity, providing affordable diagnostic tests, and ensuring adequate staff training.

Collaboration of Health Agencies

The 2022 Mpox outbreak led the WHO to create the Mpox Strategic Preparedness, Readiness, and Response Plan (SPRP) [5]. Collaboration between WHO staff and national and provincial health agencies is crucial for addressing global disparities in poxvirus vaccination. The WHO can adopt a proactive approach to assist countries in implementing the SPRP, increasing monkeypox vaccine production, donations, and subsidies, and enhancing disease surveillance systems and vaccine awareness campaigns.

Vaccines

Jynneos, Imvanex, and Imvamune vaccines can prevent Mpox, but the rollout of vaccination campaigns exposed significant global disparities in vaccine procurement and distribution. High-income countries or those with high vaccine production capacities were prioritized. In 2022, nearly 80% of the world’s Mpox vaccine supply was held by the U.S., while African nations faced considerable challenges in accessing vaccines [6]. The global shortage of Mpox vaccines, coupled with high prices, excluded low-income countries. Despite the U.S. allocating $1 billion for Mpox vaccines, only half of the affected countries received access [7].

To contain Mpox outbreaks in endemic African countries, subsidies for a low-cost vaccine are essential. A targeted vaccination approach, focusing on exposed and high-risk populations, requires fewer donated doses and is more cost-effective for donors. Despite facing high mortality rates from infectious diseases, Africa’s vaccine manufacturing capacity is limited. In response, the African Union and GAVI, The Vaccine Alliance, are expanding this capacity by increasing the number of manufacturers from 10 to 17 and diversifying vaccine portfolios [8]. American Tonix Pharmaceuticals, in collaboration with the Kenya Medical Research Institute, is also working on potential local vaccine production [9].

Vaccine Education

The distribution of the limited vaccines in African nations was impeded by an intricate tapestry woven from factors including unaffordable costs, lack of proximity to vaccination sites, inadequate medical services, and deeply entrenched socioeconomic and cultural barriers such as mistrust of vaccines, misinformation, and cultural opposition [10,11]. At the community level, vaccine advocates and opinion leaders should collaborate to disseminate vaccination knowledge to ensure that vulnerable populations understand the importance of vaccination and have easy access to it. Authorities should establish a monitoring system to engage with targeted communities, delivering timely and accurate information on poxvirus transmission, preventive measures, and treatment. Additionally, they should enhance access to vaccination sites through the use of mobile apps.

Conclusion

African nations are likely to experience more severe impacts from modern epidemics. Recognizing this sobering reality is essential for creating global cooperative pandemic-control organizations. Their collective efforts should focus on expanding vaccine procurement, production, and allocation in African nations. Drawing lessons from the global inequities in vaccination during the Covid-19 pandemic, high-income countries should support these nations, which face persistent infectious diseases and fragile healthcare infrastructures, by helping to expand preventive measures, vaccine donations, and subsidies [12]. As worldwide epidemics may occur routinely, healthcare decision-makers should continue to promote risk-mitigating behaviors, maintain open and transparent risk communication with the public, and foster community compliance. Future pandemic control efforts will depend heavily on global coordinated actions, cooperation, and communication, rather than competition and concealment, to develop affordable, widely distributed, broad-based, and long-lasting vaccines.

References

  1. Son BWK, Wambalaba OW, Wambalaba WF (2024) A Multi-pronged Approach to Addressing Global Poxviruses Vaccine Inequity: A Case of Monkeypox. In: Rezaei N (eds) Poxviruses. Advances in Experimental Medicine and Biology, vol 1451. Springer, Cham. [crossref]
  2. Mutono N, Wright J, Mutembei H, Muema J, Thomas M, Mutunga M, Thumbi SM (2020) The nexus between improved water supply and water-borne diseases in urban areas in Africa: a scoping review protocol. AAS Open Res 8(3): 12. [crossref]
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  4. Boodman C, Heymann D, Peeling R (2022) Inadequate diagnostic capacity for monkeypox—sleeping through the alarm again. The Lancet 23(2): 140-141 [crossref]
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  6. Molteni M, Branswell H, Joseph A, Mast J (2022) 10 key questions about monkeypox the world needs to answer. Statnews. August 30, 2022.
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Progress towards Elimination of Viral Hepatitis B and C

DOI: 10.31038/IDT.2024514

Abstract

Worldwide the major causes of viral hepatitis are 5 viruses: the RNA hepatitis A virus (HAV), the  NA hepatitis B virus (HBV), the RNA hepatitis C virus (HCV), the RNA hepatitis delta viroid (HDV) and the RNA hepatitis E virus (HEV). Their epidemiology, life cycle, diagnosis, clinical course and associated diseases have been studied in great detail. Furthermore, effective treatment strategies and preventive measures have been developed and entered clinical practice.

lmportantly, with recent political commitments, policy updates and universal availability of highly effective preventive and therapeutic strategies against viral hepatitis B and C, respectively, low- and middle-income countries are scaling up their viral hepatitis prevention and therapy programs. ln this context, Egypt was leading the way for a public health approach to eliminate viral hepatitis C in October 2023.

While better tools and data than ever are now available to prevent, diagnose and treat viral hepatitis, including chronic hepatitis B and chronic hepatitis C and the recent political commitment of low- and middle-income countries with a high burden of viral hepatitis, such as China, lndia and Pakistan, the latest data from WHO show that hepatitis B and C are still a major public health challenge and far from the WHO goal of their elimination by 2030.

Keywords

Chronic viral hepatitis B and C, diagnosis, treatment, prevention, morbidity, mortality

Introduction

Worldwide, the causes of viral hepatitis are 5 hepatotropic viruses: the RNA hepatitis A virus (HAV), the DNA hepatitis B virus (HBV) [Figures 1 and 2], the RNA hepatitis C virus (HCV) [Figures 1 and 3], the RNA hepatitis delta viroid (HDV) [Figure 1] and the RNA hepatitis E virus (HEV). They infect the liver and can present with a broad spectrum of clinical signs and symptoms, ranging from an asymptomatic carrier state to acute/ fulminant hepatitis or chronic hepatitis with the potential to progress to liver cirrhosis and its sequelae, including hepatocellular carcinoma (HCC) [1]. Thus, viral hepatitis can be associated with significant morbidity and mortality and represents a global health care problem. ln the following, the history and epidemiology of viral hepatitis B [2-7] and hepatitis C [8-10], the world-wide burden of these diseases and the goals for their global elimination will be addressed.

FIG 1

Figure 1: Hepatitis B virus (HBV), hepatitis delta viroid (HDV), hepatitis C virus (HCV)

FIG 2

Figure 2: Worldwide prevalence of HBV infection in 2005 [13]

FIG 3

Figure 3: Worldwide prevalence of HCV infection in 2005 [14]

Combined, hepatitis B and C cause daily 3,500 deaths with increasing mortality and 6,000 new infections [1]. Worldwide, an estimated 254 million people are infected with hepatitis B and 50 million with hepatitis C. ln numerous countries, many people remain undiagnosed and even when diagnosed, the number of people receiving treatment is incredibly low. Although therapeutic agents are available at affordable prices, many countries do not take full advantage of this situation. Similarly, many infants do not receive the hepatitis B birth dose vaccination, despite the low cost of this intervention. Unfortunately, funding for viral hepatitis remains limited given the fact that viral hepatitis is about eight times more prevalent than HIV infection but receives less than one tenth of funding [1].

The COVID-19 pandemy severely affected strategies aimed at the elimination of viral hepatitis B and C

The COVID-19 pandemy urged many countries worldwide to adjust their health care priorities. ln particular, the COVID-19 pandemy affected 10 out of 38 WHO focus countries for the viral hepatitis response (China, lndia, lndonesia, Nigeria, Pakistan, Ethiopia, Bangladesh, Vietnam, Philippines and the Russian Federation). Among these 10 countries which account for about 80% of the global disease burden of viral hepatitis B and C, nearly two thirds were very much restricted in their viral hepatitis programs [1]. Together with a universal access to diagnosis, treatment and prevention by the special effort of the African Region, it is the goal to regain the momentum for achieving the Sustainable Development Goals.

Key findings of the WHO Global Hepatitis Report 2024. Overall, 304 million people were living with hepatitis B and C in 2022: an estimated 254 million (84%) with hepatitis B and an estimated 50 million (16%) with hepatitis C. Half the burden of chronic hepatitis is among people between 30 and 54 years old. Approx. 58% of all patients had a history of medical injections or other medical procedures, of newborns and children at risk for mother-to-child transmission of hepatitis B, of indigenous populations and mobile and migrant populations from countries with higher prevalence rates as well of key populations, such as people who inject drugs, people in prison or other closed settings, and men who have sex with men.

According to recent data from 187 countries [1] the estimated number of deaths from viral hepatitis increased from 1.1 million in 2019 to 1.3 million in 2022. 83% were caused by hepatitis B and 17% by hepatitis C. The estimated number of individuals newly infected by viral hepatitis declined from 2.5 million in 2019 to 2.2 million in 2022. Of these, 1.2 million (55%) were infected by hepatitis B and 1.0 million (45%) by hepatitis C. This reduction is due to hepatitis B and C prevention through immunization against hepatitis B and safe injection practices and the initial impact of novel curative antivirals against hepatitis C. Both HBV vaccination and cure of hepatitis C by widely available directly active antiviral agents (DAAs) are central for a sustainable viral response. Taken together, deaths from viral hepatitis B and C, unfortunately, increased from 2019 to 2022 while infections decreased.

Diagnosis, treatment and prevention of hepatitis B and C is still too low to achieve their elimination by 2030. By the end of 2022, 13% of people have been diagnosed with hepatitis B and only about an estimated 3% (7 million) have received long-term antiviral therapy, e.g., adefovir, entecavir, lamivudine, telbivudine, tenofovir disoproxil fumarate and tenofovir alafenamide [1-7].

Between 2015 and 2022, globally 36% of individuals with hepatitis C infection were diagnosed and 20% received curative treatment, e.g., genotype-specific or pangenotypic drugs or drug combinations (DAAs), After decades of interferon-based therapeutic strategies, the availability of DAAs has revolutionized the treatment of patients with chronic hepatitis C of any genotype with HCV elimination rates approaching 95-100% after treatment for 8-12 weeks [8-10]. The DAAs include protease inhibitors (e.g., telaprevir, boceprevir, asunaprevir, simeprevir, faldaprevir), non-nucleoside polymerase inhibitors (e.g., deleobuvir, filibuvir, setrobuvir, tegobuvir), NS5A inhibitors (e.g., daclatasvir, ledispavir) and NS5B polymerase inhibitors (e.g., sofosbuvir, mericitabine).

Vaccination against HBV infection, a cost-saving strategy in countries with high and intermediate endemicity, was applied to an estimated 45% of newborns within 24 hours after birth. Coverage varies between 18% in the African region and 80% in the Western Pacific Region [1].

To date, the global response to viral hepatitis B and C is off-track towards the global elimination of viral hepatitis and far below the global targets for eliminating viral hepatitis by 2030 [1-11]. Major public health activities are expected to reduce the incidence of chronic viral hepatitis by 95%, mortality by 65% and the cost by 15%. The benefits of achieving these global targets will save 2.85 million lives, avert 9.5 million new infections and 21 million cases of cancer. Looking to 2050, this will save nearly 23 million lives and prevent nearly 53 million new viral hepatitis infections and 15 million cases of cancer [1].

Summary and Perspectives

Overall, the worldwide prevalence of hepatitis B and C decreased from 2019 to 2022 while the deaths from these infections increased. ln 2022 about 1.3 million people died from chronic viral hepatitis, similar to the number of deaths from tuberculosis. lmportantly, the COVID-19 pandemy severely affected hepatitis services. The 2024 WHO report [1] presents information on access to health products from 38 WHO focus countries for viral hepatitis response. These countries account for about 80% of the global disease burden of hepatitis B and C. These 38 countries include 10 that account for nearly two thirds of the global burden: China, lndia, lndonesia, Nigeria, Pakistan, Ethiopia, Bangladesh, Viet Nam, Philippines and the Russian Federation. Universal access to prevention, diagnosis and treatment in these countries by 2026 together with a special effort in the African region should enable the global response to gain momentum for the elimination of HBV and HCV infections and their associated morbidities and mortalities by 2030.

The recent WHO report on the global health sector strategies for the period 2022-2030 [11] focuses on their implementation to achieve progress and to fill gaps in the worldwide elimination of HBV and HCV lnfection [12].

Conflict of interests

The author declares no conflict of interest.

Financial disclosure

The author has no financing to disclose.

Acknowledgement

The excellent contribution of Mr. Alain Conard to the content and formatting of the manuscript is gratefully acknowledged.

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