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Importance of Single Nucleotide Polymorphisms (SNPs) of Insulin-like Growth Factor-1 (IGF-I) and Ovocalyxin-32 (OCX-32) Genes for Production Traits in Mazandaran Indigenous Chicken

DOI: 10.31038/JMG.2020333

Abstract

We suggested two important proteins (insulin-like growth factor-I (IGF-I) and ovocalyxin-32 (OCX-32) have crucial effects on muscle differentiation, growth, and reproductive traits in chicken production. On the association between IGF-I gene polymorphism and production traits, the evaluation of the associations between SNPs with reproductive traits suggests a positive effect of genotype AC with average egg weight at age of 30 (EW30) (P < 0.05) compared with genotype CC. We confirmed that the g.570 C > A polymorphism is significantly associated with average egg weight at age of 30 (EW30). On the other hand, for the association between OCX-32 gene polymorphism and production traits, two single nucleotide polymorphisms (SNPs) c.381G > C and c.494 A > C, were confirmed. Associations of OCX-32 genotypes with egg number (EN) were significant (p<0.05). From these findings we concluded that these markers should be considered for growth and production traits in chicken.

Keywords

Production traits, Chicken, IGF-I, OCX-32, PCR-RFLP

Introduction

Economically important livestock products are dependent on production and reproductive traits in domestic animals, which are under the control of multiple genes, mapping and analyzing polymorphisms of genes involved in the main metabolic pathways related to animal growth and distribution of nutrients to different tissues [1,2]. Understanding the genetic information of related genes is helpful for the selection and breeding course through marker assisted selection (MAS) in domestic animals. Candidate genes have well-known biological functions related to the development or physiology of important traits [3]. Such genes can encode structural proteins or a member in a regulatory or biochemical pathway affecting the expression of the trait [4] and can be tested as putative QTLs [5].

For poultry industry, meat and eggs are main products, for which some genes impact on such as insulin-like growth factor (IGF-I) and ovocalyxin-32 (OCX-32) have crucial roles on muscle differentiation, growth and reproduction. The presence of IGF-I in blood was detected as one of skeletal growth factors that produced in the liver tissue [6]. Therefore, insulin-like growth factor 1 is a key growth factor involved in a variety of biological processes [7,8]. Some study has shown that IGF-I mRNA levels were significantly lower in the low growth rate line than in the high growth rate line [9].

Recent studies on a single nucleotide polymorphism (SNP) in the chicken IGF-I gene have reported that there are significant associations between a polymorphism in this gene and its promoter in production and reproduction traits in poultry [10-12]. And the other hands, one group of detected eggshell matrix proteins related to major proteins of the egg white. Ovalbumin was the first egg white protein that explained in the matrix of the eggshell [13]. A second group contains proteins such as osteopontin that are also found in other tissues [14]. Finally, a third group of proteins includes those specific to the uterine tissue and to the eggshell that have only been detected in extracts of eggshell. Recent studies have shown associations between single nucleotide polymorphism of ovocalyxin-32 gene its family genes and egg production traits [15-18]. The eggshell contains some eggshell-specific matrix proteins such as ovocleidin-17, ovocleidin-116, ovocalyxin-32 and ovocalyxin-36 [14,19]. It was demonstrated that ovocalyxin-32 (OCX-32) is a 32 kDa protein that found in the outer region and cuticle of the shell [20]. Dunn et al. [16] reported that a single nucleotide polymorphism in the intron of the OCX-32 gene was associated with the thicknesses of the mammillary layer. Some studies have shown that low egg production strains expressed more transcripts of the OCX-32 gene in comparison of high strains at egg-laying stages and offered that the OCX-32 gene is a crucial marker that associated with egg production [21,22].

The objectives of the present study was 1) to detect SNPs of IGF-I and OCX-32 genes by developing PCR-RFLP methods, and 2) to investigate and analyze associations between those SNPs and growth and egg production traits in Mazandaran indigenous chicken.

Material and Methods

Growth and Egg Production Traits

The evaluated traits and their descriptions were presented in Table 1.

Experimental Population and Sampling

Chickens were raised in Native Chicken Breeding Station of Mazandaran, and they belonged to generation 19 of the breeding station pedigreed animals. Blood sample (1 mL) was taken in an EDTA-containing tube and all samples were freeze. Whole DNA was extracted by using DNA Extraction Kit [23]. The DNA samples were stored at -20ºC for use.

Primer Synthesis and PCR–RFLP Reactions

IGF-I analysis: Promoter region of the IGF-I gene amplified to a product of 361 bp using the oligonucleotide design tool Primer 5.0 software based on the IGF-I gene sequence of the fowl (Accession number: M74176). Primers were F: 5′-CTCTGCCACGAATGAAATGTGC-3′ and R: 5′-GGGAGCATTTGCCTTCTCTC-3′ for IGF-I gene. PCR method was used to optimize the reaction accuracy: 94ºC for 2 min, 30 cycles of 98ºC for 30 s, annealing at 55ºC for 30 s, 68ºC for 40 s, and a final extension at 72ºC for 7 min. Finally, PCR products were electrophoretically separated on 2% agarose gel (5 V/cm) and stained with ethidium bromide.

The fragment was amplified for PCR–restriction fragment length polymorphism (RFLP) analysis. An amplified fragment was digested by HinfI for detecting the g.570C > A genotypes. The restriction enzyme digestion was incubated at 37°C for 4 h.

OCX-32 Analysis

With forward primer 5′-CTCCAAACGTATGCTTCACTTA-3′ and reverse primer 5′-ATTCTTGTGTTCGGTTACTTGT-3′, approximately 342 bp covering complete exon-3 was obtained. As well as forward primer 5′-TGTTTCTGATGAAGAGCCAGA-3′ and reverse primer 5′-CTTTGCCACTCTGTAGGCTGT-3′, approximately 250 bp covering exon-4 was obtained. Two fragments containing the OCX-32 polymorphisms (NM_204534: c.381G>C; and NM_204534: c.494A>C) were amplified for PCR-RFLP analysis. An amplified fragment was digested with NcoI for detecting the c.381G>C and c.494A>C genotypes, respectively. The restriction enzyme digestions were incubated at 37°C for 4 h.

Statistical Analyses

The relationship between genes polymorphism and related traits were calculated using general linear model of SAS 9.0 (SAS Inc., Cary, NC, USA). The used models in matrix notation were as follows:

Y = Xb + Za + e

Where, Y is the vector of observations; b the vector of fixed effects of generation, sex and hatch; a the vector of random direct genetic effects; e the vector of random residual effects; X and Z are incidence matrices relating the observations to the respective fixed and direct genetic effects.

Results

The Production Traits

The means and SD of the traits measured in the chickens are shown in Table 1.

Table 1: Statistical description of data set for growth and egg production traits.

Traits

No. of animal Mean

Coefficient of variation

BW1 (gr)

34,277 34.53

8.13

BW8 (gr)

42,057 553.7

17.12

BW12 (gr)

37,207 943.9

14.51

WSM (gr)

30,137 1684

11.92

ASM (day)

30,339 155.5

9.25

EN (number)

30,349 36.66

39.76

EW1 (gr)

26,284 40.21

15.77

EW28 (gr)

16,215 45.91

8.43

EW30 (gr)

18,021 47.12

8.52

EW32 (gr)

17,945 48.22

8.31

EW12 (gr)

17,837 48.62

9.34

AV (gr)

27,715 45.84

13.34

EM (gr)

27,725 1758

39.13

EINT (%)

30,339 53.07

33.33

BW1, BW8, BW12 = Body Weight at Birth, 8, 12 weeks of age, WSM = Body Weight at sexual maturity, ASM = Age at first egg, EN = Egg Number, EW1 = Weight of First Egg, EW28, EW30 and EW32 = Average Egg Weight at 28, 30 and 32weeks of age respectively, EW12 = Average egg weight for First 12 weeks of production, AV = Average for EW28, 30 and 32, EM = Egg Mass (=EN×EW12), EINT = Egg Production Intensity (=Egg Number/Days Recording)×100).

Phenotypic Analysis and Sequence Analysis

IGF-I

The single nucleotide polymorphisms was located in the promoter region and produced an A→C substitution at base 570 (accession number M74176), which was the same mutation identified in previous studies [10,11,24]. Genotypes of chickens were investigated by PCR-RFLP (Figure 1). Genotype and allele frequencies of the SNP in chickens are shown in Table 2. In this population, the AA genotype had the highest frequency (0.62), followed by AC (0.32) and CC (0.06), and the A and C allele frequencies were 0.78 and 0.22, respectively.

fig 1

Figure 1: Representative genotyping of IGF-1 gene at locus g.570C > A. by agarous gel electrophoresis. Strands with 361 for CC genotype, 117, 244 and 361 for AC genotype and 117 and 244 for AA genotype appeared at this locus.

Table 2: Genotypic and gene frequency of IGF-I gene.

IGF-I

Frequency

Allele Frequency No.

Genotype

0.78

A 0.62 113

AA

0.22

C 0.32 59

AC

0.06 11

CC

1 183

Total

OCX-32

The SNPs in exon 3 and 4 were a C→G substitution at base 381 (c.381 G > C; accession number NM_204534) in exon 3, and C→A substitution at base 494 (accession number NM_204534) in exon 4, respectively, which was the same mutation reported in the previous study [21].

We observed 3 band on gel for OCX-32 exon 3 (Figure 2). Three genotypes in this segment GG, GC and CC had the genotypic frequencies of 0.61, 0.26 and 0.13, respectively (Table 3). Two band patterns for OCX-32 exon-4 (Figure 3) were observed. Three genotypes in this segment AA, AC and CC had the genotypic frequencies of 0.11, 0.36 and 0.53, respectively (Table 3).

fig 2

Figure 2: Representative genotyping of OCX-32 gene at locus c.381 G>C. by agarous gel electrophoresis. Strands with 342 for CC genotype, 155, 187 and 342 for GC genotype and 155 and 187 for GG genotype appeared at this locus.

fig 3

Figure 3: Representative genotyping of OCX-32 gene at locus c.494 A > C. by agarous gel electrophoresis. Strands with 250 for AA genotype, 56, 194 and 250 for AC genotype and 56 and 194 for CC genotype appeared at this locus.

Table 3: Genotypic and gene frequency of OCX-32 gene.

SNP

Frequency genotype

Frequency allele

c.381G>C

GG GC CC G

C

0.61

0.26 0.13 0.74

0.26

c.494A>C

AA AC CC A

C

 

0.11

0.36 0.53 0.29

0.71

Associations between Genotypes and Production Traits or Breeding Values

IGF-I

Results on the effects of IGF-I SNP on production and growth traits are shown in Table 4. The g.570 C > A genotype was significantly associated with average egg weight at age of 30 (EW30) (P < 0.05) in this population. No significant association was found between the IGF-I SNP and other traits (Table 4).

Table 4: Association of the IGF-I genotypes at the growth and egg production traits (Mean ± S.E.).

Traits

 

Genotype AA

Genotype AC

Genotype CC

WSM

1726.18 ± 20.22

1740.25 ± 17.84

1765.15 ± 42.12

ASM

175.81 ± 1.06

177.97 ± 0.79

174.68 ± 2.79

EN

39.28 ± 0.89

40.07 ± 0.80

40.09 ± 1.70

EW28

44.30 ± 0.52

45.51 ± 0.46

43.10 ± 1.01

EW30

48.44 ± 0.49 ab

48.41 ± 0.45 a

46.27 ± 0.96 b

AV

51.91 ± 0.44

51.38 ± 0.40

51.03 ± 0.83

EM

1929.45 ± 446.35

2019.28 ± 41.43

1958.00 ± 87.54

EINT

59.29 ± 2.64

61.26 ± 1.49

61.03 ± 3.07

a,bValues with different superscripts within the same row differ significantly (P<0.05).

OCX-32

Results on the effects of OCX-32 SNP on growth and production traits are shown in Table 5. At exon 3, genotype GC had higher egg number compared with genotype GG (P < 0.05, Table 5). At exon 4, genotype CC was significantly associated with egg number (P < 0.05, Table 5) compared with genotype AC.

Table 5: Effects of c.381G>C and c.494A>C SNPs of the OCX-32 gene on growth and production traits (least squares means ± SE).

SNP

c.381G>C

c.494A<C

Genotype

GG GC CC AA AC

CC

BW12 (gr)

751.33 ± 14.36 733.25 ± 16.24 707.71 ± 29.69 688.82 ± 26.03 732.47 ± 14.62

756.56 ± 13.50

WSM (gr)

1738.36 ± 21.54 1729.77 ± 26.07 1706.98 ± 53.00 1685.13 ± 46.32 1713.00 ± 24.07

1761.97 ± 23.05

ASM (day)

175.37 ± 1.66 177.76 ± 1.10 179.32 ± 3.25 172.34 ± 1.83 173.24 ± 1.99

172.42 ± 1.90

EN (number)

41.30 ± 0.79 b 43.64 ± 0.96 a 43.42 ± 1.95 ab 41.83 ± 1.72ab 43.54 ± 0.89 a

341.39 ± 0.85 b

EW28 (gr)

44.56 ± 0.45 44.62 ± 0.57 45.51 ± 1.16 43.29 ± 0.98 44.53 ± 0.50

45.18 ± 0.50

EW30 (gr)

48.25 ± 0.35 47.84 ± 0.44 49.31 ± 1.01 46.81 ± 0.82 48.65 ± 0.49

48.13 ± 0.49

EW32 (gr)

52.56 ± 0.43 52.01 ± 0.52 49.70 ± 1.06 51.10 ± 0.97 52.06 ± 0.49

52.54 ± 0.47

EW84 (gr)

51.68 ± 0.49 51.46 ± 0.60 49.71 ± 1.21 49.38 ± 1.10 50.31 ± 0.56

51.81 ± 0.53

AV (gr)

50.22 ± 0.38 50.19 ± 0.46 48.19 ± 0.94 48.26 ± 0.83 50.03 ± 0.43

50.47 ± 0.41

EM (gr)

1947.08 ± 40.96 2070.16 ± 49.21 1987.59 ± 100.22 1907.50 ± 88.20 2061.73 ± 45.84

1958.06 ± 44.32

a,bValues with different superscripts within the same row differ significantly (P<0.05).

Discussion

In the present study, the g.570 A < C polymorphism of the IGF-I promoter was detected in Mazandaran indigenous chicken: allele frequencies for A and C were 0.78 and 0.22, respectively. The g.570 A < C polymorphism has been reported as a candidate mutation influencing growth and carcass traits [10,11,25]. Previous studies have shown that the g.570 A > C polymorphism is significantly related to body weight at 107 days of age [10], 2, 4, 6 and 8 weeks of age [11], and 5 weeks of age [25].

For production traits, however, no significant differences were found in the association between the g.570 A < C polymorphism and other traits. In contrast, the g.570 A < C polymorphism is strongly assumed to be involved in 30 weeks (EW30). These results support the notion that selection of average egg weight at age of 30 weeks (EW30), is a powerful method to increase production traits and the g.570 A<C polymorphism might become a marker for elevating average egg weight at age of 30 (EW30). In particular, we propose that the identification of g.570 A < C genotypes may be useful in the selection for reproductive traits. To make further progress, it is necessary to investigate the associations between the g.570 A<C genotypes and production traits in the other breed.

The relationship between the IGF-I promoter mutation and growth or carcass traits has been studied in some breeds of chicken and cattle. For example, effects of the polymorphism IGF-I gene were surveyed on egg quality in Wenchang chicken [12]. Some results showed single nucleotide polymorphisms 512-bp upstream from the start codon had significant associations with weight gain during the first 20 days after weaning and on-test weight in Angus cattle [26]. Furthermore, the same report indicated that the g.570 C > A substitution A→C in the promoter region involved the suppression of one potential CdxA transcription factor binding site. Hence, the different alleles detected in the present study might alter the transcription rate and the gene expression level of IGF-I, thereby affecting circulating IGF-I concentrations and muscle development.

An association between the single nucleotide polymorphisms of the OCX-32 gene and the thicknesses of the mammillary layer was recently reported by Dunn et al. [16]. In the present study, the SNP of the OCX-32 gene were significantly associated with body weight at age of 12 weeks, average of EW28, EW30 and EW32, egg number and average egg weight at age of 32 and 84 weeks. We did not find any significant association between these single nucleotide polymorphisms and the other investigated traits. In the case of c.494 A > C SNP in exon 4 implied that the chicken OCX-32 gene may affect reproductive and production traits related traits simultaneously. Yang et al. [22] showed that the OCX-32 expression levels and EPR were related. Therefore, to confirm the causal mutation derived by only a single SNP, we need to evaluate the effects in different breeds and lines of chickens and investigate the function of this gene in detail. Our results show that detection and utilization of candidate gene mutations and DNA markers obtained by whole-genome scanning may directly improve growth, production traits and other economic traits within the same breeds. In particular, we propose that the identification of genotypes may be useful in the selection for production and reproduction traits. To make further progress, it is necessary to investigate the associations between the genotypes and traits in the other breeds. This result shows that OCX-32 gene can be used as a candidate marker in marker-assisted selection. Further functional analysis is essential to ascertain the effects of the OCX-32 exon polymorphism.

Abbreviations

IGF-I: Insulin-like growth factor-1

OCX-32: Ovocalyxin-32

BW1, BW8, BW12: Body Weight at Birth, 8, 12 weeks of age

WSM: Body Weight at sexual maturity

ASM: Age at first egg

EN: Egg Number

EW1: Weight of First Egg

EW28, EW30 and EW32: Average Egg Weight at 28, 30 and 32weeks of age respectively

EW12: Average egg weight for First 12 weeks of production

AV: Average for EW28, 30 and 32

EM: Egg Mass

EINT: Egg Production Intensity

Acknowledgement

The authors are thankful to the researcher, F. Marandi for positive feedback on this research project.

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What to Say to Drive Opera Attendance: A Mind Genomics Cartography

DOI: 10.31038/ASMHS.2020413

Abstract

We present a novel approach to arts marketing, using Mind Genomics, demonstrating the use with a study conducted for the Arizona Opera. Respondents evaluated different messages about opera, rating combinations of these messages, the combinations created according to experimental design. The deconstruction of the responses revealed the part-worth contribution of each element to interesting the respondent in opera. The deconstruction of the response time showed the elements which engaged the respondent’s attention. Two mind-sets emerged, those interested in the educational aspects of opera, and those interested in the entertainment value of the experience. We introduce the PVI, the personal viewpoint identifier, a tool to assign new individuals to one of the two mind-sets, and suggest how the PVI may contribute to a more effective digital marketing campaign.

Introduction

Patrons of the arts, especially opera but also of the other arts, are well aware of the need of those who both fund and stage the artistic efforts to understand the mind of their audiences. When it comes to the more conventional things that are marketed, the objective is stated in economic terms, such as maximizing share, or maximizing profit. The economic aspects are paramount. When it comes to certain other aspects of human effort, such as culture, and specifically in our case, opera, the introduction of the ‘marketing concept’ is fraught with more equivocation, more tension. Some of this may come from the nature of the topic, and the realization that the marketing concept is a crude, unfeeling alternative to the higher order efforts of that which is being marketed, namely ‘culture.’

When we move to marketing for non-profits, and especially those dealing with the arts, we move from working with products and services delivering concrete benefits to products and services existing because they deliver aesthetic experiences to their audiences. How does one deal with these experiences? Is the marketing effort to be geared to the experience as an economic construct, or as an experience construct? Is there a measure of pleasure?

The literature of marketing and the arts is quite rich, perhaps because those in the arts realize how important it is to gain the patronage of those who enjoy the arts. Arts marketing is not necessarily as rich in academic studies, but arts marketing has its array of practical work, and books. Thus, we have titles such as Diggles’ 1986 book on ‘Guide to Arts Marketing: The Principles and Practice of Marketing as They Apply to Arts’ (Diggles, 1986), going in hand in with books about non-profit organizations such as Rados’ 1996 book ‘Marketing for Non-Profit Organizations’ (Rados, 1996).

When it comes to arts and marketing in the academic literature, there are few studies reported in the spirit of what we would call an experiment. The studies tend to deal with the topic of marketing from the point of view of sociology (e.g., Butler, 2007; Colbert, 2003; Ventakatesh & Meamber, 2006). That is, the studies report about what is being done in society at large. The spirit of the research focuses on the common patterns of behavior used by those trying to raise money from subscribers or patrons.

One possible reason for the lack of literature featuring ‘experiment’ is the nature of art. Art is an expression of the nobler characteristics of the human spirit. Hirschman (1983) put it this way:

It is proposed that the marketing concept, as a normative framework, is not applicable to two broad classes of producers because of the personal values and social norms that characterize the production process. These two classes of producers are artists and ideologists. Artists are those who create primarily to express their subjective conceptions of beauty, emotion or some other aesthetic ideal. Ideologists are those who put forward an integrated set of positive and normative statements that describe what the world is and what it should be.

Steps in the Mind Genomics Process

The study reported here focuses on what can be said specifically about the Arizona opera to drive positive behaviors, either in terms of attitude or in terms of action. The study can be best described as an experiment, to understand how the specific communications drive responses. The study follows the tenets of Mind Genomics, an emerging science which deals with the way we respond to the specifics of ordinary, daily life, such as the opera. Mind Genomics focuses on the responses to messages about the different topics of daily life, not to show the rationality or irrationality of people, but rather to discover the aspects of daily life to which people pay attention when asked to make a decision (Moskowitz & Gofman, 2007; Moskowitz et. al., 2006).

Mind Genomics is evolving to a set of defined steps in order to understand the everyday ‘mind’ of an individual faced with information about the ordinary information that must be used to make a decision. The steps are not ‘fixed in stone.’ Rather, the steps reflect a work in progress, a system to develop a deeper understanding of how a person weighs specific ‘pieces of information’ to make a decision (Moskowitz, 2012; Moskowitz et. al., 2006; Moskowitz & Gofman, 2007.)

Step 1: Define the Topic

The topic is ‘What to say to prospective opera attendee to make that individual want to subscribe to the Arizona Opera’. It is clear that the topic is limited and specific. Often, the depth of information to be gained ends up far greater and more useful when the researcher focuses on specifics, and limits the topic. With the limitation, it becomes possible to probe deeply, testing many different specific messages relevant only to the subscription to the Arizona Opera. If the topic were more general, such as ‘what makes a good opera experience,’ we might have many elements as well, but we would lack the specifics which make the idea real in the mind of the reader. We might end up testing generalities which lack the cognitive richness of the particular.

Step 2: Create a Set of Four Questions, and for Each Question, Provide Four Answers

The questions should ‘tell a story,’ and be answered by a phrase, not just yes/no nor just a single word. The rationale for requiring a phrase for the answer is that later, during the actual Mind Genomics experiment, the answers, now elements, will be mixed and matched to create vignettes. It is easier when the pieces of information can be read as phrases, the combination of which ‘tells a story.’

Table 1 presents the four questions, and the four answers. The selection of questions, and then the four answers for each question, is done with the full understanding that this specific set of questions and answers is only a small fraction of the possible questions and answers. The terms ‘answers’, ‘messages’, and ‘elements’ will be used interchangeably in the rest of this paper.

Table 1: The four questions about attending opera, and the four answers to each question.

Question A: What is it?
A1 AZ Opera … Bold, Brave, Brilliant
A2 Presenting artists of both international stature and emerging talent
A3 Elevates the transformative power of storytelling through music
A4 One of the only Operas in the country that regularly performs in two cities
Question B: Why do I like it?
B1 a special place where I can get really dressed up and be glamorous
B2 Shouting “BRAVO!” during the show and at the final curtain call
B3 Dinner plus the show … a total night out on the town
B4 AZ Opera performances I can listen to on public radio
Question C: How do I do it?
C1 An Opera season where I can choose my own subscription
C2 AZ Opera … I can mix and match the performances
C3 English translations of the lyrics are projected on a screen above the stage as they are sung
C4 Arrive an hour before curtain to learn about the show you are about to see!
Question D: Why does it matter to the community?
D1 Free music and lecture series examine each opera in detail
D2 Free brown bag operas on Fridays before the big event
D3 A traveling troupe brings opera to schools
D4 Arizona Opera’s book club … a great way to meet fellow audience members and discuss, learn, and connect

Step 3: Create Vignettes

The vignettes comprise combinations of elements (viz., answers), arranged one on top of the other, centered. A vignette comprises at most one element or answer from each of the four questions. The vignette comprises 2-4 elements but often, and by design, no answer from one or two questions. The vignettes are created according to an experimental design, with each design comprising 24 different vignettes. The mathematical structure underlying the experimental design ensures that the 16 elements or answers are statistically independent of each other (Heller, 1986). In the actual experiment, each respondent will be presented with a permutation of the basic design, a permutation which maintains the same statistical benefits (independence of elements, individual-level experimental design). In actuality, the permutation simply creates different sets of combinations from respondents, allowing the researcher to explore a many possible combinations, and build up knowledge by exploring the topic broadly, rather than build up knowledge by exploring one little region of the topic with precision by replicating the same set of 24 vignettes across many respondents. The permuted experimental design ensures that one can analyze the data from as few as one respondent to obtain clear information. The permuted experimental design is a key feature of Mind Genomics (Gofman & Moskowitz, 2010), and metaphorically can be likened to understanding the topic using an MRI (magnetic resonance). The MRI takes pictures of the tissue from many angles, and puts the data together to create a single, coherent picture.

Step 4: Invite Respondents to Participate

Mind Genomics experiments typically require about five minutes of a respondent’s time. Although it seems a good idea to invite respondents from among one’s friends and associates, the reality is the abysmally low response rate, usually around 10% or lower. People simply do not want to volunteer their time in a world where many factors compete for a person’s attention. The solution to this conundrum is to work with a panel company, which specializes recruiting and compensating individuals for these studies. The Mind Genomics study was executed among respondents provided by Luc.id, Inc. a company specializing in these studies. The respondents were invited to participate by email.

Step 5: The Test Stimuli and the Respondent Instructions

The Mind Genomics experiment comprises the evaluation of 24 different vignettes, rating each vignette as a single ‘message’ or single ‘idea.’ As noted above, the vignettes are combinations, comprising 2-4 elements, so it is impossible for a respondent to ‘game’ the system by rating the single vignette in the way that the respondent believes the researcher wants to hear. The vignettes are compounds of different messages, each message pulling in its own direction. The respondent may begin by trying to be consistent and ‘politically correct,’ but ends up disinterested, responding to the vignette in an indifferent, almost automatic fashion. That condition of ‘disinterest’ ends up ensuring that the data represent what the respondent truly feels.

The Mind Genomics experiment prefaces each vignette with the same simple instructions about what to do:

You will be presented with a series of statements. Please respond to the statements with your initial reaction. Use the number scale where 1 means I don’t like it at all and 9 means I love it.

Step 6 – Transform the Data

The Mind Genomics study generates ratings on a 9-point scale. Best practices in the world of applied consumer research suggest that it is easier to understand data when the data presented in binary form, no/yes, 0/100. For this study using the 9-point rating scale as the dependent variable, the typical transformation is ratings of 1-6 transformed to 0, and ratings of 7-9 transformed to 100. This is called TOP3. A second transformation changed ratings of 1-3 to 100, and ratings of 4-9 to 0. This is called BOT3 to reflect the elements which drive people away from opera. Finally, the Mind Genomics program also measures the Consideration Time (aka Response Time), defined as the time in seconds between the appearance of the vignette and the respondent’s rating. The Consideration Time is measured to the nearest tenth of a second.

Step 7 – Create Individual Level Models Relating the Transformed Rating (Binary) to the Presence/Absence of the 16 Elements, and then Cluster the Respondents on the Basis of the 16 Coefficients, k1 – k16

The experimental design used to create the 24 vignettes for each respondent ensures that the 16 elements are statistically independent of each other. The first statistical analysis uses OLS (ordinary least-squares) regression to create an equation describing how each of the 16 elements contributes to the binary transformed rating. The equation is expressed as: Rating = k1(A1) + k2(A2) … k16(D4). There is NO additive constant used in the modeling. The individual level modeling generates a matrix, in which each row is a respondent and each column is an element. The numbers in the body of the matrix are the coefficients for the 16 elements, on a respondent by respondent basis. The additive constant is not retained for this first analysis.

The second statistical analysis uses clustering to divide the respondents into two, and then three complementary groups, based upon the pattern of the 16 coefficients. The coefficients for TOP3 are used in the clustering. The clustering program computes a distance between respondents (D=(1-Pearson R)). Pairs of respondents with similar patterns of coefficients show a high Pearson R (Pearson correlation coefficient), and assigned to the same cluster. Pairs of respondents with different patterns of coefficients show a low Pearson R and are assigned to different clusters (Jain & Dubes, 1988).

Step 7 is done completely automatically, without any interpretation about what the cluster might actually be called. Everything in Step 7 is done under strictly mathematical rules.

Step 8: Define the Key Subgroups

These subgroups may be the standard ones of age and gender, obtained by a short classification questionnaire which is part of the Mind Genomics experiment. The subgroups may also correspond to the clusters determined from Step 7. The latter subgroups, emerging from clustering the TOP3 coefficients, are renamed ‘Mind-Sets’ to reflect the fact that they represent groups of individuals who view the topic in different ways. For this study on marketing the Arizona Opera, we end up with the Total panel and six key subgroups. The subgroups are:

From self-classification:                                     Gender                  Male vs Female

From self-classification:                                     Age                       19-29 years old vs 30 years and older

Emergent from clustering coefficients:                Mind-Set                MS1 (Learning) vs MS2 (Entertainment).

Step 9: Relate the Elements to the Dependent Variables, Using Regression

For all the respondents in either the Total Panel or key subgroup, combine the data into one file, and use OLS regression to relate the presence/absence of the 16 elements to three dependent variables: TOP3 (Interested), BOT3 (NOT Interested), and CT (consideration time). The OLS regression estimates the model using all of the data for the key group, rather than estimating individual level models.

The model is written without an additive constant, in order to allow comparisons across groups, and across dependent variables.

The equation is expressed as: Dependent Variable = k1(A1) + k2(A2) … k16(D4)

Step 10: Extract the ‘Story’ from the Coefficients

The data emerging from Mind Genomics comprise elements and their coefficients, the latter estimated by regression. The data is doubly rich. First there are the elements and their respective coefficients. Each element stands by itself. Simply knowing the element and its coefficient for a specific dependent variable, tells the researcher either how important the element is in terms of attitude (TOP3 = Like; BOT3 = Dislike), or in terms of engaging attention (Consideration Time). Second, the pattern linking together the strongest performing elements also tells a story, this time a more general one. There may or may not be a coherent story linking together the strongest performing elements. The absence of a story does not weaken the data, but simply prevents the discovery of the general pattern.

The data are shown in tabular form. For the binary dependent variables (Like, TOP3; Dislike, BOT3), coefficients appear in shaded cells when the coefficient is 15 or higher. For the Consideration Time (CT), coefficients appear in shaded cells when the consideration time or engagement time is 1.5 seconds or higher for the element. The selection of a coefficient of 15 or higher is based upon independent analysis which related the coefficients of the 16 elements estimated in the absence of an additive constant to the coefficients of the same 16 elements estimated with the equation containing an additive constant. A coefficient of 7.5 for the latter (with additive constant) is statistically significant (p<0.05), and corresponds to an additive constant of approximately 16 for the former (without an additive constant). The selection of the Consideration Time of 1.5 seconds is based on judgment, and the search for a meaningful, easy-to-understand pattern.

Results – Total Panel

What to say (TOP3) – set of easy to customize social occasions where one learns and enjoys (Table 2)

Table 2: Performance of the 16 elements across the total panel.

table 2

B3                Dinner plus the show … a total night out on the town

C3                English translations of the lyrics are projected on a screen above the stage as they are sung

C2                AZ Opera … I can mix and match the performances

D1                Free music and lecture series examines each opera in detail

C1                An Opera season where I can choose my own subscription

What not to say (BOT3) – don’t overdo the ‘kitschy’ aspect

B1                 a special place where I can get really dressed up and be glamorous

B2                 Shouting “BRAVO!” during the show and at the final curtain call

What engages (CT) – talk about the learning and knowing opportunities

D4              Arizona Opera’s book club … a great way to meet fellow audience members and discuss, learn                       and connect

A4                One of the only Operas in the country that regularly performs in two cities

C2                AZ Opera … I can mix and match the performances

C3                English translations of the lyrics are projected on a screen above the stage as they are sung

C4                Arrive an hour before curtain to learn about the show you are about to see!

By Gender and Age

The analysis for total panel can be repeated for four key subgroups, one group at a time. The same criteria were used, namely a coefficient > 15 for TOP3 and BOT3, and a Consideration Time of 1.5 or longer. Table 3 shows the messaging which increase attendance (TOP3), and a suggestion of the common theme.

Table 3: Performance of the elements as drivers of interested (TOP3). Data from key geo-demographic subgroups. Only elements strongly interesting at least one subgroup are shown.

table 3

Males – Entertainment and Other Occasions for Listening

B3                 Dinner plus the show … a total night out on the town

B4                 AZ Opera performances I can listen to on public radio

Females – Many Elements, Especially Entertainment and Learning

B3                Dinner plus the show … a total night out on the town

C2                AZ Opera … I can mix and match the performances

D1                Free music and lecture series examines each opera in detail

C3                English translations of the lyrics are projected on a screen above the stage as they are sung

C1                An Opera season where I can choose my own subscription

C4                Arrive an hour before curtain to learn about the show you are about to see!

A1                AZ Opera … Bold, Brave, Brilliant

D2                Free brown bag operas on Fridays before the big event

A3                Elevates the transformative power of storytelling through music.

Age 19-29 – Entertainment and Learning

B3                Dinner plus the show … a total night out on the town

D1                Free music and lecture series examines each opera in detail

A3                Elevates the transformative power of storytelling through music

C2                AZ Opera … I can mix and match the performances

A2                 Presenting artists of both international stature and emerging talent

Age 30+ Entertainment

B3                Dinner plus the show … a total night out on the town

C3                English translations of the lyrics are projected on a screen above the stage as they are sung

C1                An Opera season where I can choose my own subscription

Table 4 shows what not to say. There are no strong elements. When we lower the criteria to a value of 10 or higher, rather than 15 or higher, we end up with two elements, B1 and C2, which tell no story.

Table 4: Performance of the two strong performing elements driving not-interested (BOT3). Data from key geo-demographic subgroups.

table 4

Table 5 shows what engages, operationally defined as elements which have Consideration Times of 1.5 seconds or longer.

Table 5: Performance of the elements which engage the respondent. Data from key geo-demographic subgroups.

table 5

Males – engaged strongly by five of the elements, with the most engaging elements dealing with what the person can do. That is, males are engaged by elements which get the reader to think about what to do.

Females – engaged strongly by five elements, with the most engaging elements dealing with learning and discussing.

Age 19-29 – engaged strong by two elements, both focusing on socializing.

Age 30+ – engaged strongly by seven elements, combining both the act of creating one’s series, and the act of learning and seeing others learn.

The Two Emergent Mind Sets Based on Interest

The clustering program generated two mind sets, based upon ‘interest’ (TOP3). Table 6 shows that many of the elements are strong performers, albeit in only one of the two mind-sets. Mind-Set1 can be labelled those who are interested in the educational aspects of the opera. Mind-Set 2 can be labelled those who focus on the entertainment experience.

Table 6: Performance of the 16 elements across the two mind-sets. MS = Education Focused, MS2 = Entertainment Focused.

table 6

It is clear from Table 6 (columns labelled TOP3) that what strongly appeals to one mind-set (e.g., education) tends not to appeal to the other mind-set (viz., entertainment). Furthermore, the strong and rather polar nature of the elements, in terms of how they drive the response of the mind-sets, suggests that there are at least two clear groups in the world of respondents to whom one must appeal. What appeals to one mind-set will not generally appear to the other mind-set.

When we turn to what does not appeal to the two mind-sets (BOT3) we see no pattern.

When we turn to what engages (Consideration Time we see that Mind-Set 2 (Entertainment) seems more likely to be engaged by what interests them, and that Mind-Set 1 (Education) seems to be less engaged by what interests them. This pattern emerges when we compare strong performing elements (high TOP3) to the level of Engagement (CT). The correlation between TOP3 coefficient and CT coefficient across the 16 elements is +0.04 for Mind-Set 1 (Education) and +0.39 for Mind-Set 2 (Entertainment). The difference in the magnitude of the correlation suggests radically different strategies to engage the respective attentions of individuals in the two mind-sets.

Finding Mind-sets in the Population

In today’s world of abundant data, a world filled with questionnaires, where interviews abound, and where it seems one can hardly do anything without a follow-up request to rate the product or rate service, one might think that we can find these mind-sets easily. The answer is that we cannot. The mind-sets uncovered above, the education vs experience mind-sets, are particular to the experience of opera. The two mind-sets may be reflections of different ways of enjoying public performances of the arts, but it would take massive efforts and monetary expenditure to establish that, and then use the findings to guide marketing. In the meanwhile, the Mind Genomics study reported here was set up, executed, and completely reported in less than three hours. The paradox is that it becomes almost a ‘trivial’ effort to establish valuable information for science and for marketing, but a very difficult, labor-intensive, resource-intensive effort to apply the findings. Simply said, databases do not have fields for ‘the way the person enjoys the performing arts.’

Table 7 shows the distribution of respondents by mind-set, as well as by gender, age, and self-profiling of interest in opera. It is extremely difficult to predict the messages to give to a respondent, knowing gender, age, and even general behavior with respect to attending opera. The messages themselves are straightforward, emerging from the Mind Genomics effort. It is the assignment of an individual to a mind-set which is difficult. Knowing who a person “IS” does not predict how a person “THINKS.”

Table 7: Cross tabulation showing the distribution of respondents into age, gender, and responses to the up-front classification question about opera attendance. The classification information was collected at the start of the Mind Genomics experiment.

  Total MS1 Education MS 2 Entertainment
Total 100 45 55
Gender: Male 52 23 29
Gender: Female 48 22 26
Age: 18-29 22 11 11
Age: 30+ 78 34 44
Opera – Season subscriber 3 2 1
Opera – A few shows a year 28 15 13
Opera – Not subscriber but would like to be 36 14 22
Opera – Not subscriber, not interested 29 14 15

Recently, authors Gere and Moskowitz have developed an implemented a rapid technique to assign new people to one of two (or three) mind-sets. The approach uses the basic sets of coefficients for the two mind-sets, shown in Table 6 (columns marked Top 3). The approach adds ‘noise’ to the set of coefficients, and identifies the pattern of response ‘under noise’ which best differentiates the mind-sets and reproduces the original results. This Monte-Carlo simulation is followed by the creation of a simple 6-question matrix, shown in Figure 1. The matrix requires the respondent to answer using a two-point scale, the anchors of which are chosen by the researcher. The pattern of responses of responses determines the mind-set to which the new person is assigned. The respondent begins by providing classification information, information that can be suppressed and not required if so desired. The respondent then answers the six questions in different orders to reduce order bias, as well as answering other, optional questions about the topic. Finally, the respondent submits the completed form, and immediately receives feedback regarding the mind-set to which the respondent belongs. The information is stored in a database for subsequent personalized marketing. The PVI opens up new opportunities for marketing, especially for digital marketing, which can change the content of an advertising piece as soon as the PVI assigns the new person to one of the two mind-sets.

fig 1

Figure 1: The PVI (personal viewpoint identifier), and the feedback to the participant.

Applying Mind Genomics Knowledge to Create an Effective Digital Media Strategy

A key benefit of the Mind Genomics science is its immersion in the world of the everyday, and the opportunity therefore to use the results in practical application. The principles emerging from Mind Genomics teach us about the mind-sets of people, in this paper the mind-sets related to opera. The elements are phrases having meaning to the average person, and thus to the potential opera fan, or at least the potential opera attendee. Unlike other types of studies to understand the person, studies which use artificial stimuli of little cognitive richness, Mind Genomics attempts to work within the structure that has every day meaning.

One consequence of the everyday meaningfulness of Mind Genomics cartographies is the potential application of the findings for opera companies in social media, the application being called ‘digital media strategy.’ Digital media strategy divides into two areas, paid advertising where the goal is to directly broadcast to convince the audience, and organic digital strategy with content placed on websites and other media, which convince by the nature of the facts conveyed, and their efforts to inform.

Let us first look at the ‘Organic Digital Strategy,’ namely websites and social media other than paid advertising. This organic digital strategy typically constitutes the foundation of an organization’s ONLINE presence. It is difficult, if not impossible, to segment individuals on social media platforms, at least in terms of the specifics for the opera. The optimal strategy for the Arizona Opera would thus be to use the most persuasive language across the Total Panel. It is here, at the stage of messaging, that the granularity of Mind Genomics does best. The four strongest performing elements promise the greatest positive response, in the absence of any additional information. These are the specific messages:

A3: Elevates the transformative power of storytelling through music

B3: Dinner plus the show… a total night out on the town

C3: English translations of the lyrics are projected on a screen above the stage as they are sung

D1: Free music and lecture series examine each opera in detail.

Using this language ensures the highest probability of converting website visitors and social media followers to Arizona Opera attendees and subscribers. The elements which strongly resonate across all viewers can enhance the “About” section of the Arizona Opera’s social media channels and website, executed through the captions of the content (e.g. images, videos, and GIFs), as well as within the content itself.

Paid Digital Strategy synergizes with the organic digital efforts but produces benefits regardless of the organic strategy. For the Arizona Opera, the likelihood of high returns may be accomplished by focusing the advertising budget on Facebook Ads, especially when the ads can be targeted to specific demographics of age and gender, with the proper messages. The messages below show elements with coefficients around 20 or higher for each group. These messages are expected to perform best. Note that the four demographic subgroups show different numbers of strongly appealing messages. Other elements may be substituted, but may be expected to perform less impactfully (Table 3). The key benefit here of Mind Genomics is the ability to provide a reservoir of possible messages, each pre-tested, at least in the Mind Genomics experiment.

Males

B3          Dinner plus the show … a total night out on the town

Females

B3          Dinner plus the show … a total night out on the town

C2          AZ Opera … I can mix and match the performances

D1          Free music and lecture series examine each opera in detail

Age 19-29

B3          Dinner plus the show … a total night out on the town

D1          Free music and lecture series examine each opera in detail

Age 30+

B3          Dinner plus the show … a total night out on the town

The data presented here provide the opportunity to create a potentially powerful, and more individualized campaign. One example is a campaign working with Facebook. Within Facebook Ads, marketers who create conversion campaigns can track the path of user behavior. Using the example of Arizona Opera ad, it is first seen on a social media platform. The ideal end of the path is the purchase of a ticket. By launching a campaign, Facebook’s ‘internal learning processes’ discover the commonalities (known to Facebook) among those individuals who purchase the tickets to the Arizona Opera. The operating assumption is that ‘birds of a feather behave similarly,’ i.e., people who are like each other will act similarly. The belief is that by finding out what is similar among those who purchased tickets for the Arizona Opera, one can fine-tune the advertising, selecting only people with similar profiles, at least profiles known to Facebook.

The PVI, personal viewpoint identifier, makes a contribution to digital marketing campaigns, albeit in a different way. By knowing the mind-set of an individual, either ahead of time from a previous campaign, or during the current campaign, the marketer for the Arizona Opera need not invoke the learning algorithm. One already knows far more about the opera-relevant messages for the individual, and need only pull out the appropriate messages, either for Mind-Set 1 or Mind-Set 2. Thus, the combination of topic, speed and ease of Mind Genomics knowledge development, and the deployment of the PVI, produce a new vista for digital marketing.

Discussion and Conclusions

The combination of arts marketing and Mind Genomics opens up a new opportunity to understand people, as well as to enhance the cultural offerings of a region. The literature of arts marketing provides a sense of the ‘touch points’ of a relatively ambiguous topic, the topic being an entity which is both a business and a social good. Arts marketing is vital for the culture to maintain its soul and vitality, but at the same time arts marketing is a business, feeding people and organizations.

The introduction of Mind Genomics to the issues involved in arts marketing, typified by the study of the messaging for the Arizona Opera, suggest that it may be possible to move arts marketing to a new level of effectiveness by understanding the mind of the prospective opera-goer. Mind Genomics provides solid, concrete, and specific knowledge about a person’s response to messages about opera. The academic foundations of Mind Genomics, especially those studying trade-offs and choice (Green & Srinivasan, 1991) are enhanced by focus on everyday decision making using our ‘fast thinking’, viz., System 1, in the words of Nobel Laureate psychologist, Daniel Kahneman (Kahneman, 2011). The two emergent benefits are, respectively, a deep understanding of the topic for science and arts, as well as a practical database to drive a person’s behavior by the proper messaging.

As the present study shows, such information can move from question to study to results, and even to the PVI, in a matter of a day or even a few hours. The output of one of these studies can help the opera, as well as provide deep information about the mind of the opera-goer, or prospective opera-goer. The output of a set of these studies provides a fuller profile of the mind of the typical person with respect to the performing areas, and, in turn, what effective messages should be communicated. Finally, putting the data about mind-set into the digital marketing effort, as customer-volunteered information, means that the marketing efforts are directed at people with similar mind-sets, not similar demographics.

References

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  2. Colbert F (2003) Entrepreneurship and leadership in marketing the arts. International Jouqrnal of Arts Management 6: 30-39.
  3. Diggles K (1986) Guide to Arts Marketing: The principles and practice of marketing as they apply to arts. London: Rhinegold Pub. Limited.
  4. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127-145.
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Opinion: Why Should We Care about Endocrine Disruptors?

DOI: 10.31038/CST.2022711

 

The Endocrine Disruptors (EDCs) are defined as “exogenous chemical, or mixture of chemicals, that interfere with any aspect of hormone action”, and in 2015, the Endocrine Society convened a large group of experts to review in-depth the state of science on EDCs [1]. Over the years a massive accumulation of data supports growing concern on EDCs’ harmful effects on humans and all other living organisms. 

A. Why Do We Care so much about EDCs?

  1. We care because EDCs interfere with the normal function of the endocrine system and can harm every organ of a living organism.
  2. EDCs are especially dangerous for the developing fetus and their effects can persist to affect early life, adulthood, and even follow to the next generations.
  3. EDCs are present in food, water, air, soil, cosmetics, medicines, toys, and other items. They accumulate in living organisms and the aquatic species are particularly vulnerable. 

B. What Do We Need to Know for Efficient Detection and Monitoring of EDCs?

  1. The status on the methods of detection 

C. Why Do We Need Public Awareness of EDCs Effects?

Because their presence in the environment is not well sufficiently regulated, and the screening methods do not always include a biological read-out. An excellent example is Bisphenol A (BPA) which was synthesized in 1936 as an estrogenic compound. Subsequently it was discovered that BPA activates other nuclear receptors, including thyroid receptor (TR). Despite recent restrictions, BPA is one of the highest production-volume chemicals used in manufacturing polycarbonate plastics and epoxy resins.

  1. Several major manufacturers of baby bottles removed BPA from their products after a public outcry.
  2. Unfortunately, all of us have BPA in our bodies because it is in food, household, and industrial items, including linings of canned foods and drinks.

D. Why are We Still Deliberating about Harmful Effects of EDCs?

  1. The major reasons are that we lack uniform agreement among scientific community on “safe” levels of EDCs. Some consider that any exposure is unacceptable, while others call for establishing a low dose limit for specific products.
  2. Regulatory agencies world-wide have not provided sufficient restrain for continuing accumulation of EDCs in the environment.
  3. Industry and environmental non-government organizations present conflicting information, and the lay press oversimplifies the research results, leading to a confusing state of information for many EDCs.

A. Why Do We Care so much about EDCs?

The endocrine system evolved to respond to very low levels of hormones [2-4]. Because of common receptor-mediated mechanisms, EDCs that mimic natural hormones are likely to have biological effects in humans and other species [4-6]. Moreover, small changes in hormonal concentrations can have biologically important consequences [2,4]. Thus, EDCs can have adverse effects on living organisms, and even low doses of contaminants cannot be ignored.

Many EDCs exert their effects as agonists or antagonists by direct interaction with hormonal receptors: estrogen (ERs), progesterone (PR), androgen (ARs), thyroid hormone (TRs), and with nuclear receptors that regulate metabolism and differentiation, such as aryl hydrocarbon (AhR), retinoid X (RXR), peroxisome proliferator-activated (PPARs), liver X (LXRs), and farsenoid X receptors (FXRs) [7]. Following ligand binding, the receptors become transcription factors that regulate expression of many genes.

The most sensitive time for exposure to EDCs is during fetal development [8]. Some EDCs affect fetal development in late pregnancy [9] whereas others are harmful even before the woman is aware of her pregnancy [10,11]. EDCs can also lead to harmful traits carried over to future generations (transgenerational effects) [12], although they do not induce changes in DNA sequence [13]. Thus, the harmful effects may not be immediately apparent, which makes it difficult to discern from other causes.

Long-lasting effects on male and female fertility in several species are particularly of concern [14,15] and the decline in male and female fertility has been detected world-wide [16]. Detection of EDCs in blood, urine, milk, and tissues showed alarming results reflecting global exposure [10].

EDCs can harm every organ in the body. Let’s start with the brain. EDCs can change the expression, abundance, and distribution of steroid hormones and other nuclear receptors in the developing brain. There are multiple documented functional consequences of altered receptor action in fish brain and the most widely studied compounds are BPA and polychlorinated biphenyls (PCBs) [17,18]. All living organisms that consume untreated water are exposed because water is frequently contaminated by pollutants originating from municipal and industrial wastewater effluents, as well as runoffs from livestock and agricultural areas.

In addition to harmful effects on the brain, perinatal exposure to low doses of BPA causes metabolic derangements: increased body weight; adiposity; alterations in blood levels of insulin, leptin, and adiponectin; as well as a decrease in glucose tolerance and insulin sensitivity in an age-dependent manner [19-21].

One of most studied group of EDCs are estrogenic compounds which regulate estrogen receptor (ER) with broad effects on bone mineralization, immunity, male and female reproduction, metabolism, and many other biological processes. The presence of estrogenic substances in the environment has been known for over a century and increased significantly across the globe in the last 50 years. Clover species were documented to contain high amounts of estrogen receptor-activating compounds leading to reproductive disorders in cows and sheep fed with clover-rich diet [22]. Because hormonal synthesis and their world-wide use exploded during the 1940’s, toxicologists noticed their presence in the environment and described the effects on organisms. In US, studies in 1965 [23], in 1970 [24] and thereafter increased public concern for estrogenic chemicals. Although in 1990 the United States Congress updated the US Safe Drinking Water Act to include screening programs to detect estrogenic contaminants, harmful effects of estrogens [25,26] and progestogens, specifically on fish reproduction, have been increasingly documented [27,28].

Thyroid hormone (TH) disruptors are also of particular concern because they govern neurodevelopment and metabolic homeostasis. Exposure during pregnancy has been linked to the rise in autism and cognitive disorders [29-32], as well as increased risk to develop thyroid cancer [33]. Because TH cooperates with progesterone during implantation, TH disruptors also impair pregnancy [34]. Thyroid receptor interacting compounds are widely spread in the US rivers [35,36]. The agonists and antagonists are especially prevalent in water downstream of intense urbanization and livestock production. Triiodothyronine (T3)-like activity are reported in effluents from water treatment plants (WWTP) in Japan [37], and anti-T3 hormonal activity was found in WWTP effluent in Thailand [38].

Weakened immune systems with increased susceptibility to infections are likely due to exposures to glucocorticoids alone or in combination with other EDCs, have been associated with fish kills [39-42].

These are only a few examples of well-documented studies on harmful effects of EDCs.

B. What Do We Need to Know for Efficient Detection and Monitoring of EDCs?

Because of the growing concern on contamination of the environment [1,37,38,43-46], significant attention and investment has been devoted to their detection [47]. Laborious chemical methods of isolation and identifications by a combination of HPLC, liquid or gas chromatography and/or mass spectroscopy, were followed by “omic” approaches (genomics, transcriptomics, proteomics, and/or metabolomics) in fish and other affected organisms [48,49]. Unfortunately, these assays are laborious, costly and identify only a single compound. In addition, lack of uniform quantification and uncertainty of their biological effects limit their use. Thus, analytical strategies based on target chemical analyses have been insufficient to depict meaningful environmental contamination.

Technical innovations using luciferase reporters or fluorescent tags in genetically engineered yeast, mammalian cell lines, or whole organisms, such as zebra fish, led to development of assays in which the read-out is a biological effect elicited by a specific receptor [35,36,50-53]. Many of these methods are sensitive in the below nanomolar range, amenable to high throughput and do not require identification of ligand’s chemical structure.

C. Why Do We Need Public Awareness of EDCs Effects?

Extensive documentation on the adverse effects of exposure to BPA on reproduction and development, cardiovascular, neurological, metabolic, and immune systems [54,55], led to reduction of reference dose by European Food Safety Authority, stronger restrictions and regulations on the production and usage of BPA in North America in 1990, European Union and in Canada in 2010 [56]. It was estimated that 93% of Americans have measurable amounts of BPA in urine [57,58] and because of the wide-spread contamination with BPA, these levels are likely to persist. After substantial public pressure, in 2008 six major manufacturers of baby bottles removed BPA from their products and the trend continues in developing BPA-free goods and materials.

However, many recently developed BPA analogues have also been detected in the environment. Some have similar estrogenic, antiandrogenic and TH disrupting activities [59]. Thus, sustained public awareness and negative publicity is needed to remove BPA and its analogs to prevent further environmental contamination and human exposure.

D. Why are We Still Deliberating about Harmful Effects of EDCs?

Lack of consensus in the scientific community on quantitative methods for detection and “safe” levels of sex hormones in the environment and other EDCs is a major obstacle for development of a rational policy for efficient monitoring and establishing safety limits to protect wildlife and human health. Scientific evidence indicates complex mechanisms operating at low doses showing nonmonotonic dose-response curves (2). A largely unexplored issue is the combined effect of a mixture of EDCs detected in the same sample. Many water sites have several EDCs that interact with glucocorticoid, estrogen, progesterone, thyroid, aryl hydrocarbon and other nuclear receptors [35,52,60-63]. The combinations further modify the biological outcomes as these mixtures are likely to have unexplored effects on target tissues [4,64]. Interactions with receptors, nuclear cofactors, and chromatin remodelers through “assisted loading” mechanisms further modify gene expression [47,65,66]. Some of these epigenetic changes may be long-lasting and possibly inheritable.

As presented in this Opinion, scientific evidence linking EDCs to health effects is strong, but regulations have not kept up with the endocrine science. Despite EPA regulation in US, and WHO efforts in periodic updates (most recently in 2012) the state of science on contamination of water, air and soil, EDCs threaten the integrity of the planet’s ecosystems and pose serious concerns for human and animal health [1,46].

The potential to link epidemiological studies with individual exposure assessments is now feasible. Current eHealth programs, such as All-of-Us, can be critical in evaluating pathophysiology and establishing the temporal relationship between markers of exposure and long-term effects. This is the time for high-level meetings to bring together all critical players with the twin goal of sharing information and considering options for investment in global EDCs detection and monitoring. Only then we can advise on regulatory policies with particular emphasis in relation to human disease. Virtual platforms, popular since 2020 during the COVID-19 pandemic, can make such efforts possible. Scientific knowledge gives national and international agencies an informed opinion on controlling specific aspects of environmental contaminants. A coordinated program encompassing governmental and public organizations and industry leaders with scientists would enable a science-based approach to better understand and halt the impact of EDCs pollution on ecosystems and human health.

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A Case of Severe Exercise Associated Hyponatremia after Running Marathon

DOI: 10.31038/IJNUS.2020213

Abstract

Exercise associated hyponatremia (EAH) can cause serious neurological manifestations. We report a case of EAH presented with convulsion and drowsiness after running marathon. The patient’s plasma sodium level on presentation was 119 mmol/L. He was given intravenous hypertonic saline infusion for 2 times. His conscious level improved after hypertonic saline and plasma sodium level corrected. He regained full consciousness 3 days after admission and was discharged in good condition. In this report, we reviewed the underlying pathophysiology, clinical features, risk factors, prevention measures, and treatment options of this disease entity. Early recognition of this disease entity and timely treatment with hypertonic saline is life saving.

Background

Exercise associated hyponatremia (EAH) is not uncommon and can cause serious neurological manifestations and even death. Early recognition of the diagnosis and timely treatment can be life saving. We here report a case of EAH and review the management for this disease entity.

Case Report

A 39-year-old gentleman with good past health was admitted to Princess Margaret Hospital after developing an episode of tonic clonic seizure. On the day of admission, he had been participating in a marathon run from 8:30 am till 4:30 pm. He did not have any fever, headache, neck pain, photophobia, weakness or numbness beforehand. He took an over-the-counter “Japanese medication” before the race, which was suspected to be a non-steroidal anti-inflammatory drug (NSAID). Otherwise he did not have any history of drug abuse or herbal medication consumption. He had no family or personal history of epilepsy.

On arrival at the emergency department, the patient was drowsy with Glasgow Coma Scale (GCS) of E2V1M4. His seizure had aborted spontaneously. He was normothermic with stable hemodynamics. Blood pressure was 135/75 mmHg and pulse 65/min. His spot glucose was 8.6 mmol/L. On physical examination, he was well hydrated. His pupils were equal and reactive to light and there were no focal neurological deficits or meningism. ECG and CXR were unremarkable. CT brain showed mild cerebral edema. Blood tests revealed a plasma sodium (Na) level of 119 mmol/L. His plasma potassium, urea, creatinine, and creatinine kinase were 3.4 mmol/L, 7.2 mmol/L, 85 µmol/L, and 2732 U/L respectively. Urine myoglobin was negative. White cell count was 17 x 109/L, otherwise the complete blood count and liver function tests were normal. Further workup for hyponatremia were performed. Paired plasma osmolality, urine osmolality, and spot urine sodium checked 5 hours later were 244 mmol/Kg, 580 mmol/Kg, and 46 mmol/L respectively. There were no adrenal insufficiency or hypothyroidism.

Hypertonic saline (HTS) 20 ml 5.85% sodium chloride (NaCl) in 100 ml normal saline infused intravenously over 2 hours was given for 2 times. The patient’s conscious level improved as the plasma sodium level was corrected and his plasma sodium level normalized to 137 mmol/L. He regained full consciousness 3 days after admission and was subsequently discharged home on the third day.

Discussion

Incidence

Exercise associated hyponatremia is defined as hyponatremia that occurs during or up to 24 hours after physical activities, especially after endurance events [1]. It has been reported in marathons, military training, long distance hiking, and even yoga [1]. It is unheard of until 1981, as historically, runners are advised to restrict fluid intake during races [2]. After 1981, runners were advised to consume as much fluid as possible, so asymptomatic EAH is common with an incidence of 12-15% [3,4], and up to 50% among ultramarathon runners [5,6]. Symptomatic EAH is less common with incidence range from 0.1-1% [6,7], but can be as high as 38% in longer distance events [8]. Deaths are rare though, with only 14 reported in literature [7,9].

Pathophysiology

The mechanism leading to hyponatremia during exercise is mainly by dilution [7]. During exercise, fluid ingestion is driven by thirst and conditioned behavior. The abundant fluid supply during the race and the recommendation to drink in order to avoid dehydration can result in excessive fluid ingestion relative to fluid loss. The hypotonic replacement fluid results in an increase in total body water (TBW) relative to total body exchangeable sodium. Metabolism of glycogen store and triglyceride also produce free water. As a result, hyponatremia occurs due to dilution. Overhydration alone, however cannot fully explain the pathophysiology of EAH as hyponatremia can still occur in athletes who drink less than the maximum water excretion capacity [7]. This suggests that a defect in renal water excretion through an increase in antidiuretic hormone (ADH) also play a role in the development of EAH. ADH during exercise is not just stimulated by volume depletion, but also by other nonspecific stresses like physical exercise, pain, emotion, and cytokine release during muscle injury [10]. Therefore the ADH level can be inappropriately elevated during marathon running even when volume depletion is not present, resulting in hyponatremia [3]. Catecholamine and angiotensin II release during exercise may also impair the dilution capacity of the kidneys. This explained why the urine osmolality of our patient was inappropriately high.

Exchangable sodium stores also play a role in EAH. Although overhydration is a feature of EAH, 70% athletes with increased TBW did not develop hyponatremia in a study done by Noakes et al [7]. The author suggested that some people can mobilize osmotically inactive sodium from bone and cartilages so as to maintain normonatremia. EAH may develop if the body is unable to mobilize osmotically inactive sodium [7].

Overhydration is the number one risk factor for developing EAH as evident by a fall in the incidence after revising the upper limit of fluid consumption to 1-1.5 L/hour [11]. Intra-race weight gain is suggestive of overhydration. Participants with smaller body weight are also at risk as they tend to ingest more fluids relative to TBW [12]. Exercise duration of longer than 4 hours or in slow runners correlate with increased water consumption and increased sodium loss [13]. All these risk factors contribute to the development of hyponatremia in EAH. NSAID is also found to be associated with EAH in some studies by theoretically potentiating the effect of ADH [14-16]. Our patient ran for 8 hours and was suspected to have taken NSAID. He also had significant muscle injury as evident by the elevated creatinine kinase level, which might have further stimulated ADH release [10]. All these predisposed him to develop EAH.

Clinical Features

Most patients with EAH are asymptomatic or have non-specific symptoms like dizziness, nausea, and headache only. Symptoms are more likely to occur if Na <126 mmol/L, but the rate and extend of the drop in extracellular tonicity are more important determinants [1]. Severe symptoms including confusion, seizure, and altered mental state are caused by cerebral edema secondary to hyponatremia. Respiratory distress due to non-cardiogenic pulmonary edema may also occur.

Treatment

Vigilance of the diagnosis is most important. Ideally, medical facilities at endurance events should be equipped to measure serum Na. In the absence of Na level, empirical treatment should be initiated if clinically suspicious [9].

For asymptomatic patients, fluid restriction till urination is enough. If the serum Na <130 mmol/L, oral HTS with 3% NaCl 100 ml or 4 broth cubes dissolved in ½ cup water may be administered to reduce risk of progression to symptomatic EAH [9,17]. Mildly symptomatic patients should be given oral HTS [9,17,18]. Hydration with normal saline may cause further decrease in Na level if ADH level remain elevated and therefore should not be given until diuresis occur [17].

For severe symptomatic patients, HTS 3% saline 100 ml administered every 10 minutes until clinical improvement is recommended [17]. In patients with significant antidiuresis, higher dose of HTS 3-4 ml/kg/hr with administration of loop diuretics may be necessary [1]. In Hong Kong, we use 5.85% (1 mmol/ml) HTS. Since EAH develops acutely, rapid correction of hyponatremia is safe and no cases of osmotic demyelination syndrome have been reported [17].

For the prevention of EAH, recommendation by the Statement of the Third International EAH Consensus Development Conference 2015 is to drink according to thirst [9]. Using the innate thirst mechanism to guide fluid consumption should limit drinking in excess and developing hyponatremia while providing sufficient fluid to prevent excessive dehydration [9]. Measuring serial body weights during training can guide the amount of fluid replacement. Sports drinks are hypotonic fluids and will not prevent EAH in runners who overdrink, as all sports drinks have a significant lower Na level (10-38 mmol/L) than serum (~140 mmol/L) [9]. Education is the cornerstone for preventing EAH.

Timely administration of HTS is paramount in treatment of severe EAH. For those runners presenting with symptoms of severe EAH, emergent treatment with intravenous HTS is necessary and should not be delayed pending laboratory measurement of serum Na level [9]. Medical practitioners, especially medics who work at the field during endurance events should be well aware of this disease and be familiar with its treatment.

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Identity Style and Academic Burnout with Internet Addiction in Students

DOI: 10.31038/ASMHS.2020414

Abstract

Introduction: In a world becoming more complex, the necessity of using the internet for human especially students is more than ever, because the internet can play a major role in gaining mastery. Students as those who can have an important role in current situation and especially the future of a country in order to be favorable conditions for using cyberspace are undoubtedly more vulnerable to the dangers of cyberspace. Therefore, this research intends to determine whether identity styles and academic burnout are effective on internet addiction in students?

Method: To investigate this, we used the correlation research method and the Pearson and regression statistical method. And among all students of the Islamic Azad University of Sari, three sample groups were selected 155 people equally as examples and were used to collect data required from the ISI Browinsky identity questionnaire and for educational assessment of the questionnaire and to measure the Internet addiction assay from the Kimberly Young questionnaire.

Conclusion: There is a relation between identity styles and Internet addiction in students, it is found that the link between the style of identity and normative information identity with Internet addiction is negative. It may be because the use of the internet is slowly addicted to the negative attractiveness of the internet, creating the impression that it can provide psychological and emotional needs. It is also found that there is a correlation between academic exhaustion with Internet addiction and increasing the Internet addiction، Perhaps the reason for this is that the Internet addiction has the ability to recruit an individual as it tries to pay attention to the educational tasks

Introduction

Computer and internet as essential tools of life are responsible for facilitating the lives of people who have created new dangers that one of these risks is the creation of neglect or academic burnout in students [1]. In a world becoming more complex, the necessity of using the internet for human especially students is more than ever, because the internet can play a major role in gaining mastery [2]. On the other hand, anonymity appears on the internet and virtual communities to give people a chance to play with their identity or build a new identity so that they can have different personalities and affect the lifestyle of people and their types of emotions, and studies have shown that technology addiction affects the actual purposes of technology users. This is primarily due to the maladaptive understanding that is thus shaped as a result of technology addiction [3]. Also the results of research have shown that social networks lead to changes in the lifestyle of youth in the fields such as leisure time, attention and tendency to the body to how to cover, style of speech, creating conditions for communication with opposite sex and gaining ability of the day in attitude toward the world. People with low-risk seeking experience enjoy a healthier lifestyle [4]. Student as those who can play an important role in the current situation and especially the future of a country, the students are more likely to be exposed to the dangers of cyberspace to be conducive to the use of cyberspace. As the main pillar of the educational system of the country in achieving the goals of the educational system, they have a special role and status, so paying attention to this huge and young people of society, fertility and prosperity have the most educational system in society. The main objective of any educational system is to create suitable ground for learning and actualization of potential human potential. On the other hand, gaining success and learning needs to have a healthy and lively spirit and all the efforts done in the process of education tend to develop healthy personality of students [5]. Considering the negative role of internet addiction in the desire to educate [6] and also the role of internet addiction in reducing academic performance [7], this research intends to determine whether the style of identity and academic burnout with internet addiction is effective in students? In this regard, by reviewing the literature and literature, some basic hypotheses have been formed and that there is a relationship between identity styles and internet addiction. Also there is relation between identity styles and academic burnout in students. And some other research hypotheses…

Method and Result

To examine this issue, correlation research method and the Pearson and regression statistical method was used. Of all students of the Islamic Azad University of Sari, three sample groups were selected 155 people equally as examples. To collect data required from the ISI Brownsky identity style questionnaires and for educational assessment academic burnout questionnaire, and the extent to which Internet addiction Kimberly Young questionnaire has been used, and finally to investigate the first process of research using Pearson correlation test, the following techniques were extracted.

 

Styles Number Coefficient of correlation Research coefficient Probability value
Information identity style 155 -0.454 0.206 0.000
Normative identity style 155 -0.426 0.181 0.000
Confused identity style 155 -0.464 0.215 0.000

 

On the basis of these data, the relationship between identity styles and internet addiction is confirmed and also for the study of the second process, the relationship between academic burnout and internet addiction has been used and the following data were extracted.

 

Variable Number Coefficient of correlation Probability value
Academic burnout 155 0.461 0.000

 

Accordingly, the relationship between academic burnout and internet addiction is confirmed.

To investigate the relationship between identity styles and academic burnout, Pearson correlation statistical method was used.

 

Styles Number Coefficient of correlation Determination coefficient Probability value
Information identity style 155 -0.460 0.184 0.000
Normative identity style 155 -0.420 0.176 0.000
Confused identity style 155 -0.467 0.218 0.000

 

According to the above data, the relationship between identity styles with academic burnout is also confirmed.

It is also used to examine the fourth hypothesis, each of the identity styles in the prediction of Internet addiction in different students from a step- by- step analysis method between identity styles and Internet addiction. And the result has shown that each of the identity styles is different in explaining Internet addiction.

Conclusion

The main purpose of this study was to investigate the relationship between identity styles and academic burnout with internet addiction in Azad university students. According to the proposed hypotheses, we discuss each of these hypotheses. The first hypothesis is that there is a relationship between identity styles and internet addiction among students, it was found that the relationship between informational and normative identity style with internet addiction is negative, This finding is inconsistent with Jamshidei and Sarvqad’s [8] findings, and its direction is positive in relation to the confused identity with the Internet addiction that aligns with findings of Jamshidei and Sarvqad [8] and Piri [9] and Kamali et al. [10]. The reason for this can be explained by Dastjerdi’s [11] research under the title An Investigation of the role of Cyber Networks in Cultural Identity of Students at the University of Isfahan, based on the false attractiveness of the internet, which creates the impression that it can provide psychological and emotional needs.

Therefore, replacing social networks on the internet instead of presence and interaction with people in the real world will cause users social and emotional relationships to be disrupted.

In the study of the second hypothesis that academic exhaustion with Internet addiction has been found on students, there is a relationship between them. The results of this study are based on the results of Ganji [6] and Pourmirzai [7] based on the negative role of addiction to internet and performance and education; in explaining this, it can be concluded Jin et al. [12] and Shahbaziyan [1] researches; that there is a positive and significant relationship between procrastination in preparing academic term papers with dependence on internet and a negative and significant relationship with academic self- efficacy. Procrastination in preparing for the exam is not correlated with Internet dependence and academic efficiency, but between Internet dependence and academic self-efficacy plays a major role in predicting the degree of Internet dependence, and in the second step, procrastination in homework could play a significant role. Based on the findings, male students reported more Internet dependence than female students, which is in line with the process presented in this section. In examining the third hypothesis; Based on that; there is a relationship between identity styles and academic burnout in students, according to the results, it was found that there is a negative relationship between informational and normative identity style and academic burnout. In the context of this finding based on Bruce [13] results, it can be said that stress and avoidance of academic burnout that several factors such as social support failure, stress over size and personality traits can be the cause of academic burnout. The fourth hypothesis is that the contribution of each identity style to internet addiction is different in students. In examining the fourth hypothesis that the contribution of each identity style in predicting Internet addiction in students is different. The data show that identity styles are simultaneously effective in the occurrence of Internet addiction and the share of each identity style among Internet addiction is different, which can be concluded based on the results of Sadeghi and et al. [14] and Thomas [15] explained. According to this study, identity style has a significant negative relationship with information identity with Internet addiction and confused identity style has a positive relationship with Internet addiction, and therefore the relationship between normative identity style and Internet addiction is not significant.

References

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  7. Pourmirzai H, Asgari G (2017) Predicting Internet Addiction as a Factor Affecting Academic Performance Based on D-Personality Type and Humorous Styles in Medical Students. Iranian Journal of Medical Education 17: 1-10.
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  10. Kamali N, Houseini F (2020) A study of the relationship between neuroticism and Internet addiction among young people. Study of Borazjan Azad University students. Bushehr Disciplinary Science Quarterly 10: 69-75.
  11. Dastjerdi N (2014) An investigation of the role of Cyber network in cultural identity of students at the university of Isfahan. Applied Sociology 25: 159-70.
  12. Liu S, Jin C (2018) The relationship between college students mobile phone addiction and learning burnout: personality as a moderator. Chinese Journal of Special Education 2: 86-91.
  13. Bruce S (2016) Recognizing stress and avoiding Burnout. Currents in Pharmacy Teaching and Learning 1: 57-64.
  14. Doostani P, Sadeghi A (2019) Predicting career goal discrepancy based on career- related stress, career goal feedback, and field of study in students. Journal of Counseling Research 17: 22-43.
  15. Thomas D (2016) Cellphone addiction and academic stress among university students in Thailand. International Forum 19: 80-96.

Mapping Contextual Drivers of HIV Vulnerability: A Qualitative Study of African, Caribbean, Black Youth in Windsor, Canada

DOI: 10.31038/AWHC.2020353

Abstract

Background: Based on POWER study: Promoting and owning empowerment and resilience among African, Caribbean, and Black Canadian (ACB) youth, this paper explored the contextual factors that expose ACB youth to HIV infection.

Method: We conducted six focused community-mapping sessions with 43 purposively drawn ACB youth living in Windsor, Canada. Based on socio-environmental approach, we investigated a number of issues including, where to find ACB people, places afraid to go, places to find casual partners, where they spend leisure time, healthy and unhealthy places.

Results: The findings showed that ACB population mainly resides in poor areas, with close proximity to bars, strip shops, recreational/sports places. And, multifaceted factors, such as economic deprivation, marginalization, discrimination, and substance use provided an enabling environment for ACB youth exposure to HIV/AIDS. Conclusion: Future HIV/AIDS prevention must be locality specific and culturally sensitive, by taking into account individual, structural, environmental and socio-cultural factors in future HIV prevention strategies.

Keywords

HIV/AIDS, ACB youth, Community mapping, Contextual factors

Introduction

According to 2018 HIV surveillance report in Canada, Ontario accounted for the highest population of HIV cases (39.2%), with the second highest reported cases among 20-29 at 22.5% Gay, bisexual and men who have sex with men (gbMSM) continue to account for the highest exposure to HIV 58.1%, while heterosexual transmission accounts for 32.3%, of which 15.4% are from HIV endemic countries [1]. Similarly in 2017, Ontario accounted for the highest population of new HIV cases (38.9%), and ACB people infected with HIV through heterosexual contact account for 20% of the estimated total of all HIV-positive people, and youth aged 15 to 29 accounted for 23% of HIV cases, and between 2016 to 2017 a 17% increase in 15 to 19 and 4% decrease among 20 to 29 [2]. More so, the Black population, which makes up 3.9% of the population accounts for 22.5% of persons living with HIV in the province [3]. It also has been estimated that in Ontario, Windsor diagnosis of HIV new cases of 5.7 was fifth, with Toronto having the highest diagnosis rate of 15.7 [4].

Community-based and participatory action research programs on HIV/AIDS risk behaviors have reported that mapping of locations with high concentrations of bars, shops, strip clubs, trucking places, sex workers and other geographical places is crucial in identifying at-risk places, groups, as well as, in designing and implementing effective and sustainable HIV prevention interventions [5]. Community mapping has been used to address development and health issues across multidisciplinary sectors, particularly health issues like infectious diseases [6-8] and HIV/AIDS [9,10]. Other focus of community mapping includes HIV prevention intervention [11,12], and health promotion [13], sex and HIV education [14].

However, mapping as a social research approach has become a growing basis for many interventions in developing countries/contexts, on development interventions to promote HIV prevention [15-17]. Community mapping is a mixed method approach that involves brainstorming and geographical mapping to visually present ACB youth ideas and perceptions of their vulnerability and resilience to HIV/AIDS. Participants actively participated in ensuring that the maps are explicit, representing and providing adequate knowledge that represents the diverse views of participants.

The present paper explores the factors that expose young ACB youth to HIV infection in a border city, Windsor, Ontario Canada. It focuses on individual, interpersonal, societal and environmental factors (e.g. access to resources, oppression, discrimination, poverty, and racism) that are often beyond the control of individuals [18-21].

Theoretical Perspectives

Based on socio-environmental approach, this paper recognizes that individual and collective health are intertwined, such that health disparities are the outcomes of intersecting social determinants including neighborhoods, access to economic and social resources, everyday encounters of discrimination and racism, and social exclusion [22]. Integral to this paper are the concepts of masculinity and vulnerabilities. According to UNAIDS [23], people’s vulnerability to HIV depends on their personal circumstances, societal factors such as disempowering cultural practices and laws, and the extent to which they have access to appropriate services and supports. However, the UNAIDS definition of HIV vulnerability neglects the role of structural determinants, such as various forms of social oppression, deprivation, and poverty [24]. This paper measures vulnerability in terms of individual attributes such as self-esteem, personal competence, optimism, and related attributes. The focus on individual factors makes invisible those situational and socio-environmental factors (e.g. cultural safety, access to resources, social capital, intergenerational trauma) that are often beyond the control of individuals [21].

Methodology

Study Community

Windsor, located in southwestern region of Ontario, and has also been identified as has one the highest rates of immigrants proportional to its population, having the sixth largest concentration of people who have ancestral ties to Africa [25]. According to Statistics Canada (2011) [26], Windsor has the highest proportion (33.3%) of low-income population living in very low-income neighborhoods. Windsor with the fifth highest HIV diagnosis rate (5.7) among new cases is also a border town with Detroit, Michigan, USA, which has 603 positive sero-status persons per 100,000 people [27]. In addition, its low legal age for alcohol and tobacco consumption, attracts young Americans to visit Windsor bars regularly on weekends and has opened more avenues for social and sexual networking [28]. This networking is likely to create unique local issues. Therefore, it becomes crucial to conduct a study that focuses on Windsor because issues such as youth’s and parents’ socioeconomic status, inter-country migration or mobility, social hubs, and diversity may nurture cross-border politics and relations.

This study is based on the community mapping of a larger CIHR (2009-2012) funded project on “Promoting and owning empowerment and resilience among African, Caribbean and Black youth in Windsor (POWER)”. Engagement process began by organizing a public forum for ACB youth and community based organizations and stakeholders. At the public forum, we developed a list of volunteers to serve in the Youth Advisory Committee (YAC). YAC became a bridge that links the project to the study communities, target population (youth) and promoted participatory involvement of youth at all levels of the research process. We provided a brief overview of the project and particularly the community-based approach that focus on partnering with the communities and target group as significant actors in the project implementation.

Data Collection

Two investigators and three staff undertook six focused community mapping group sessions between May and November 2015 with 18-24 years ACB youth living in Windsor. The six group sessions comprised of Youth Advisory Committee (YAC) of university of Windsor students (7), St Claire College (7), Caribbean non-students (7), Black non-students (8) and African non-student (7). Purposive sampling was used to recruit a total of 43 participants. Each group session comprised of homogenous participants in terms of racial/ethnic groups and student status. Two project staff facilitated after being trained over one-week training on community mapping. Each focused group session included seven to eight participants of the same ethno-racial group organizations and student status. Two staff and one investigator facilitated the focused sessions. To begin each session, facilitators introduced the community mapping methodology, including a de-briefing on what the project purpose and goals. Facilitators used a focused semi-structured guide containing prompt questions to lead the discussions, exploring commonalities and differences across the conversation. After each session, the project team debriefed with facilitators, providing additional coaching on issues or ideas that arose during the session. Going around the table, each participant was giving the opportunity to contribute to the discussions. Participants were provided with sticky notes to put down their response if too shy to speak out. Participants had ample uninterrupted time to respond promptly. Participants as a group placed some of their answers on the map of Windsor. Each session lasted between 90 and 120 minutes. The language of communication was English. We took notes and audio taped the discussions. We served snacks and paid participants stipend of $25, which included $5 for transportation.

Data Analysis

The staff transcribed the audio recordings verbatim. Two investigators verified the transcripts for accuracy. Project coordinator created the codebook used for coding the transcripts. We used pattern coding by Miles and Huberman (1991) to summarize each transcript. Codes were compiled to record the experiences and perceptions of barriers that tend to expose ACB youth to HIV/AIDS. Staff and two investigators re-examined the coded transcripts for accuracy. And, N6 qualitative software, online coding and data management was used to organize and code the transcripts. The coding process resulted in the identification of the data supporting the emergent themes and the corresponding quotations buttressing the arguments. We made a table of emergent themes, sub-themes and corresponding quotations, which was further reviewed by staff and one investigator for validation. The team overseeing the community mapping read and re-read the themes against the quotations to identify the pattern of arguments.

Results and Discussion

Background of Participants

Table 1 shows that participants of African heritage make up the majority (51.2 percent), those of Black heritage were 23.3%, while Caribbean were 20.9% and only 4.6% classified themselves as of mixed heritage. Additionally, in terms of gender, males were 55.8% and females were 19%. All the sessions were held in a place of close proximity to the participants. For example for university of Windsor and St. Claire College, the sessions were held in the two campuses, while others tended to be held at downtown Windsor.

Table 1: Participants’ Background Characteristics.

Characteristics

Frequency

Percent

Race/Ethnicity (N= 43)

No.

 

African

22

51.2

Black

10

23.3

Caribbean

9

20.9

Mixed

2

4.6

Gender (N=43)
Female

19

44.2

Male

24

55.8

Places to Find ACB People

The study probed for the places where ACB people commonly lived. The participants reported that ACB people commonly resided in places where there were affordable housing, with close proximity to social institutions and amenities such as schools, recreations centers. Government provided most of affordable housing tailored to income of tenants. Public maintenance of these housings was timely and at no extra cost to the tenant. More importantly, it was a common practice for newcomers to seek and identify residential places populated by ACB people. Participants identified the west, around sandwich, central and downtown areas as the places to find most ACB people, while they are sparsely located in South Wood Lake area, where the wealthy and affluent ACB families reside. More ACB people are congregated in the west end/Sandwich, central and downtown, which are crime and poverty-ridden areas. They also noted that a high population of ACB youth, as students, wage earners and those not gainfully employed resided in these areas, either alone or with parents/guardians. Participants also reported a number of social vices such as availability and accessibility to drugs like marijuana, partying, and sex work, which are common around affordable housing places. These social vices expose ACB youth to risk behavior and HIV infection.

In terms of their opinion on living in these places, there were varied ideas. In the Black Canadian mapping session, participants described these areas as: Dirty, lot of prostitutes, Rough area that used to be more violent back in (10), it’s a bad area, prostitution, people get robbed beat up all the time (13), it’s so retched, ghetto, lots of poverty, No money or jobs are here, A lot of drugs and violence.

The YAC Group Noted That

There are a lot of young people; a lot of influence, peer pressure, drugs, sports, unprotected sex, good or poor academics, some of the neighborhoods are associated with public housing, immigrant settlement, Glengarry has a waterpark, STAG, community centers, where people can go, ———————, black people are excluded from networking (union)

In the University Students’ Session, a Participant Noted

Relatively impoverished; roads and everything is poorly cared; not much of the city funds go there; a little dangerous; its more affordable; but there is always some type of altercation on my lawn or across the street; I just assumed I would find something more affordable in West Windsor; familiar; they might also feel they can find someone they can relate to (Female Caribbean).

While in the Non-student Group Session, a Participant Added

Black people are spread out in little areas; West Windsor; bad; but I think it is inclusive, culturally sensitive a good place; unkempt; drugs, boarded houses; not true; there is Windsor housing for immigrants.

Discrimination and Contact with the Police

Despite the importance of social networking with friends and peers, participants reported that the presence of ACB youth in predominantly white residential neighborhoods at out-skirts of Windsor, high-end stores, and electronic sections/units of departmental stores, grocery stores and around police stations raises suspicion. Other places identified where teen health center and blood clinic (cited by University group), and prisons (African non-students). The common reasons provided for avoiding these areas are to avoid confrontations with the police, and confrontations involving wrong identity. Participant noted that “If a conflict/confrontation occurs- automatically the Black person(s) will be confronted even though the fight was from another race” (African female session). Other youth reported that “violence and crime” are high at downtown Windsor, and ACB youth are often the first suspects.

Participants also reiterated their experiences with the police in a number of places such as residential areas around downtown, west end, university areas; clubs – Boom Boom, house parties; highways and other places such as the mall and stores. Often such encounters with peers and relatives end up as mistaken identity, or it involves highway offense and road checks. A youth noted that with police in Windsor, “they think all Blacks look alike” (African Female, AF). A participant reported that there was a time when a “girl’s house was robbed; a dozen police car were present, the last one had a gun pulled out, stopped us for an hour, asked foolish questions, and said you fit the description”.

A participant also noted an incident downtown, where ACB boys were hanging out at “McDonalds with white girls, cops harassed us, told us to go home or be arrested for loitering, and promised to call the girl’s parents.” Police officers would stop an ACB youth and say, “Are you up to something? Are you from Somalia?” (African Male) A student participant also noted: “walking home from university, 20 minutes-walk from home, 2am I was questioned about seeing someone in the area” (AM).

Where do Youth Spend their Free Time?

In response to the question, “where do youth spend their free time?” participants highlighted a number of places in west of Windsor, such as Sandwich and downtown areas where ACB youth most frequently spend their free time. These places included bars, clubs, strip shops, parks, and sport centers like St. Denis center at the University of Windsor and YMCA, house parties, malls, University library – Leddy and at the theaters. These were common meeting places where they engage in social and sexual networking with each other. Data also showed gender differences as males frequented more places for sports and clubbing, while females tended to patronize places that are less costly, for dancing and were often in company with older siblings and friends. During the walking tours of these areas, the research team and staff were informed that other ACB youth residing in other places in Windsor tended to visit and congregate in these areas to be in company of other peers and friends. We also probed for healthy and unhealthy places in Windsor. The participants reported diverse settings. The healthy places ranged from sport places like gyms at YMCA and St. Denis of the University of Windsor; leisure places like STAG, water front located at downtown Windsor; faith-based institutions-churches and mosques, NGO offices like Windsor Women Working With Immigrant Women, Women Entrepreneur Skills Training, New Canadian Center for Excellence, AIDS Committee of Windsor, Youth Connection Association, Salvation Army, and community centers like STAG, Caribbean center. For these youth, these places provided low cost services and were safe and fun places. However, they noted that unhealthy places included parks; downtown area, street allies, and places where many sex workers line the streets, and house parties. The reasons provided ranges from availability of drugs, sexual networking, and exposure to unhealthy behaviors such as sexual activities, drugs and despicable behaviors such as sexing in public places like parks. A participant in identifying what makes these places unhealthy said: Downtown; drugs and alcohol; white women approach Black men; border city; girls from Cincinnati, Pittsburgh, Detroit; 1 in 4 Americans have an STI; Black women give stink eye because it’s not healthy (sexually networking with men who have exposed themselves to “risky” White women); strip clubs; studio 4; Teasers; human and drug trafficking; leopards owns 2 houses; keep green cards in safe; European girls; you don’t know what they have; police department; racial profiling; west end (street level crime); university of Windsor; break ins and misdemeanours (Caribbean Black Male).

Where to Find Casual Sex Partners

Participants identified downtown area and facilities -bars, strip clubs, house parties, Studio 4, casino, riverside after hour, massage parlors, parking lots, university library and residences, High school, St Clair, workplaces – factories, street corners – next to Bistro, shops – sex shops (Maxine, Dougall), residential Areas – condos downtown, restaurants – McDonalds (Escorts) as places to find casual sex partners. These places have close proximity to places where ACB people reside provided easy access to “alcohol and casual sexual activity” (African Female, AF). A participant in the University community mapping session said:

You will be surprised at what goes on at this campus. A friend finds a message at Leddy “for a good time call this number” (African Male, AM).

Another participant added, “campus for variety and safety” (African Female, AF)

A participant from the university also said:

AM: bars, strip clubs; university (you would be surprised at what goes on at this campus); speaks about friend who finds a message at Leddy; “for a good time call this number; meet at a house;” (African Male, AM)

Silvers on Seminole, Casino (Caribbean Female, CF).

Secret Places for Secret Things

To the probe on the secret places where ACB visit and/or congregate to do secret things, not to be heard or known by their parents/guardians, the participants reported bars/s clubs, located in the Sandwich and downtown areas, and specifically university and college campuses where a variety of activities occurred including “alcohol and casual sexual activity” (AF), and youth solicitation for sexual activity. Other activities included drugs, illicit sex, unsafe sex, and prostitution, which are unhealthy and expose persons to STIs including HIV/AIDS. The common reason given for engaging in these activities at these places is that they are “away from home and parents and no need to keep good name”.

P4 AF: residence; houses near campus; sell drugs; Askin street near the university; friends of friends; word of mouth

P1 BM: university; residence; college life involves it; alcohol and weed; houses right by campus

P6 CF: apartments on Peter Street; people come in and out at odd hours

P5 ACF: parks; accessible for sex and drugs

P7 AM; coronation school pike park; when house party ends, can go there to be loud or drink

CBM: Riverfront (car sex); hotels on Huron church (strippers from Ottawa, nova scotia); downtown Windsor condos by police station (drugs); Wyandotte and Windermere (S and M club); massage parlours downtown; houses in west end (coke spots); south Windsor (behind Devonshire mall area; cocaine); Banwell (ecstasy).

Discussion

Community mapping sessions and walking tours provided the researchers and staff a journey into the lived experiences and observations of ACB youth in Windsor, Ontario. The common thread in these accounts and activities was the social inequality, which was more along racial lines that tended to create social exclusion, perpetuating feelings of discrimination and overt racism, which have been reported to have serious impact on ACB communities particularly youth [18,19,29,30] and their attitude to the police [31]. Although these experiences results in lack of entitlement and privilege, thus threatening the social existential survival of ACB population, particularly youth, the community mapping strategies, gave back to these youth some elements of power not just as research participants but also as researchers in the front drive of data collection, informing and making contributions to all stages in the project.

The findings that neighborhoods’ context and organization promote ACB youth vulnerability to HIV infection has been buttressed by similar findings from existing studies from the United States and Canada depicting the influence of neighborhood environment and social disorder [19,20,32] neighborhood economic disadvantage [33-35] on HIV exposure.

The study also reported that the proliferation of some neighborhoods densely populated by ACB populations with bars, street allies, abandoned houses, availability and accessibility to drugs and alcohol, perpetuate risky behaviors like drug and alcohol use, accessibility and availability of female sex workers. Of significance is the report by participants that there have been rape cases of male and female victims in such neighborhoods due to bad people hiding in abandoned properties, and coercing or luring young persons and children into such places. Similarly, a few studies [36-38] suggest that physical environment influences sexual risk and HIV vulnerability. For instance [36], study notes that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes. They contend that the physical, social and cultural characteristics of urban environment have tolerant social policies through which behaviors and identities may be enacted with less fear. Also noted that inadequately housed individuals tend to be socially isolated or involved in networks that support risky behaviors such as drug use, unstable intimate relationships, multiple sex partners, casual sex exchange and low rates of marriage [39].

The present study also found that a majority of ACB population resides in affordable housing for low to medium very income people families. According to Statistics Canada (2011) [26], Windsor as a town has the highest proportion of low-income populations living in very low-income neighborhoods. Research evidence also shows that people living in very low-income neighborhoods appear to have higher HIV risk profile than those living in higher income areas [18]. Similarly, studies from North America also bear credence to the findings by its association of poverty from social and economic deprivation with HIV risk behaviors [39,40].

Of great importance are past evidence that local bars in Windsor, which attracts youth across the border due to its lower age for alcohol consumption increases the scope of social and sexual networking among Canadian and American youth [28]. Noting that the HIV prevalence rate is very high across Windsor’s border city of Detroit (35 new cases per 100,000 residents), and coupled with the early initiation of sex in youth and the poor attitude to and low use of condoms [27,41] the networking between the two cities is likely to increase the exposure of youth to HIV infection. In addition, participants reported going to hidden places away from parents and homes to use drugs, party and indulge in sexual activity. These findings have been documented in other empirical studies showing that young boys and girls use drugs like marijuana and alcohol, which may affect their decision-making [42], and invariable lead to risky behaviors including anal sex [43-46], violence [47-51], unprotected sex [52], and having casual and/or opportunistic sex [53-58].

Finally, low parent-child communication on sex also matters. It has been well documented that there is lack of sex talks in families and particularly between parents and children [59-61]. This gap exposes younger ACB youth to risky sexual behaviors such as low condom use and ability to negotiate sex, which has been reported to have serious sexual and reproductive heath consequences like exposure to sexually transmitted infections including HIV/AIDS. However, existing studies on Caribbean population have shown parents willingness to talk about sex and related issues with children [62]. And, it has been reported that parents talk about sex with children leads to abstinence, postponement of sexual initiation, positive attitude to safe sex practices including condom use, and engagement in monogamous relationships [63-68]. Invariably, parent-child communication about sex better prepares children when faced with the decision to have or not to have sex [69]. On the contrary, other studies however reported that some parents feel talking about sex matters with their children and adolescents will introduce them into sexual activities and therefore, they avoid such conversations [64,70]. Although studies remain inconclusive on the outcomes of parent-child talk about sex matters, parental efficacy to improve effective parent-child communication about sex matters remains important [71-85].

Conclusion

For decades, many HIV prevention research focused on determining, planning and implementing interventions to address individual-level risk behaviors that expose individuals to HIV infection. This present study indicates the importance in examining the environment, social and cultural impediments influencing risky behaviors. African, Caribbean and Black youth in Windsor, specifically young men face pressure from parents and families on children to conform to the social and cultural gendered expectations that makes you a woman (practicing abstinence) and a real man, like being the provider, economically stable, having multiple sex partners, and engaging in unprotected sex, which invariably are likely to increase exposure to HIV infection. This gives credence to this study that engaged AB youth as both research participants and as researchers, through membership in the Youth Advisory Committee, and actively engaged in recruiting and participating in community mapping and walking tours. More future research need to adopt a mixed method approach, which includes community and/or concept mapping, and other qualitative methods like focus groups, in-depth interviews, photovoice, and questionnaire to study specific subgroups of ACB population like self-identified heterosexual ACB youth, men and women, on a broader scale, provincially or regionally. So doing, we will then be able to establish the differences and similarities across space, neighborhood, race/ethnic subgroups, religion, class and gender in the general population.

The mapping and construction of factors in the environment, neighborhoods, social and cultural contexts among ACB boys, men, girls and women would gain immensely from further investigations. Such interests may provide broader-based data on perceptions of HIV vulnerability, environment and neighborhood factors, with issues of masculinity, specifically perceptions of black masculinity and sexuality that affect sexual scripts, what having sex means, condom use decision making, opportunistic sex, and perceptions of HIV testing.

Furthermore, the findings from this study can begin to inform HIV prevention strategies among ACB youth on how best to increase HIV prevention services. Such programs will focus efforts on addressing multi-level factors by adopting multidimensional, effective and sustainable interventions, which address individual, social, cultural and environmental risky behaviors, like unsafe sexual practices (having multiple sex partners, lack of effective condom use), while also addressing and implementing policies and interventions to improve the environment, neighborhoods, and socio-cultural factors like perceptions of a real black man that hamper the delivery of HIV services aimed at buttressing the sexual and reproductive health of ACB population, specifically youth.

Acknowledgements

Canadian Institutes of Health Research (CIHR) provided the funding. The ACBY team includes Kenny Gbadebo, Youth Connection Association; Eleanor Maticka-Tyndale, University of Windsor; Valerie Pierre-Pierre, African Caribbean Council of HIV in Ontario; Robb Travers, Wilfrid Laurier University; Jelani Kerr, University of Louisville, Louisville, KY. Thanks to the study participants for their contribution. The content is solely the responsibility of the author.

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Application of Drainage Position Ventilation and Real- Time Bedside Monitoring in Mechanical Ventilation of Patients Infected with nCov-19

DOI: 10.31038/IMROJ.2020543

Abstract

At present, the new coronavirus has spread to more than 200 countries and regions around the world. Up to now, no specific antiviral drugs are proved effective in defeating the new coronavirus, some measures, such as postural drainage ventilation, real-time bedside pulmonary ultrasound and chest electrical impedance monitoring may provide some new ideas for mechanical ventilation patients infected with new coronavirus.

Keywords

New coronavirus, ARDS, Mechanical ventilation, Bioelectrical impedance tomography, Pulmonary ultrasound

Etiology and Pathogenesis

The novel coronavirus (2019-nCoV) belongs to the beta genus of coronavirus, the S protein of the new coronavirus binds to the angiotensin-converting enzyme 2 (ACE2) receptor of human alveolar type II epithelial cells, and then enters into the cell to replicate and spread through respiratory droplets and contact [1].

Clinical Manifestation

Fever, dry cough and fatigue are the main symptoms of the people infected with novel coronavirus. Critically ill patients usually have dyspnea and (or) hypoxemia one week after the onset of the disease. Some patients can rapidly progress to acute respiratory distress syndrome, septic shock, uncorrectable metabolic acidosis, coagulation dysfunction and multiple organ failure [1].

Chest Imaging

Chest radiographs showed multiple small patch shadows and interstitial changes in the lungs, especially in the lateral pulmonary zone in the early stage of the patients infected with new coronavirus. Then it developed into multiple ground glass shadows and infiltration shadows in both lungs, and in severe cases, lung consolidation could occur [1-3].

Pulmonary Pathophysiology

Lung pathology showed focal hemorrhage and necrosis, marked proliferation of the type II alveolar epithelial cells in the lung tissue. Serous, fibrin exudates, and hyaline membrane formation were seen in the alveolar cavity; it could also be observed that the alveolar septal vascular congestion and edema, and some alveolar exudates organization and pulmonary interstitial fibrosis. Part of the bronchial mucosa epithelium was shed; mucus and mucus emboli could be seen in the bronchial lumen. A small number of alveoli were over-inflated, the alveolar septum was broken or the cysts were formed [4].

Thus, critically ill patients infected with new coronavirus may present abnormal pathophysiological changes such as obstructive ventilation disorder, lung gas exchange disorder, imbalanced ventilation blood flow ratio, and increased shunt.

Antiviral Therapy

During the emergency clinical trial of antiviral drugs, a number of randomized, double-blind, antiviral-placebo controlled studies have been carried out, but no antiviral drugs proved effective in treating the new coronavirus infection.

Mechanical Ventilation

Early and appropriate invasive mechanical ventilation is an important treatment for critically ill patients. In general, when PaO2/FiO2 is less than 150 mmHg, the effect of high flow oxygen therapy or noninvasive ventilation is not good, endotracheal intubation should be considered in time for invasive mechanical ventilation in severe and critical ill cases [2]. The strategies of lung protective mechanical ventilation and lung recruitment are implemented. If there is no contraindication, it is suggested to implement prone position ventilation at the same time. Prone position ventilation can improve oxygenation in patients with ARDS by increasing functional residual volume, improving ventilation/blood flow ratio (V/Q), reducing shunt (Qs/Qt), improving diaphragmatic movement and promoting secretion excretion. In the airway management, posture drainage and sputum suction by bronchoscope should be adopted to promote the sputum drainage and lung rehabilitation [2].

Lung Protective Mechanical Ventilation Strategy

The individualized strategy of mechanical ventilation is to adopt the most suitable methods or parameters in ventilation mode, lung recruitment, tidal volume, PEEP and mechanical ventilation posture for patients according to their different pathophysiological conditions, so as to achieve the best treatment effect. At present, low tidal volume, high PEEP, lung recruitment and prone position ventilation are widely used in patients infected with new coronavirus [2]. The characteristics of severe new coronavirus cases, such as inflammatory serous and fibrin exudate, exudate organization, pulmonary fibrosis, alveolar septum destruction, atelectasis and pulmonary bullae, coexist in the patients’ lung [4]. Large tidal volume is not suitable for patients infected with new coronavirus due to the potential mechanical ventilation lung injury [2]. The selection of PEEP should be guided by the best pulmonary mechanics, the reduction of pulmonary shunt, the improvement of oxygenation and the function of stable circulation, while the effect of pulmonary recruitment should be examined by CT, MRI, bioelectrical impedance tomography (EIT) and ultrasound imaging. In the process of lung recruitment, there is the possibility of lung over inflation and the original pulmonary injury aggravation, and the effect on the hemodynamics should be concerned at the same time. The optimal method, opportunity and parameters of lung recruitment have not been determined, but it is necessary to judge the potential of pulmonary reinflation under real-time bedside EIT and ultrasound pulmonary monitoring.

The Advantage of Real Time Bedside Monitoring of EIT and Ultrasound

The goal-oriented mechanical ventilation is to adjust the mechanical ventilation strategy in time with the aim of imaging, respiratory and oxygen dynamics monitoring, blood gas examination, the function of circulatory system and the condition of other organs [2]. Blood oxygen saturation, blood gas, hemodynamics and respiratory mechanics are still routine and convenient monitoring methods of mechanical ventilation. Traditional lung images, such as X-ray, CT, MRI, certainly have the characteristics of clear images and easy analysis and diagnosis, but they are complicated to operate under the special circumstances of isolation and transportation of patients infected with new coronavirus. The chest electrical impedance tomography cannot provide clear image, but it is convenient to operate and can be continuously imaged [5]. Ultrasound lung images also have unique advantages in the diagnosis of pneumonia and the effect of ventilation [6]. These two methods can be real-time bedside monitoring, which are simple and practical to guide lung recruitment, to diagnose pneumonia, and to evaluate the mechanical ventilation effectiveness. In addition, while monitoring respiratory mechanics and oxygenation parameters during mechanical ventilation, we should pay close attention to the corresponding changes in the circulatory system and make timely adjustments.

Electrical Impedance Tomography

Electrical Impedance Tomography (EIT) is to use the impedance changes of living organisms or biological tissues, biological organs, and biological cells under the action of a safe current below the excitability threshold to obtain the organism internal resistance rate of distribution and changing images through image reconstruction [5,7]. The resistivity of different tissues or the same tissue under different physiological and pathological conditions is different. The periodic changes of air and blood flow in the lungs together determine the changes in the electrical impedance of the chest. The advantage of EIT lies in the use of the rich physiological and pathological information carried by bio-impedance to obtain damage-free functional imaging and medical image monitoring. Chest X-rays and CT are widely used in the diagnosis of lung infections. But they cannot monitor lung lesions in real time, cannot measure lung ventilation status, and most importantly cannot be used in patients with severe pneumonia and respiratory failure who cannot easily access these examination, so their application are limited. Lung EIT, as a brand new medical imaging technology, which is different from traditional imaging technology and conventional lung function monitoring, has outstanding features such as injury-free, portable, low-cost, functional imaging, and image monitoring. EIT can real-time dynamic monitor the pulmonary ventilation and blood flow distribution, evaluate the effectiveness of clinical treatment methods such as mechanical ventilation by measuring electrical resistance under different ventilation conditions [5,7].

At present, the commonly used methods to monitor the effectiveness of lung recruitment strategy and the suitability of PEEP include arterial blood gas analysis, peripheral oxygen saturation, pulmonary and chest maximum compliance, static pressure volume curve and so on, but these methods cannot meet the requirements of dynamic monitoring of regional lung perfusion. A number of studies have showed that in mechanical ventilation patients with ARDS, EIT has been used to accurately measure the whole lung and regional lung ventilation distribution, to show the influence of PEEP changes on alveolar expansion and collapse by gradually increasing and decreasing PEEP level, and in the end to obtain the optimal value of PEEP, which improves the ratio of ventilation and blood flow (V/Q), and plays an important role in individulized lung protective ventilation strategy [5,7].

Pulmonary Ultrasound

Bedside lung ultrasound can be used for the diagnosis and differential diagnosis of various lung diseases by using a low-frequency convex probe of 3 to 5 MHz and a high-frequency linear probe of 8 to 12 MHz [8]. Normal lung ultrasound images include bat sign, lung sliding sign, and A-line. Pathological images mainly include abnormal pleural lines, pulmonary consolidation, interstitial syndrome, fragmentation sign, dynamic bronchial signs, pleural effusion and so on [9].

With the development of ultrasound technology, pulmonary ultrasound is gradually found to be of great value in diagnosing acute respiratory distress syndrome, pulmonary edema, pneumonia, pneumothorax, pulmonary embolism and so on [6,10,11]. It can be used to monitor the changes in lung ventilation, to guide clinical fluid management and evaluate prognosis, especially in patients with severe diseases. Since chest X-rays and CT examinations are unsuitable for rapid diagnosis of critical diseases due to the shortages of inconvenient carrying, radiation exposition, poor reproducibility, position limitations, and high costs, and compared with chest CT, bedside lung ultrasound has advantages of non-invasive, dynamic and repeatable observation of patients with lung disease.

The Advantage of Drainage Position Ventilation

At present, prone position mechanical ventilation is widely used in patients infected with new coronavirus, which may be helpful to the drainage of pulmonary inflammation and the reduction of pulmonary shunt volume [2]. So far, no effective antiviral drugs have been found in defeating new coronavirus, so drainage becomes an important treatment for pulmonary inflammatory lesions. Because of inflammatory lesions in different parts of the lung, prone position ventilation is not suitable for all patients, and it may be more beneficial to adopt drainage position mechanical ventilation combined with tracheal suction with the infected side of lung lesions upper side. For example, the lateral and head-down position mechanical ventilation with the inflammatory lung upper side according to the characteristics of pulmonary imaging of some patients infected with new coronavirus. The lateral prone position can be tried to improve the inflammatory side lung ventilation, reduce pulmonary shunt, increase blood reflux and improve hemodynamics. However, it is important to avoid excessive head down, which increases abdominal pressure on the chest cavity.

In summary, based on the autopsy, clinical manifestations, lung pathological characteristics and present treatment of the patients infected with the new coronavirus, this article describes some possible improvement measures for the mechanical ventilation strategy. We believe that postural drainage ventilation, real-time bedside pulmonary ultrasound and chest electrical impedance monitoring will improve the clinical treatment of critical patients based on the previous guidelines for ARDS treatment. These methods provide some new ideas for clinical treatment and need to be used and verified in future clinical work.

References

  1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, et al. (2020) Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med.
  2. Lingzhong Meng, Haibo Qiu, Li Wan, Yuhang Ai, Zhanggang Xue, et al. (2020) Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience. Anesthesiology 132: 1317-1332. [crossref]
  3. Huang C, Wang Y, Li X, Ren L, Zhao J, et al. (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395: 497-506.
  4. Qin Liu, Rongshuai wang, Guoqiang Qu, Yunyun wang, Pan Liu, et al. (2020) Gross Observation Report on the Autopsy of a nCov-2019 Pneumonia Death. Journal of Forensic Medicine (Chinese) 36: 21-23. [crossref]
  5. Hsu CF, Cheng JS, Lin WC, Cheng KS, Lin SH, et al. (2016) Electrical impedance tomography monitoring in acute respiratory distress syndrome patients with mechanical ventilation during prolonged positive end-expiratory pressure adjustments [J]. J Formos Med Assoc 115: 195-202. [crossref]
  6. Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R (2019) Lung ultrasound for the emergency diagnosis of pneumonia, acute heart failure, and exacerbations of chronic obstructive pulmonary disease / asthma in adults: a systematic review and meta-analysis. J Emerg Med 56: 53-69. [crossref]
  7. Heines SJH, Strauch U, Van de Poll MCG, Paul MHJR, Dennis CJJB (2018) Clinical implementation of electric impedance tomography in the treatment of ARDS: a single centre experience [J]. J Clin Monit Comput. [crossref]
  8. Rouby JJ, Arbelot C, Gao YZ, Zhang M, Lv J, et al. (2018) APECHO Study Group. Training for lung ultrasound score measurement in critically ill patients. Am J Respir Crit Care Med 198: 398-401. [crossref]
  9. Lichtenstein DA (2015) BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest 147: 1659-1670.
  10. Chavez MA, Shams N, Ellington LE, Naithani N, Gilman RH, et al. (2014) Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 15: 50. [crossref]
  11. Long L, Zhao HT, Zhang ZY, Wang GY, Zhao HL (2017) Lung ultrasound for the diagnosis of pneumonia in adults: a meta-analysis. Medicine (Baltimore) 96: e5713. [crossref]

Differences in Evaluation of Hydroxychloroquine and Face Masks for SARS-CoV-2

DOI: 10.31038/JNNC.2020342

Abstract

Current medical opinion, based on randomized controlled trials (RCTs), is that hydroxychloroquine is ineffective for treatment of SARS-CoV-2. Previous anecdotal and uncontrolled evidence that the drug might be helpful is now outweighed by RCTs. However, leading medical authorities and public health organizations such as the CDC, the Surgeon General and NIAID are strongly recommending wearing of face masks in public to reduce coronavirus transmission. Many governments and businesses are mandating face masks. These recommendations are based on weak, anecdotal, uncontrolled evidence and there are multiple meta-analyses of RCTs in the literature, not one of which found a single RCT in which face masks reduced viral transmission in public. The RCTs are ignored and not referenced on the CDC website. Organized medicine is taking the risk of serious blowback when and if the public learns that face masks are ineffective in viral pandemics. This blowback could undermine public confidence in vaccines and many other interventions and treatments for many different medical problems.

Criteria Applied to Hydroxychloroquine for SARS-CoV-2

In a recent opinion piece in JAMA, Saag [1] defined the criteria for evaluating scientific medical evidence, and specifically for evaluating potential interventions for treatment and prevention of coronavirus infections. His comments included the statement that: “First, a single report based on a small, nonrandomized study must be considered preliminary and hypothesis generating, not clinically actionable. Likewise, anecdotal case reports and case series that include several cases likewise must be considered anecdotal and preliminary.” (p. 2162) These criteria are undisputed in medicine. They should be applied to all public health, pharmacological, vaccine and other preventive and treatment interventions for SARS-CoV-2. Saag applied these criteria in evaluating the effectiveness of hydroxychloroquine for the treatment of SARS-CoV-2 and concluded that: 1) based on the highest level of evidence, randomized controlled trials (RCTs), hydroxychloroquine is ineffective and should not be used, and 2) enthusiasm for hydroxychloroquine was not based on science or data, but instead was due to the politization of the pandemic: “However, the politicization of the treatment was a more important factor in promoting interest in use of this drug. On April 4, the US president, “speaking on gut instinct,” promoted the drug as a potential treatment and authorized the US government to purchase and stockpile 29 million pills of hydroxychloroquine for use by patients with COVID-19. Of note, no health official in the US government endorsed use of hydroxychloroquine owing to the absence of robust data and concern about adverse effects.” (p. 2162).

“The clear, unambiguous, and compelling lesson from the hydroxychloroquine story for the medical community and the public is that science and politics do not mix. Science, by definition, requires diligence and an honest assessment of findings; politics not so much. The number of articles in the peer-reviewed literature over the last several months that have consistently and convincingly demonstrated the lack of efficacy of a highly hyped “cure” for COVID-19 represent the consequence of the irresponsible infusion of politics into the world of scientific evidence and discourse. For other potential therapies or interventions for COVID-19 (or any other diseases), this should not happen again” (p. 2162). The present author is in agreement with these statements by Saag concerning hydroxychloroquine for treatment of SARS-CoV-2, and evaluation of any intervention for prevention or treatment of coronavirus infections. Presumably, the large majority of physicians are in agreement with Saag on these points. Initial hopefulness about hydroxychloroquine early in the pandemic was understandable, but it is now time to abandon that drug for that indication. Public health authorities such as the CDC, the NIAID and the U.S. Surgeon General are all in agreement on that point.

Criteria Applied to Face Masks for SARS-CoV-2

When we turn to the use of face masks for reducing coronavirus transmission in the community, a very different picture emerges. Now we see the CDC, NIAID and the Surgeon General strongly recommending the wearing of face masks in public, and we see governments and businesses mandating the wearing of face masks. This is said to be based on science and data. However, the evidence cited for the effectiveness of facemasks is anecdotal and uncontrolled. At the same time that face masks are being strongly recommended or mandated, five meta-analyses of RCTs for the use of face masks for reducing the transmission of viruses in public have not found a single RCT that showed any effect of face masks. This is why, in their December 1, 2020 Interim Guidance on mask use in the context of COVID-19, the World Health Organization [2] stated that: “At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking of healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” (p. 8) In support of this conclusion, the World Health Organization referenced two recent papers published in the Annals of Internal Medicine, one of which was a randomized controlled trial of facemasks in Denmark with 4862 participants [3] that found no evidence of a protective effect of face masks. The second reference was to a review paper [4] of seven randomized controlled trials in the community and two in health care settings that found no protective effects of facemasks. Additional meta-analyses of RCTs for wearing of face masks in public include reviews of three RCTs [5], nine RCTs [6], four RCTs [7], ten RCTs [8] and most recently eleven RCTs [9]. The meta-analysis of eleven RCTs by Pezzolo et al. [9] involved a total of 7469 participants and found the relative risk for becoming corona virus-positive in people who wore face masks compared to people who did not to be 0.92. They stated that this difference is not significant. Prior to April, 2020, the WHO, CDC, NIAID and Surgeon General were stating that there is no need to wear face masks in public to reduce transmission of any type of virus, and they had been saying so for years. Within a few months, in the United States but not in the WHO, a complete about face took place. This was justified as being based on newly emerging evidence, but in fact the new evidence was small, uncontrolled and anecdotal. As of December, 2020, the list of references on the CDC website used to justify public wearing of face masks for the COVID-19 pandemic is entirely anecdotal. Not one of the RCTs is referenced. Rather than the CDC basing its recommendation on RCTs, the RCTs are ignored.

An example of an anecdotal observational study referenced by the Director of the CDC [10], in a paper on which he is a coauthor, is a study of two coronavirus-positive salon workers who wore facemasks at work, as did 102 of their 104 exposed clients. None of the clients became ill, but none of them were tested for coronavirus so the number of asymptomatic carriers in the client group is unknown, therefore we can’t reach any conclusion about the effectiveness of the face masks. In their paper, published in JAMA on July 14, 2020, the authors stated that, “At this critical juncture when COVID-19 is resurging, broad adoption of cloth face covering is a civic duty.”

In the present climate, anyone questioning the effectiveness of face masks for preventing transmission of the coronavirus in public takes the risk of being attacked as a conspiracy theorist, a right-wing extremist, a racist, a white supremacist, a narcissist, or even as being brain damaged [11]. Writing in JAMA, Miller [11] offered possible explanations for science denial in the context of the SARS-CoV-2 pandemic, specifically denial that face masks are effective for reducing coronavirus transmission in public. He stated that, “The relationship between anti-science viewpoints and low science literacy underscores new findings regarding the brain mechanisms that form and maintain false beliefs.” (p. 2255) Miller then went on to discuss how conspiracy theories that face masks do not work could be due to a variety of forms of neurological impairment including several different forms of dementia: “Conspiracy theories may bring security and calm, as with the patient with frontotemporal dementia who is content to believe they are rich.” (p. 2256) Organized medicine has maintained a stance of being based on science and data, and it has stated that the wearing of face masks in public is proven by science, when in fact the opposite is true. There are more RCTs confirming that face masks do not work than there are RCTs confirming that hydroxychloroquine does not work.

The Pore Size of Surgical Masks

It is not physically possible for surgical masks to reduce transmission of the coronavirus by asymptomatic carriers. The size of the coronavirus is about 0.1 microns, and the size of respiratory aerosols is about 2-3 microns. The pore size of surgical masks is 50-100 microns. Wearing a mask to prevent catching or transmitting the coronavirus is like putting a stake in the ground every 40 feet to prevent mice from coming onto your property [12-14]. Uninfected people and asymptomatic carriers are not coughing and sneezing in public, so they are not emitting any significant number of larger respiratory droplets. People who are symptomatic should stay at home. Isolation and quarantining should be the public health interventions for them. Face masks were never recommended for the flu because they don’t work. Face masks for coronavirus are not based on science. They may be a symbol of solidarity, a social control mechanism, an anti-hysteria strategy, or a well-intentioned effort to help people feel safe. Whatever the motives of face mask advocates, face masks are not science or data-based and are not effective for reducing coronavirus transmission in public. The medical profession is taking the risk of future blowback and loss of confidence in all its public health recommendations, including vaccines, by insisting that doctor knows best concerning face masks.

Conclusions

Organized medicine and public health authorities have been stating for more than six months that face masks are effective for reducing coronavirus transmission in public. This is not scientifically true. If the criteria that are applied when evaluating hydroxychloroquine for COVID-19 were applied to face masks, the CDC, the Surgeon General and NIAID would be stating, as they did up till early 2020, that there is no need to wear face masks in public.

References

  1. Saag MS (2020) Misguided use of hydroxychloroquine for COVID-19: The Infusion of Politics Into Science. JAMA. [crossref]
  2. World Health Organization (2020) Mask use in the context of COVID-19. Interim guidance, December 1, 2020.
  3. Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, Buchwald CV, Todsen T, et al. (2020) Effectiveness of adding a mask recommendation to other public health measures to prevent SARS-CoV-2 infection in Danish mask wearers: A randomized controlled trial. Annals of Internal Medicine. [crossref]
  4. Chou R, Dana T, Jungbauer R, Weeks C, McDonagh MS (2020) Masks for prevention of respiratory virus infections, Including SARS-CoV-2, in health care and community settings: A living rapid review. Annals of Internal Medicine 173: 542-555. [crossref]
  5. Brainard J, Jones N, Lake I, Hooper L, Hunter PR (2020) Face masks and similar barriers to prevent respiratory illness such as COVID-19: A rapid systematic review. Medrxiv.
  6. Aggarwhal N, Dwarakananthan V, Gautham N, Ray A (2020) Facemasks for prevention of viral respiratory infections in community settings: A systematic review and meta-analysis. Indian Journal of Public Health 64: 192-200. [crossref]
  7. Cowling BJ, Zhou Y, Ip DK, Leung GM, Aiello AE, et al. (2010) Face masks to prevent transmission of influenza virus: a systematic review. Epidemiology of Infection 138: 449-56. [crossref]
  8. Xiao J, Shiv EYC, Gao H, Wong JY, Fong MW, et al. (2020) Nonpharmaceutical measures for pandemic influenza in nonhealthcare settings – personal protective and environmental measures. Emerging Infectious Diseases 26: 967-975.
  9. Pezzolo E, Cazzaniga S, Gallus S, et al. (2020) Evidence from randomized controlled trials on the surgical masks’ effect on the spread of respiratory infections in the community. Annals of Internal Medicine 26 November.
  10. Brooks JT, Butler JC, Redfield RR (2020) Universal masking to prevent SAR-CoV-2 transmission – the time is now. JAMA. [crossref]
  11. Miller BL. Science denial and COVID conspiracy theories (2020) Potential neurological mechanisms and possible responses. JAMA 324:2255-2256. [crossref]
  12. Ross CA (2020) Thoughts on COVID-19. Journal of Neurology and Neurocritical Care 3: 1-3.
  13. Ross CA (2020) Facemasks are not effective for preventing transmission of the coronavirus. Journal of Neurology and Neurocritical Care 3: 1-2.
  14. Ross CA (2020) How misinformation that facemasks are effective for reducing is transmitted. Journal of Neurology Neurocritical Care 3: 1-2.

Perception and Understanding of Greek Dentists on Periodontal Regenerative Procedures: A Questionnaire Based Study

DOI: 10.31038/JDMR.2020345

Abstract

Objectives: The aim of this cross-sectional questionnaire study was to evaluate the perception and preferences of Greek dentists who either specialised in or had an interest in periodontal regenerative procedures and to compare the results with corresponding findings from two previous studies from different countries.

Materials and methods: The questionnaire was divided in two main sections and included multiple choice and/or open/closed questions. The first section consisted of six questions and was designed to collect demographic data of the sample and the second section, consisting of 15 questions, included general questions regarding periodontal regeneration procedures and questions based on specific clinical cases. 200 questionnaires were distributed at selected venues in Greece by the investigators. The participants were given one month to complete and return the questionnaires to the School of Dentistry in Thessaloniki.

Statistical analysis: Data management and analysis was performed using both Microsoft Excel 2007® (Microsoft Corporation, Reading, UK) and SPSS® version 22.0 software (IBM United Kingdom Ltd, Portsmouth, UK). Frequencies and associations between the demographic profiles of the participants were evaluated and presented in the form of frequency tables, charts, and figures.

Results: 104 questionnaires (67 males, 37 females: mean age 43.2 years [±9.8]) (52% response rate) were received. Of those who responded 56.7% (n=59) specialized in Periodontics and 43.3% (n=45) specialized in a variety of other dental disciplines (General Dentistry, Oral Surgery and Implantology). Guided tissue regeneration procedures and the use of enamel matrix derivative were recommended for the reconstruction of bony defects and both subepithelial connective tissue graft and coronally advanced flap with or without enamel matrix derivative were the most popular choices for root coverage. Smoking was considered a contraindication by most of the participants and conflicting responses were given regarding the use of antibiotics as part of the post-operative care following regenerative procedures.

Conclusions: The participants incorporated both traditional and “novel” techniques and products in reconstructive procedures and appeared to be up to date with the evidence from the dental literature. However, it was evident that there was confusion regarding the role of antibiotics in regenerative procedures.

Introduction

Reconstructive periodontal surgery has been one of the most dynamic and innovative therapeutic procedures in periodontology over the last 30-40 years. However, the goal of regeneration of the periodontal supporting tissues remains both unpredictable and challenging to the clinician [1,2]. Previously published cross-sectional surveys have reported on the management of regenerative procedures and techniques such as the regeneration of intrabony defects and the coverage of exposed root surfaces [1-4] and several investigators have indicated that there are numerous factors that need to be accounted for and modified before undertaking any surgical procedure of this manner [2-6]. Several reviews have previously established the use of Guided Tissue Regeneration (GTR) procedures for the reconstruction of intrabony and interradicular defects [5-10]. More recently with the advent of tissue engineering in Dentistry and the development of novel biomaterials such as enamel matrix derivatives (EMD) in combination with surgical procedures such as GTR have been utilised in general and specialized dental practices [1-2,5-8]. The type of surgical procedure including the flap design and the choice of whether to include regenerative materials or not, is important to achieve complete resolution of both the osseous and soft tissue defect [1]. There have been a number of regenerative materials and surgical techniques such as the Coronally Advanced Flap (CAF) with or without use of Sub-Epithelial Connective Tissue Graft (SCTG), enamel matrix derivatives (EMD), as well as the Free Gingival Graft (FGG) procedure which have also been recommended for root coverage [11-15]. Several studies have previously sought to evaluate whether the outcomes from clinical research in specialized and hospital-based practices has been translated into mainstream dental practices and whether the clinicians were conversant with the current recommendations and familiar with utilising the new regeneration techniques. The purpose of the present questionnaire-based study was to evaluate the knowledge and preferences of a selected group of Greek dentists in the treatment of a variety of common periodontal defects such as gingival recession, intrabony and furcation defects and to compare the results with corresponding findings from two previous studies using a similar questionnaire in two different countries.

Materials and Methods

The questionnaire was used in previous studies [1,2] and translated into Greek by native speaking Greek Dentists (DC, DS) and retranslated back into English to check for clarification of the text. The design of this study was previously assessed by the Queen Mary University of London Research Ethics Committee, London, UK (Reference: QMREC1343b) Two hundred questionnaires were prepared and distributed by two of the authors (AV, GAM) at several venues as follows: 1) the School of Dentistry of Aristotle University Thessaloniki, Greece, 2) private clinics in Thessaloniki and 3) a national periodontology conference. The participants were given one month to complete and return to the questionnaires to the Dental School in Thessaloniki.

The questionnaire consisted of 21 open and closed questions, divided in two main sections. The questions’ format was multiple-choice or open-ended or dichotomous in nature. The first section consisted of six questions and was designed to collect demographic data of the sample such as age, gender, specialty (periodontics, general dentistry, implantology, or other) as well as their year of graduation. To estimate the interest in periodontal regenerative procedures of the participants, they were asked to mark a line on a numerical scale from 1 (no interest) to 10 (high interest) based on the number of subscriptions to periodontal journals as well as the estimated number of periodontal regenerative procedures performed annually. The second section of the questionnaire, consisting of 15 questions, included general questions regarding periodontal regeneration, the site-specific factors that should be considered during the pre- and post-surgical assessment and the type of regenerative materials used in the procedure (Q. 5-6). The second section also included a set of questions about the management of four selected clinical case scenarios with labial marginal tissue recession of different stages (Miller class I–IV) [16] together with the relevant clinical photographs in colour and simplified line diagrams depicting the clinical situation. The participants were asked to choose between the following clinical options (Q. 7) and procedures (Q. 8-12): (1) CAF with or without EMD, (2) SCTG, (3) FGG, (4) laterally positioned flap (LPF), (5) double papilla flap (DPF), (6) GTR, and/or (7) other treatment. Following this section four further clinical photographs in colour with accompanying simplified diagrams of three-, two-, one-wall intrabony defects and class II furcation defects required from the participants to provide a response about the potential management of the specific clinical scenario. (Q. 13-16). Several treatment choices were provided for each of the clinical scenarios such as: (1) open flap debridement alone (OFD), (2) resective surgery, (3) GTR, (4) bone graft with or without barrier membrane, (5) EMD with or without bone fillers, and/or (6) other options A final set of questions asked about the frequency of EMD use per month and whether the participants used any special flap designs during periodontal regeneration procedures such as a papilla preservation or a coronally advanced flap procedure [CAF] (Q 17-18). Last but not least, questions relating to the exclusion of smokers from regenerative procedures and whether systemic antimicrobials should be prescribed as part of the postoperative care as well as an estimation of patients’ acceptance of using animal derived regenerative materials in regenerative procedures were also included (Q. 19-21].

Results

104 questionnaires (67 Male; 37 female participants; mean age 43.2 ± 9.8 years) were returned (52% response rate) to the School of Dentistry in Thessaloniki. The mean years after graduation from University was 19.3 ± 10.2 for the participants (range 1-41 years). Of those who responded 56.7% (n=59) specialized in Periodontics and the rest of the participants (43.3%; n=45) specialized in a variety of other dental disciplines (General Dentistry, Oral Surgery and Implantology). Data management and analysis of the returned responses was performed using both Microsoft Excel 2007® (Microsoft Corporation, Reading, UK) and SPSS® version 22.0 software (IBM United Kingdom Ltd, Portsmouth, UK) and presented in the form of frequency tables, charts, and figures. 71.2% (n=74) of the participants responded that they have a subscription in at least one periodontal journal whereas 28.8% (n=30) reported not having any. 94.5% (n=69) of those who subscribed to periodontal journals answered that they had up to four subscriptions, whereas (29.8% of the participants declined to give an answer). When asked to express their interest in periodontal regeneration procedures 76% (n=79) recorded a Visual Analogue Scale score of 7 and above, 19.2% (n=20) a score of 4-6 and 4.8% (n=5) indicated a VAS score between 1-3 (Q. 5). When asked to estimate the number of regenerative procedures (%) that they had performed in one year (Q.6) 87.5% (n=91) estimated that up to 30% of the surgeries performed in their clinical practice annually were regenerative in nature (mean percentage 20.5% ± 17.1%).

The main clinical parameters that were evaluated prior to and following a regenerative procedure are shown in Figure 1.

fig 1

Figure 1: Parameters considered prior to and following a regenerative procedure (Q.7).

In response to the techniques and materials commonly used in regenerative procedures (Q.8) the most popular choices were 1) EMD (74%; n=77), 2) GTR with a resorbable barrier membrane (57.7%; n=60), 3) Allogenic graft (with or without a barrier membrane) (57.7%; n=60) and 4) Xenogenic graft (with or without a barrier membrane) (51%: n=53) (Figure 2).

fig 2

Figure 2: Techniques and materials used in regenerative procedures.

Q. 9-12 required the participants to indicate their preferences for treatment of four clinical scenarios corresponding to each of the four categories of the Miller Classification for marginal recession defects.

The responses for treating a Miller Class I defect were as follow: 1) CTG (69.2%; n=72), 2) CRF (42.3%; n=44), 3) CRF with EMD (28.8%; n=30) and 4) LSF (13.5%; n=14) (Figure 3a). Of the participants who chose “other” as a response, the double papilla flap (11.5%; n=12) and free gingival graft (7.7%: n=8) were more frequently suggested. The responses for the treatment of a Miller Class II marginal defect were: 1) Connective Tissue Graft (68.3%; n=71), 2) CRF (19.2%; n=20), 3) CRF with EMD (19.2%; n=20), 4) FGG (15.4%; n=16) and 5) LSF (14.4%; n=15) (Figure 3b). Of the other responses a CRP/CTG combination (30%; n=3) and a mucogingival graft ((20%; n=2) were suggested as alternative options. The responses for the treatment of a Miller Class III marginal defect were: 1) Free Gingival Graft (26.8%; n=28), 2) GTR (17.3%; n=18), 3) CTG (5.8%; n=6) and 4) ‘Other’ (51.9%; n=54) Figure 3c). Of the 19 ‘Other’ responses, 36.8% (n=7) of the participants administered no treatment, 15.8% (n=3) suggested a mucogingival graft and 10.5% (n=2) suggested a subepithelial graft with a tunnelling technique. The responses for the treatment of a Miller Class IV marginal defect were as follows: 1) Free Gingival Graft (26.8%; n=28), 2) GTR (17.3%; n=18), 3) CTG (5.8%; n=6) and 4) ‘Other’ (51.9%; n=54) (Figure 3d). Of the ‘Other’ responses, 53.7% (n=29) of the participants offered no treatment, 7.4% (n=4) suggested extraction, 5.6% (n=3) offered non specified conservative treatment and 4) 5.6% (n=3) suggested a mucogingival graft.

fig 3a

fig 3b

fig 3c & 3d

Figure 3a-3d: The preferences of the participants regarding the various treatment options available for the different Miller Classification marginal recession defects (a) Miller Class I; (b) Miller Class II; (c) Miller Class III; and (d) Miller Class IV.

The preferences of the participants regarding various surgical options available for the treatment of intrabony defects namely: (a) 3-wall defect; (b) 2-wall defect; and (c) 1-wall defect were addressed in Q. 13-15. The main preferences for treating a 3-wall defect were: 1) use of a bone filler (45.2%: n=47), 2) EMD (43.5%: n=45), 3) GTR with a resorbable membrane (40.4%: n=42) and 4) EMD with a bone filler (29.8%: n=31) (Figure 4a)

The main preferences for treating a 2-wall defect were: 1) use of a bone filler (51.9%: n=54), 2) EMD with a bone filler (34.6%: n=36), 3) Open flap debridement only (27.9%: n=29) and 4) GTR with a resorbable membrane (25%: n=24) (Figure 4b).

The main preferences for treating a 1-wall defect were: 1) Open flap debridement alone (39.4%: n=41), 2) using a bone filler (35.6%: n=37), 3) Resective procedure (28.8%: n=30) and 4) EMD with a bone filler (19.2%: n=20) (Figure 4c).

fig 4a & 4b

fig 4c

Figure 4a-4c: The preferences of the participants in relation to the various surgical options available for the treatment of intrabony defects namely: (a) 3-wall defect; (b) 2-wall defect; and (c) 1-wall defect.

The main preferences for treating a Class II furcation defect (Q. 16) were as follows: 1) GTR with a barrier membrane (39.4%; n=41), 2) Open flap debridement alone (34.6%: n=36), 3) use of a bone filler (29.8%: n=31) and 4) EMD (26.9%: n=28) (Figure 5).

fig 5

Figure 5: The main preferences for treating a Class II furcation defect.

92.3% (n=96) of the participants indicated that they used EMD in regenerative procedures (Q. 17). When asked how often was EMD used in regenerative procedures within a month, 58.3% (n=60) of the participants indicated that they applied the product 1-3 times per month. Of the other responses 14.6% (n=14) applied EMD 4-6 times within a month, a 6.8% (n=7) 7-9 times a month. and a 5% (n=5) of the participants indicated that they never applied EMD during regenerative procedures (Figure 6).

fig 6

Figure 6: Estimated monthly application of EMD in regenerative procedures.

The most popular flap design incorporating a minimally invasive surgical approach (Q. 18) included 1) a papilla preservation technique (38.5%; n=40) and 2) MIST (30.8%: n=32) (Figure 7).

fig 7

Figure 7: Choice of a specific flap design incorporating a minimally invasive surgical approach.

70.2% (n=73) of the participants responded that they usually exclude smokers from regenerative procedures whereas 29.8% (n=31) indicated that they would attempt a periodontal regeneration surgery to smokers (Q. 19). The main reasons for the exclusion of smokers were compromised host response, impaired wound healing, risk of membrane exposure and a low success rate.

88.2% (n=90) of the participants stated that they would prescribe antibiotics (e.g., Amoxicillin and Metronidazole) after a regenerative procedure, but 11.8% (n=12) indicated that they would not (Q. 20). Of those participants who would prescribe antibiotics 46.1% (n=47) indicated that they would do so for at least 9 out of 10 of their patients (Figure 8).

fig 8

Figure 8: Estimated percentage of patients receiving antibiotics after regeneration procedures.

The main antibiotics prescribed after a regenerative procedure (Q. 20) were: 1) Amoxicillin (54.8%; n=57), 2) Amoxicillin and Clavulanic acid (35.6%: n=37), 3) Metronidazole (16.3%: n=17) and 4) Clindamycin (15.4%: n=16).

When asked whether any of their patients had refused to have an animal derived product placed in situ as part of a regenerative procedure, 84.6% (n=88) of the participants gave a negative answer (Q. 21), whereas of those participants who indicated that their patients may refuse to receive one of these products, (8.7%; n=9), although, ≤ 5% of the patients would actually refuse an animal derived product as part of a regenerative procedure.

A comparison of the results from the present study together with the previous outcomes from the UK and Kuwaiti studies are shown in Table 1.

Table 1: Comparison of studies in the UK, Kuwait and Greece.

Question Siaili et al. (UK) Abdulwahab et al. (Kuwait) Violesti et al. (Greece)
Q. 1-2 Demographics (Age: Gender) 141 participants (M:84: F: 51 mean: 44 ± 1.05 years) Response rate: 38.5% 129 participants (M 90: F 39; mean age: 35.7 ± 7.2 years). Response rate 86%. 104 participants (M 67: F 37; mean age 43.2 ± 9.8 years). Response rate 52%.
Q. 3 Professional Status 65.5% (n=91) specialized in Periodontics and 35.5% (n=50) were General Dental Practitioners with a special interest in Periodontics. 55.8% (n=72) were General Dental Practitioners, 26% (n=34) specialised in Periodontics. Other disciplines included Oral Surgery, Orthodontics Implantology and Prosthodontics. 56.7% (n=59) specialized in Periodontics, 43.3% (n=45) specialized in a variety of dental disciplines including Periodontics, General Dentistry, Oral Surgery and Implantology)
Q. 4 Years from Graduation 20 ± 1.04 years (range 2–50 years) 9.8 ± 7.0 years (range 0-33 years) 19.3 ± 10.2 years (range 1-41 years)
Q. 5a-b Journal Subscription 68.1% (n=96) subscribed to one or more journals 30% (n=39) subscribed to one or more journals 71.2% (n=74) subscribed to one or more journals
Q. 5c Interest in Periodontal Regenerative procedures Mean VAS 7.57 ± 0.2 (High) Mean VAS 6.5 ± 2.3 (Moderate) Mean VAS 7.79 ± 2.2 (High)
Q. 6 Estimation of the number of Regenerative procedures Mean percentage 14% ± 1.96% Mean percentage 27.5% ± 25.5%. Mean percentage 20.5% ± 17.1%.
Q. 7 Parameters to be considered prior to and following a regenerative procedure Oral hygiene, pocket depth measurement, radiographic presentation and, CAL Oral hygiene, tooth mobility, probing depth measurements and radiographic presentation Oral hygiene, pocket depth measurement, radiographic presentation and, CAL
Q. 8 Techniques and materials used in regenerative procedures 1) EMD, 2) GTR with a resorbable (absorbable) membrane 1) GTR, 2) allogenic graft (with or without a barrier membrane), 3) alloplastic grafts (with or without a barrier membrane) and 4) EMD 1) EMD, 2) GTR with a resorbable barrier membrane), 3) Allogenic graft (with or without a barrier membrane) and 4) Xenogenic graft (with or without a barrier membrane)
Q.9 The preferences of the participants regarding the various treatment options available of a Miller Class I marginal defect 1) SCTG, 2) CAF, 3) FGG and 4) CAF with EMD 1) CRF, 2) CTG, 3) FGG and 4) CRF with EMD 1) CTG, 2) CRF 3) CRF with EMD and 4) LSF
Q.10 The preferences of the participants regarding the various treatment options available of a Miller Class II marginal defect 1) SCTG, 2) FGG, 3) CAF with EMD and 4) CAF 1) CTG, 2) CRF, 3) GTR and 4) CRF with EMD 1) CTG 2) CRF, 3) CRF with EMD and 4) FGG
Q.11 The preferences of the participants regarding the various treatment options available of a Miller Class III marginal defect 1) SCTG, 2) FGG and 3) ”Other” (e.g., non-surgical treatment) 1) GTR with a resorbable barrier membrane 2) FGG, 3) CTG and 4) LSF 1) FGG, 2) GTR, 3) CTG and 4) ‘Other’ (no treatment, a mucogingival graft and a subepithelial graft with tunnelling)
Q.12 The preferences of the participants regarding the various treatment options available of a Miller Class IV marginal defect 1) FGG and 2) GTR procedures were indicated although 3) other treatment options such as ‘nonsurgical treatment’ and extraction were preferable GTR with a resorbable barrier membrane and CTG were recommended although ‘Extraction’ was the preferred option 1) FGG, 2) GTR, 3) CTG 4) other options preferred such as no treatment, extraction, and non-specified conservative treatment or a mucogingival graft.
Q. 13 The preferences of the participants in relation to the various surgical options available for the treatment of a 3-wall infrabony defect 1) EMD without and with bone grafts (filler) and 2) using bone grafts (filler) with or without the use of barrier membranes 1) GTR with a resorbable barrier membrane, 2) bone grafts (filler), 3) OFD and 4) EMD combined with bone grafts 1) using a bone filler, 2) EMD, 3) GTR with a resorbable membrane, and 4) EMD with a bone filler
Q. 14 The preferences of the participants in relation to the various surgical options available for the treatment of a 2-wall infrabony defect 1) EMD combined with bone grafts, 2) bone grafts (filler) with or without barrier membranes, 3) GTR with resorbable membranes and (4) EMD 1) GTR with a resorbable barrier membrane, 2) bone grafts (filler), 3) combined with bone grafts and 4) OFD 1) using a bone filler, 2) EMD with a bone filler, 3) OFD and 4) GTR with a resorbable membrane
Q. 15 The preferences of the participants in relation to the various surgical options available for the treatment of a 1-wall infrabony defect 1) Resective surgery and 2) OFD 1) Resective surgery, 2) OFD, 3) Bone graft and 4) GTR with the use of a resorbable barrier 1) OFD 2) using a bone filler, 3) Resective procedure and 4) EMD with a bone filler
Q. 16 The main preferences for treating a Class II furcation defect 1) EMD, 2) GTR with the use of resorbable barrier membranes 3) OFD 4) EMD and bone grafts 5) resective surgery And 6) bone grafts with or without barrier membranes 1) GTR with a resorbable barrier, 2) OFD and bone graft. EMD was the least preferred option for the management of a Class II furcation defect 1) GTR with a barrier membrane 2) Open flap debridement only, 3) using a bone filler, and 4) EMD
Q. 17 Estimated monthly application of EMD in regenerative procedures The main response was one to three times per month The main response was one to three times per month The main response was one to three times per month
Q. 18 Choice of a specific flap design incorporating a minimally invasive surgical approach 1) The papilla preservation flap and 2) coronally advanced flap 1) Papilla preservation 2) coronally displaced (advanced) flap 1) a papilla preservation technique and 2) MIST procedures
Q. 19 Would Smokers be excluded from regenerative procedures Smoking was considered a contraindication for regenerative procedures by most of the participants. Vasoconstriction, impaired postoperative healing, and compromised outcomes were reasons why Smokers should be excluded from these procedures. Smoking was not considered a contraindication for regenerative procedures by most of the participants of those participants who would exclude Smokers factors such as impaired healing, poor prognosis, vasoconstriction and, treatment results in failure (low success rate) Smoking was considered a contraindication for regenerative procedures by most of the participants. The main reasons for exclusion included a compromised host response, wound healing, risk of membrane exposed and a low success rate.
Q. 20 Prescription of antibiotics following regenerative procedures Most of the participants reported that they would prescribe antibiotics for their patients with 35% indicating that they would not prescribe antibiotics Most of the participants reported that they would prescribe antibiotics for their patients with 9.6% indicating that they would not prescribe antibiotics Most of the participants reported that they would prescribe antibiotics for their patients with 11.8% indicating that they would not prescribe antibiotics
Q. 20 Choice of Antibiotic prescribed to patients 1) Amoxicillin, 2) Combination of Amoxicillin and 3) Metronidazole and 4) Doxycycline Metronidazole, 1) Combination of Amoxicillin and Metronidazole, 2) Augmentin, 3) Amoxicillin and 4) Clindamycin 1) Amoxicillin, 2) Amoxicillin and Clavulanic acid), 3) Metronidazole and 4) Clindamycin
Q. 21 What % of your patients undergoing a regenerative procedure would reject an animal derived material Variable response with at least one-third of the participants indicating that their patients would not reject an animal derived material. Of those participants who indicated that their patients may refuse to have one of these products <5% of their patients would do so Most of the participants reported that

their patients would reject an animal-derived material. According to the participants’ responses, at least 30% of their patients would reject the product.

Most of the participants indicated that none of their patients would reject an animal derived material. Of those participants who indicated that their patients may refuse to have one of these products <5% of their patients would do so.

Key: M: Male; CAF: Coronally Advanced Flap; F: Female; FGG: Free Gingival Graft; VAS: Visual Analogue Scale; CRF: Coronally Repositioned Flap; EMD: Enamel Matrix Derivative; LSF: Laterally Sliding Flap; GTR: Guided Tissue Regeneration; OFD: Open Flap Debridement; SCTG: Subepithelial Connective Tissue Graft.

Discussion

The aim of the present study was to assess the awareness and preferences of a selected group of Greek clinicians and to compare the outcomes with two previous cross-sectional questionnaire studies in the UK and Kuwait [1,2]. The response rates from the three studies were at variance with each other (38.5% to 86%) differing also from the response rate of the present study, which was 52%. When comparing the age and experience of the participating dentists with the two previous studies [1,2], the age and experience of the Greek dentists were comparable with the UK study [1] although the dentists in the Kuwait study [2] were on average younger with less clinical experience. The professional status of both the UK based clinicians and those in the present study was similar with >50% of the participants being specialized in Periodontics as compared to the Kuwaiti sample where only 26% was specialized in Periodontology. This was evident when comparing the interest in performing regenerative procedures. The result of the present study was comparable to the UK based study with both groups expressing a high degree of interest in performing regenerative procedures (Mean VAS 7.79 ± 2.2 [Greek]: 7.57 ± 0.2 [UK]) whereas the corresponding result from Kuwait was moderate (mean VAS 6.5 ± 2.3). The mean percentage of periodontal regenerative procedures recorded in the present study (20.5%) was comparable to the Kuwaiti based group (27.5%) and remarkably higher comparatively to the one recorded in the UK study (14%). When considering the clinical parameters taken into account prior to and following a periodontal regeneration procedure, the overall responses from the three studies (oral hygiene, pocket depth measurements, radiographic presentation and CAL) from Greece and the UK were similar although in the Kuwaiti study the assessment of CAL seemed to be underestimated. The assessment of CAL is perhaps one of the most important factors in periodontal regeneration [9] and the apparent underestimation of this factor may be the result of the lack of experience of the younger participants in Kuwait. When considering the type of technique(s) and materials used in regenerative procedures both the UK and Greek group indicated that they prefer 1) EMD and 2) GTR with a resorbable membrane. On the other hand, the Kuwaiti group indicated that although they widely choose a GTR procedure as well, they prefer to combine this technique with either allogenic or alloplastic grafts (with or without the use of a membrane). Notably, at the time of conducting the study in Kuwait the use EMD was not as popular as in the UK and Greece.

Comparison of the preferred treatment modalities for the four selected clinical situations based on the Miller Classification [16] (Q. 9-12) evaluated the participants’ responses to root coverage procedures in terms of the ‘the most predictable’ outcome for the clinical cases (Miller Class I & II defects) as well as the ‘least predictable’ outcomes based on Miller Class III & IV recession defects. The most popular technique to treat Miller Class I defects was a CTG procedure in agreement with [1] but not with [2] where the principal choice was a CRF/CAF procedure (Table 1). For the treatment of a Miller Class II defect a CTG procedure was the most popular choice in all three studies in agreement with evidence from the published literature, indicating the superiority of CAF with or without EMD and/or CTG in root coverage procedures [15]. The responses for treating a Miller Class III defect were at variance with the other two studies in that the main choice in the present study was for a FGG procedure which was not the first choice in the other two studies [1,2] although it was popular (Table 1). The treatment preferences for managing a Miller Class IV defect were in general agreement with the studies from the UK [1] and Kuwait [2] Although the Kuwaiti study’s first preference was a GTR procedure, other options including non-surgical treatment and extractions which was also suggested in all three studies (Table 1).

Responses to Q. 13-15 related to the materials and techniques used in the management of 1, 2 or 3-walled intrabony defects indicated that in the management of both the 3- and 2- walled defects there was overall agreement between the three studies with EMD (with/without a bone filler) being favoured in the present study and the UK study [1]. On the contrary, GTR procedures were favoured in the Kuwaiti study [2] (Table 1). For the treatment of a 1-walled infrabony defect OFD was the first choice in the present study, whereas resective surgery was the preferred choice in the UK and Kuwaiti studies [1,2]. The differences in the use of EMD between the present study and the Kuwaiti study may either have been related to religious issues or the availability of the specified biomaterial. Furthermore, it should be recognised that some of the minimally invasive procedures employed in Specialist and Hospital based practices may not be undertaken in the general practice environment.

The main preferences for treating a Class II furcation defect (Q. 16) in the present study were 1) GTR with a barrier membrane (39.4%; n=41), 2) Open flap debridement alone (34.6%: n=36), 3) use of a bone filler (29.8%: n=31) and 4) EMD (26.9%: n=28) (Figure 6) in agreement with Abdulwahab et al. [2]. The main difference between the UK study and the other two was the preference for EMD [1,2] (Table 1). In response to Q. 17 there was general agreement as far as the estimated monthly EMD application was concerned (Table 1). The main choice of a specific flap design incorporating a minimally invasive surgical approach was the papilla preservation flap (Q. 18) (Table 1). Flap design is of critical importance in regenerative procedures as it facilitates both full surgical site coverage and wound stability during the healing process [11].

When asked whether smoking was a contraindication for regenerative procedures (Q. 19), most of the participants in the present study concurred with those in the UK study [1] that smokers should be excluded. This was in contradistinction to the Kuwaiti study [2] where smokers would not be excluded (Table 1). Evidence from previous studies would suggest that smokers appear to have impaired healing response as well as lower frequencies of complete root coverage compared to non-smokers [13,16].

Most of the participants in all three studies would prescribe antibiotics after a regenerative procedure (Q. 20). The number of dentists who would prescribe antibiotics was higher for both the present and the Kuwaiti study [2] as compared to the results from the UK [1] indicating that a larger number of respondents in the UK study would not prescribe antibiotics after a periodontal regeneration surgery (Table 1). According to Abdulwahab et al. [2] this response from UK dentists may be due to a greater awareness of the current problems with antibiotic resistance due to over-prescription. The choice of a specific antibiotic (Q. 20) in the present study was in general agreement with previous studies [1,2] (Table 1).

The acceptance or rejection of an animal-derived regenerative material as part of the regenerative procedure by the patients (Q. 21) may depend on the cultural or religious beliefs of the patients. For example, most of the participants in the present study would accept this kind of material in agreement with studies [1,3] but in contradiction with [2] where most of the participants would reject this material based on their patients’ preferences (Table 1).

The results from the present study appear to validate the questionnaire previously used [1,2] and there was general agreement from the three studies on how practitioners would treat the various clinical scenarios however it was evident that several points of disagreement arose from the results of the two previous studies [1,2] such as whether to exclude smokers prior to a regenerative procedure, post-operative administration of antibiotics following regenerative procedures [2] or the acceptance of animal derived products during these procedures. The results from the present study generally concur with previous European studies, particularly regarding the use of animal derived biomaterials [1,3]. The techniques and regenerative materials have changed over the last decade and this may be reflected in the responses acquired by the three studies. This may also suggest that there is a lag period regarding the transfer of information from evidence-based clinical practice to the general practice as well a lack of opportunity or availability to develop clinical skills from hands on clinical training in regenerative procedures.

Conclusion

The results of the present pilot study would suggest that dentists need to be more informed regarding recent innovations in regenerative procedures and techniques when treating a range of periodontal defects.

Acknowledgements

The investigators would like to thank all the participants who helped with this study.

References

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A Mind Genomics Cartography of Craft Beer: Homo Emotionalis vs. Homo Economicus in the Understanding of Effective Messaging

DOI: 10.31038/NRFSJ.2020312

Abstract

This mind cartography of craft beers explores what interest’s prospective consumers in a craft beer, and how much they will pay. Each respondent tested unique sets of 48 vignettes, comprising 2-4 elements selected from a set of 36 elements. The permutation strategy enables an individual-level model to be constructed relating the presence/absence of 16 elements (messages) to both rated interest in the beer, and price willing to pay. Clustering the models by individuals revealed two different patterns of mind-sets. The first triple of mind-sets emerges from the interest rating (Homo Emotionalis: Appearance & Beer Story, Flavor & Romance, and Quirky). The second triple of mind-sets emerges from the price selection (Homo Economicus: Quality Package & Flavor; Flavor & Experience; Sensory Decadence). The paper introduces the PVI, personal viewpoint identifier, expanding the findings by assigning new people to a mind-set based upon the response pattern to six question emerging from the segmentation on Question 1 The paper finishes with scenario analysis, an approach to discover how pairs of elements interact in ways that could not have been known at the start of the experiment. The scenario analysis is applied to the interaction of origin to the other elements, both for Homo Emotionalis (ratings of interest, question #1) and for Homo Economicus (selection of price, question #2).

Introduction

Craft beer, a recent development in the word of brewing, has been summarized by Wikipedia as follows:

A craft beer or microbrewery is a brewery which produces small amounts of beer…and is often independently owned. Such are brewers are generally perceived and marketed as having an emphasis on enthusiasm, new flavours and varied brewing techniques. The microbrewing movement began both in the United States and United Kingdom in the 1970’s…

In an age of automation and conformation to production and product specifications in the interest of business, the growth and flowering of the craft beer industry may be symptomatic of a deep of people, viz. to express themselves and their creativity in crafts. In a world where standardization continues relentlessly, and the economics of scale demand conformity, there is a desire for people to express themselves. This expression can be the quotidian act of preparing one’s own food in a creative way, cooking, creating one’s own mixtures of ingredients in smoothies, or creating one’s own beverage by traditional processes, viz., home brewing and the effort of craft brewing. In the world of brewing the appellation of a craft beer may become a strong marketing positive, either because of direct or because of the romanticization of the traditional, the small, and the so-called ‘authentic’ [1-6].

The food and beverage world has welcomed studies about food for more than a century. Food and beverage are important, but of greatest important is the realization that we eat and drink for many reasons, ranging from basic survival to sensory preferences to socially motivated issues like companionship. Furthermore, foods and small, inexpensive items, are purchased not in a strategic way by business specialists, but rather by the ordinary person. Understanding the features of products is important in such a world where freedom of choice is feasible, and indeed a major component with which marketers must contend.

Most of the popular literature, e.g., newspapers, bogs, videos, and so forth, talk about the interesting parts of craft beer, such as the history of the product, the emotions felt in making the product, the emotions of the trade and buyer, and so forth. The stories are ‘happy,’ topical, and of general interest. The science of beer making, and the issues faced by beer makers who are brewing their own craft beers are less interesting, but nonetheless important.

The motivation for this study was the interest in marketing messages about craft beer. The language of craft beer is a romantic one, as one which connotes a rebellion of sorts, and a focus on the ‘arts and crafts’ of brewing. Beers with connections to countries traditional perceived as brewers, e.g., England, Germany, Belgium, etc., are often romanticized as being tasty, and special. Despite the large literature on craft beer from the worlds of marketing, sociology and sensory research, there does not seem to be a systematic analysis readily available of the responses to messages about the nature of craft beer. In the spirit of Mind Genomics, thus study provides a preliminary cartography, focusing on what messages about craft beer drive interest, and what messages drive willingness to pay.

The topic of craft beer, especially the combination of economics and communications, is part of an ongoing project by the authors, focusing on a new approach to understanding of how people make decisions. The general study is Mind Genomics, described below, and the specific focus is an emerging subdiscipline of Mind Genomics, cognitive economics, which fits into the world of behavioral economics. When applied to the topic of ‘what is important’ in craft beer, and what do people say they ‘value economically,’ Mind Genomics provides a contribution both to behavioral economics, and the world of beer.

The Emerging science of Mind Genomics

Mind Genomics is an emerging behavioral science with the objective of studying the decision making of everyday life through simple experimentation. Mind Genomics can be thought as a combination of experimental psychology studying how we make decisions, anthropology to look deeply into behavior, sociology to look at that behavior in the context of life, with influences from the methods consumer research and statistics, respectively. Mind Genomics focuses on a world often overlooked, the world of the everyday, specifically how we make decisions [7-10].

A study on craft beer using Mind Genomics might easily focus on the act of ordering and drinking beer, looking at what is important in the daily acts of choosing to consume, ordering a product, and relaxing with the product. This specific study in Mind Genomics moves beyond that ‘experience-focus’ to a focus on the product per se, to understand how people react to the nature of the craft beer as it is described to them in a small, easy-to read vignettes.

The strategy of Mind Genomics follows a set group of steps, outlined below. To summarize these steps, the objective of Mind Genomics is to understand the nature of the product or experience, doing so by study responses to short, easy to read vignette. The pattern of responses to these vignettes reveals the way the respondent ‘thinks’ about the topic.

The vignettes created by Mind Genomics comprise short descriptions of a product or a service, or even a state-of-mind. The description comprises a series of short phrases, stacked one atop the other in an easy-to-search set of messages. The respondent is instructed to treat this set of disparate messages as one single idea, and to rate this composite as one single idea. The task starts out to be daunting when the first vignette is presented, simply because the vignette seems to be composed in a fashion which seems random, something which disturbs many people. The opposite, however, is true. An underlying ‘experimental design’, viz., a recipe book of specific combinations, guides the composition of each vignette.

When faced with this seeming ‘blooming, buzzing confusion’ in the words of psychologist Wm James, one might think that the respondent would just give up and leave. Most respondents do not, and rather sink down, pay less attention, and respondent to the elements and their combination in a matter that might be construed as guessing. It will be this return to an almost automatic, gut-feel response, which allows Mind Genomics to understand the mind of the consumer, defeating the attempt by people to respond in a way that they believe the researcher wants them to do, defeating the attempt to be ‘politically correct’.

The Process of Mind Genomics

Mind Genomics follows a series of steps to generate the necessary insights and understanding. The steps are straightforward, put together in a way to make research easy to do by being ‘templated’, inexpensive to execute, with deeply analyzed data and reports emerging immediately. The vision is a science which creates a ‘wiki of the mind’ for the ordinary aspects of human behavior, a science which generates databases showing the different aspects of daily life analyzed into its components, and augment with knowledge about what is important to people. We present these steps as a description of responses to craft beer, a topic of increasing interest in markets all around the world.

Step 1: Select a Topic

The topic forces the researcher to think about the issues. Our topic is craft beer. Mind Genomics allows the topic to be broad or narrow. It will not be the topic itself, however, which is important, but rather the specifics as we see in the full set of steps, which, when followed, generate that ‘wiki of the mind’.

Step 2: Select Six Questions which Tell the Story

It is at this step that Mind Genomics departs from many other approaches such as surveys. Mind Genomics begins with a set of questions which allow the research to approach the topic in a granular, ‘micro’ fashion. Rather than focusing on answering ‘big questions’ with the ‘experimentum crucis,’ just the right experiment to answer a question about mechanisms, Mind Genomics uses the questions in the manner of a cartographer, to ‘map out’ a location. The six questions force the researcher to think about what type of information will be relevant about the topic. The questions will be ones answered with a phrase, not with a yes/no or a single word. The researcher ought to think like the proverbial reporter who must focus on information which tells a story. The proper set of questions in the proper order should help that. The reader should note that the two most popular forms of Mind Genomics are the 4×4 (four questions, four answers to each question) and the 6×6 (six questions, six answers to each question, the version used in this study)

Step 3: Formulate Six Separate Answers to Each Question

It is in the selection of answers that Mind Genomics will make its greatest contribution. The iteration towards the most important answers will be the iteration towards deeper understanding of the topic, from the point of view of how people respond to the questions, and thus for our study how people think of craft beer study. At the same time, it is important to stress the simplicity and affordability of iteration, so that Mind Genomics provides a powerful tool to explore, and to learn inductively from patterns, rather than simply a tool to accept or falsify a hypothesis, in the manner of the scientific project as described by philosopher Karl Popper [11].

Table 1 presents the six questions and the six answers for each question. Note that the process is inexpensive, fast, and thus designed to be iterative, to help learning, rather than simply to answer a problem, to ‘plug a hole in the literature,’ in the common parlance of why studies are done.

Table 1: The six questions and the six answers for each question.

  Question 1 – What does the beer TASTE like?
A1 Earthy … hay-like, grassy, and woody
A2 Crisp … light and clean tasting
A3 Spicy … Orange, citrus and coriander aromas
A4 Hoppy … with a high level of bitterness
A5 Dark … bittersweet chocolate and coffee flavors
A6 Sour taste with a fruitiness … dark cherry, plum, currants
Question B: What does the beer LOOK like?
B1 A little hazy or cloudy
B2 Pale, clear and light bodied
B3 Amber colored and medium bodied
B4 Dark and full bodied
B5 Dense, long-lasting head … stays until your last sip
B6 Not too fizzy … just the right amount of carbonation
Question C: What is the drinking experience ?
C1 Long lingering finish keeps delivering pleasure
C2 Short finish prepares you for your next sip
C3 Smooth, creamy mouthfeel
C4 A mouthfeel that leaves you a little dry and puckering
C5 So good … should be appreciated without food
C6 Pairing this beer with your meal … brings out the best in both
Question D: Where is the beer brewed?
D1I From a local craft brewer … with a great story
D2 Brewed in the USA
D3 From Mexico
D4 Imported from Belgium
D5 From the UK
D6 From Germany
Question E: What is the benefit?
E1 Refreshing and thirst quenching …Hits the spot on a hot summer’s day
E2 Helps you unwind after a busy day
E3 A beer for bonding and relaxing with friends
E4 Savor and enjoy slowly
E5 Brewed from the heart … authentic, hand-crafted
E6 A great beer to include in your beer appreciation journey
  Question F: Where do you get it (venue), how do you drink it?
F1 Best enjoyed with the right type of glass … served at the right temperature
F2 Drink it straight from the can or bottle
F3 Fun, irreverent label
F4 Limited availability … buy from a beer specialty store
F5 Packaged in a brown glass bottle … to stay fresher longer
F6 Buy it anywhere beer is sold

Step 4: Create a Simple Orientation Page to Tell the Respondents about the Study

Figure 1 shows the orientation, and the scale. Note that for this version of Mind Genomics there are two scales and 36 elements, the practice appropriate during the years 2010-2016, when the consumers were not over-sampled, and when it was feasible to do studies lasting 15-17 minutes. Those ‘early days’ are now gone, and most studies must be kept to less than five minutes because of the reduced attention time characteristic of today’s over stimulating environment.

fig 1

Figure 1: The orientation page.

Note in Figure 1 that the interest scale goes from a low of 1 to a high of 9, but the price scale is in irregular order of prices. This irregular order is a precaution to ensure that the price scale does not turn into another interest scale. When assigning prices, the respondent must ‘think’ because the prices are in irregular order. It is also noteworthy that the respondent is given as little information as possible. The paucity of information is relevant when the respondent is familiar with the topic. In other situations, such as studies in the law or in medicine, the orientation page may be a good deal longer, more filled with relevant detail.

Step 5: Combine the Answers into Small, Easy to Read Combinations, So-called Vignettes

Figure 2 shows the way the vignette appears to the respondent, with the text centered, one answer or ‘element’ atop the other in centered format, with no effort to connect the answers. It is the respondent’s job to read through the information and make a judgment. The effort to connect the elements is counter-productive because the focus is on the individual elements and not on a connected paragraph.

fig 2

Figure 2: Example of a vignette (left) comprising three elements (left) and the rating scale (right).

The vignettes are created according to an experimental design, which dictates combinations comprising 3-4 elements for the 6×6 design, at most one element or answer from each question. Each respondent evaluates 48 unique vignettes. Each element appears five times, one time in each of five vignettes, and is absent from the remaining 43 vignettes. The experimental design creates combinations ensuring that each respondent will see a full design, but the specific combinations will differ across respondents thus covering a lot of the ‘design’ space. The experimental design is set up so that the 36 elements are statistically independent of each other, allowing for OLS (ordinary leas-squares) regression to relate the presence/absence of the elements to the respondent (interest, price paid).

Each respondent sees a unique set of 48 vignettes, an experimental design for that respondent. This means that the data from each respondent can be analyzed either separately as preparation for mind-set segmentation (see below), or using group data to generate a model (e.g., for all respondents in the study, viz., the total, or for all respondents in a specific mind-set).

The questions themselves do not appear in the vignette. Rather, only the answers appear; it is the answers which convey the specific information. The questions act as guides, to drive the ‘right’ type of answer. The specific information in the answer is left to the researcher, who may use a variety of sources to create the answer. The answer is usually presented as a stand-alone phrase, one emerging from competitive analysis, from published information, or even from one’s imagination in a creativity session.

Finally, the experimental design is set up so that there is absolutely no collinearity possible, and that there are ‘true zeros.’ True zeros, where a question (or so-called variable) is entirely absent from a vignette ensures that the coefficients have absolute values, comparable from study to study.

Executing the Mind Genomics Experiment and Preparing the Data for Analysis

Step 6: Invite Respondents to Participate

With the advent of the Internet, a great deal of research has migrated to online venues, wherein the respondent is invited by an email or pop-up link. At the time of this research (2016) the studies with the 6×6 design took approximately 15-18 minutes to complete, comprising 48 vignettes, each rated on two scales, along with an extensive classification. Six years before, by the year 2010 or so, respondents were tiring of the ever-increasing number of requests to participate, and it was becoming harder to get volunteers. At that point, companies began to enter the business, and provide respondents from their so-called ‘on-line’ panels; groups of individuals who agreed to participate, and were recompensed by the company. The result was an easier-to-execute study, albeit not with paid respondents. For Mind Genomics studies, looking for patterns rather than for single ratings of no/yes, the paid panel was appropriate. The panelists for this study were recruited by Luc.id, Inc.

Step 7: Execute the Study on the Respondent’s Computer, Tablet, or Smartphone

The respondent received the invitation from Luc.id, opened the study (an experiment), read the introduction, evaluated 48 vignettes unique to the respondent (ensured by the strategy of permuted experimental design), and then completed an extensive self-profiling classification.

Step 8 – Acquire the Ratings and Transform the Data

The ratings for interest were converted to two binary scales:

Top3, focusing on what interested the respondent. Ratings of 1-6 were converted to 0, to show little or no interest. Ratings of 7-9 were converted to 100, to show active interest. A random number(< 10-5) was added to each transformed rating to ensure variation in the dependent variable in case the respondent selected ratings all lying between 1 and 6 or all lying between 7 and 9.

Bot3, focusing on what actively disinterested the respondent (viz., anti-interest). Ratings of 1-3 were converted to 100, to show active disinterest. Ratings of 4-9 were converted to show little or no disinterest. Again, the small random number was added for the same prophylactic reason, viz., to ensure variation in the dependent variable.

The prices were converted to dollar values. The Mind Genomics program measured the Response Time (RT), defined as the number of seconds to the nearest tenth of seconds elapsing between the appearance of the vignette on the respondent’s screen and the first response (question #1, interest)

Step 9: External Analyses – Distribution of Ratings

Mind Genomics studies generate a great deal of data, providing a rich bed of results for analysis. The basic data, without knowledge of the composition of the stimulus vignette, are the ratings and the response times, along with external information, such as the position of the vignette in the set of 48, the respondent who assigned the rating, etc.

The analysis of these data is called ‘external analysis’, so-called because we do not know anything about the nature of the stimulus, other than the number and source of elements. There is not yet any linkage between the responses and the meaning of the elements. This is the type of data with which most researchers work, looking for patterns, but forced to work with data which themselves have no intrinsic meaning. The pattern of data emerging from this analysis tells us a great deal about how the respondent thinks about the topic, in terms of ratings, in terms of response times, and in terms of changing responses with repeated evaluation of vignettes, but without any understanding of the ‘meaning’ of the test stimuli and the differences among the feelings toward these stimuli traceable to the nature of the difference stimuli.

The first external analysis assesses the distribution of the ratings, and the response times. Figure 3 shows two histograms, the left showing the distribution of the ratings on the 9-point scale, the right showing the distribution of the prices the respondent is willing to pay. Keep in mind the prices were converted to the appropriate dollar value.

fig 3

Figure 3: External analysis showing the distribution of ratings for interest (left) and for price that one would pay (right). Data from the total population.

The ratings of interest describe a reasonable, but certain far from ideal inverted U curve, which could be interpreted as a ‘somewhat’ normal distribution. The only problem is the excessive number of ratings at level 1, the lowest interest. The price willing to pay shows no consistent patterns.

It is important to keep in mind that without deeper knowledge of what the elements mean (viz., their exact language), the researcher has nothing to analyze except for these externalities. There are no insights yet, despite the substantial amount of data used to create the graphs in Figure 3.

Step 10: External Analyses: Stability vs. Instability across the 18-Minute Experiment with 48 Vignettes

Our second ‘external analysis’ measures the change in the average rating across the 48 positions. Recall that each respondent tested a unique set of 48 combinations. One of the questions that we might ask is whether over time, and with these many combinations, do people change their criteria of judgment in a general fashion, becoming more critical, less critical, and so forth. That is do people increase their rating or decrease their rating as they evaluate the set of 48 vignettes?

The set of 48 ratings was divided into six strata, each stratum comprising data from eight positions, viz., 1-8, 9-16, 17-24, 25-32. 33-40, 41-48. The averages were computed for each position and plotted in Figure 4. The plots are linear, suggesting a systematic but modest drop in the positive ratings, a complementary but slightly steeper pattern of increase in the negative ratings, and a sharper drop in price of almost 50 cents. The pattern is sharply linear, and reaffirms the value of completely rotating the combinations, in addition to create a unique design permutation for each respondent.

fig 4

Figure 4: How the average rating and price paid change during the evaluation. Each point represents the average rating from a set of six positions in the 48 vignettes (viz., 1-8, 9-16 etc.).

Step 11: External Analyses: An Emergent Linear Relation between Interest and Price Willing to Pay

We expect that people will pay more for what they like, although we have no direct data from studies. People can be asked whether they like something, and what they are willing to pay for this. The analysis has been called ‘hedonic pricing’ [12]. The pattern will not appear from the raw data comprising 113 respondents x 48 vignettes/respondent or 5424 data points. There are so many observations that a clear pattern cannot easily emerge.

When one does this analysis by averaging the interest ratings of respondents across the 48 vignettes, and the price willing to pay across the same 48 vignettes, one has a value both for average interest and another value for average price. Across the 113 respondents there are thus 113 pairs of averages. Figure 5 shows a pattern which is linear when the independent variable is either average rating on the interest scale (question 1), average Top3 (interest), or average Bot3 (anti-interest. It is important to note that we use individual averages to get a sense of liking vs. price, an analysis that economists call ‘cross sectional analysis’.

fig 5

Figure 5: Relation between average price willing to pay (ordinate) and rating (Question 1, left panel), Top3 (interest, middle panel), and Bot3 (anti-interest, right panel). Each circle corresponds to one of the 113 respondents.

Moving from External Analyses of Patterns to Deeper Understanding through Vignette Structure

The external analysis can bring our understanding to an appreciation of possible relations between variables. Indeed, much of behavioral science stops at the observation of these observed relations, leaving the rest for conjecture. At some point during the inquiry into the topic, one or another enterprising researcher may pick up problem, and precede somewhat further, usually with a different viewpoint, different tools. The direct line is lost, viz., the line connecting the research of the problem, and the subsequent research inspired by the original investigation, usually, the research is conducted by an entirely different group, with different motivations, tools, and world views. As an aside, the inevitable is that the scientific project is often metaphorically compared to an object with many holes, many gaps, many ‘calls for further work’, and so forth.

The motive for this slight detour is the ability of Mind Genomics to move from the study of external patterns into the immediacy of the mind, at least with respect to the topic. Beyond that simple migration from the ‘external’ to the ‘internal’ is the ability of Mind Genomics to iterate through repeated and evolving studies while the topic is studied, viz. ‘to strike when the iron is hot’.

With that in mind, we move now to the beginning of the internal analysis, and the introduction of cognitive meaning. The first internal analysis looks at the general content of the vignettes, and how the content covaries with estimated Top3 (interest), estimated Bot3 (anti-interest) and estimated Price.

There are three ways to understand the relation between the surface structure of the vignette and the rating.

a.  What is the relation between the number of elements in the vignette and the response? That is, are we likely to get lower or higher ratings with vignettes comprising three elements versus vignettes comprising four elements? The approach here is to relate the number of elements to the ratings, without knowing which specific elements are present in the vignette. The statistics use regression to estimate the parameters of the equation: Rating = k1(Number of elements). We can estimate the equation for the total panel, and then estimate the equation as the respondent moves through the 48 vignettes. Is there a change in the pattern as the respondent moves from the first eight vignettes, to the second eight vignettes, until the sixth of the eight vignettes?

Table 2 shows the number of scale points corresponding to each element in the vignette. We do not know what is contained in the vignette. We just know the number of elements in the vignette, either three or four, respectively. We are beginning to get a sense that longer vignettes comprising four elements are better than shorter vignettes comprising three elements for emotion-relevant responses. As a worked example, consider the Total panel. For vignettes comprising three questions we expect to have a 9-point rating scale of 3×1.36 or 4.08. When we look at the expected rating but at the beginning of the evaluations (vignettes 1-8) we expect a rating of 3×1.42, or 4.26. When we look at the expected rating, but at the end of the evaluations, vignettes 41-48, we expect a rating of 3.99. The data in Table 2 suggests that there will be little change in the ratings, but when we look at the Top3 we expected a lower rating, when we look at the Bot3 we expect a higher rating (more negative), and when we look at price we expect little change.

Table 2: The number of points added by each element in the vignette, independent of the nature of the questions or the specific elements.

Number of points on scale corresponding to each element in the vignette
Question #1 TOP3 BOT3 PRICE
Total 1.36 8.41 6.81 $1.69
Vignettes # 1-8 1.42 9.72 6.26 $1.74
Vignettes # 9-16 1.36 8.37 6.56 $1.71
Vignettes # 17-24 1.37 8.75 6.56 $1.70
Vignettes # 25-32 1.35 8.05 6.95 $1.68
Vignettes # 33-40 1.31 7.66 7.31 $1.65
Vignettes # 41-48 1.33 7.91 7.21 $1.66

a.  On average, what does each question contribute to the rating? This question can be answered by determining which specific questions are present in each vignette and relate the presence/absence of the type of question (Taste, Appearance, etc.) to the rating. To answer this, we create a simple model for total panel, and for each set of six vignettes. The model is expressed as: Rating = k1(Taste) = K2(Appearance) + k3(Experience ) + k4(Origin) + k5(Benefit) + k6(Venue).

Table 3 shows that the most important driver of Top3 (interest) and Bot3 (anti-interest) is Taste. Appearance is a driver of interest, but not a driver of anti-interest, which makes sense from other information about food. People do not form polarizing love/hate relationships with appearance in the same way that they do with taste/flavor. Homo Emotionalis, emerging from likes and dislikes of a sensory and experiential nature, is far more expansive than is Homo Economicus, which is constricted. We know what we like, but we don’t know the value of what we like or dislike.

Table 3: The number of points added by each question in the vignette, independent of the nature of the specific element.

Top3 Total Vig. 1-8 Vig. 9-16 Vig. 17-24 Vig. 25-32 Vig. 33-40 Vig. 41-48
Taste 9.9 9.6 11.5 8.6 8.6 9.5 9.9
Appearance 9.3 10.2 9.6 7.6 7.6 10.1 7.3
Origin 8.8 6.5 6.5 9.5 9.5 8.4 11.0
Venue 8.0 9.8 3.2 8.5 8.5 9.6 6.5
Experience 7.7 11.1 10.5 6.5 6.5 2.9 10.3
Benefit 6.8 11.0 9.2 7.7 7.7 5.4 2.3
Bot3 Total Vig. 1-8 Vig. 9-16 Vig. 17-24 Vig. 25-32 Vig. 33-40 Vig. 41-48
Taste 12.1 9.2 13.0 11.3 11.3 14.6 14.3
Experience 6.6 8.4 6.8 3.7 3.7 8.8 7.8
Venue 6.3 4.0 9.8 7.0 7.0 8.4 5.3
Origin 5.7 5.7 4.9 6.5 6.5 4.7 3.5
Benefit 5.4 7.1 2.3 7.5 7.5 2.9 6.9
Appearance 4.7 3.2 2.2 5.6 5.6 4.5 5.7
Price Total Vig. 1-8 Vig. 9-16 Vig. 17-24 Vig. 25-32 Vig. 33-40 Vig. 41-48
Taste $1.72 $1.75 $1.73 $1.73 $1.73 $1.64 $1.58
Appearance $1.72 $1.91 $1.73 $1.63 $1.63 $1.78 $1.68
Origin $1.71 $1.72 $1.69 $1.62 $1.62 $1.69 $1.72
Experience $1.67 $1.50 $1.85 $1.76 $1.76 $1.48 $1.72
Benefit $1.67 $1.69 $1.72 $1.76 $1.76 $1.67 $1.62
Venue $1.66 $1.86 $1.54 $1.56 $1.56 $1.65 $1.66

a.  On average, which structure of the vignette drives the rating? There are 35 different structures of vignettes in the Mind Genomics design. Comprising six questions and six answers for each question. There are 20 different structures comprising three questions out of the six, and 15 different structures comprising four questions out of the six. Each vignette can be coded as being one of these 35 design structures. Do any of these design structures perform noticeably better or worse than others, in terms of Top3 (interest), Bot3 (anti-interest) or Price? Each of these 35 design structures became its own variable, taking on the value 1 for a vignette when the vignette conformed to that specific structure, and taking on the value 0 for a vignette when the vignette did not conform to that structure. A vignette could be coded ‘1’ for only one structure.

Table 4 shows that there is a large range of interest (Top3), from a high of 40 (Appearance, Experience, Origin; Top 3 = 40), to a low of 15 (Experience, Benefit, Venue). There is a similar range for Bot3 (anti-interest), but hardly any range for price. Once again, Homo Emotionalis is far more expansive than Homo Economicus.

Table 4: The number of points added by each design structure of a vignette, independent of the nature of the specific elements in the design.

Code Vignette comprises one element from: Est Top3 Est Bot3 Est Price
  Three-element vignettes
BCD Appearance Experience Origin 40 22 $6.32
ABD Taste Appearance Origin 37 21 $6.31
ABF Taste Appearance Venue 36 31 $6.09
BCF Appearance Experience Venue 34 23 $6.60
ADE Taste Origin Benefit 33 24 $6.12
ACF Taste Experience Venue 32 30 $6.44
BEF Appearance Benefit Venue 32 17 $6.44
ADF Taste Origin Venue 31 26 $6.46
ACD Taste Experience Origin 30 27 $6.80
ABE Taste Appearance Benefit 29 32 $6.13
ABC Taste Appearance Experience 28 25 $6.18
BCE Appearance Experience Benefit 28 28 $6.29
ACE Taste Experience Benefit 27 24 $6.54
BDF Appearance Origin Venue 27 32 $6.11
CDF  Experience Origin Venue 27 26 $5.88
CDE  Experience Origin Benefit 24 41 $5.82
AEF Taste Benefit Venue 23 30 $6.52
DEF  Origin Benefit Venue 20 29 $5.81
BDE Appearance Origin Benefit 16 39 $5.91
CEF  Experience Benefit Venue 15 35 $6.14
  Four element vignettes
ACDE Taste Experience Origin Benefit 36 30 $6.56
ADEF Taste Origin Benefit Venue 36 25 $6.59
ABCD Taste Appearance Experience Origin 35 26 $6.52
ABDE Taste Appearance Origin Benefit 35 26 $6.64
ABEF Taste Appearance Benefit Venue 35 25 $6.35
BCEF Appearance Experience Benefit Venue 35 18 $6.60
ABCF Taste Appearance Experience Venue 34 30 $6.29
BCDE Appearance Experience Origin Benefit 34 20 $6.70
ABDF Taste Appearance Origin Venue 33 30 $6.40
ACEF Taste Experience Benefit Venue 33 31 $6.42
BCDF Appearance Experience Origin Venue 33 20 $6.43
CDEF Experience Origin Benefit Venue 31 21 $6.50
ACDF Taste Experience Origin Venue 27 31 $6.18
BDEF Appearance Origin Benefit Venue 26 22 $6.45
ABCE Taste Appearance Experience Benefit 21 32 $6.16

A scattergram plot from the price structure (Table 4) of Estimated Price (ordinate) versus estimated Top3 (interest) or Bot3 (anti-interest) (abscissa) show a clear relation between price willing to pay (ordinate) and either interest or anti-interest. The triangles correspond to the vignettes comprising four elements; the crosses correspond to the vignettes comprising three elements. Figure 6 suggests a clear linear, yet somewhat noisy relation between price and interest or anti-interest.

fig 6

Figure 6: Plot of the estimate price to be paid versus the estimated Top3 (interest, left panel) or Bot3 (anti-interest, right panel). Data from Table 4, showing the estimated values for different vignette structures.

Internal Analysis: Moving from Vignette Structure to the Impact of the Individual Element

Up to now the analysis has focused primarily on the externalities of the data, the averages and distributions of the ratings, and relations between variables. There is no deep understanding of what the data mean. Indeed, we have no idea about the topic of the data, other than knowing that the data pertain to responses to messages about craft beer. We have been able to learn a lot, and in fact may even be able to create hypotheses about what might be occurring. Our hypotheses deal with the behavior of what is occurring, focusing both regularities in the data, and on emergent patterns, respectively. To reiterate, however, we would have no idea about how people describe the specifics of the craft beer experience.

It is at this point that we return to the fact that we really do ‘know’ what these elements mean, at least in a superficial way. The researcher might well have asked the respondent to rate the interest in beer and the price of the beer, after exposing the respondent to each element, one elements at a time. The answers would be ‘strained’ because it is hard to make a judgment based on one element, but the data emerging from that question and answer would, in fact, provide deeper knowledge, data which are ‘internal,’ rather than external, data which deal with the ‘meaning’ of the element.

The Mind Genomics process moves from evaluation of single elements in a question-and-answer format to the evaluation of systematically varied combinations of elements, so-called test vignettes. Respondents have an easier time reacting to a combination of elements which tell a story, even when the combination or ‘story’ emerges out of an experimental design, an underlying set of combinations fabricated according to statistical considerations, rather than dictated by the desire to tell a story.

Step 12: Lay Out the Data for OLS (Ordinary Least-Squares) Analysis

With 113 respondents, the data comprises one row for each vignette for each respondent (113 x 48 =5424 rows). The data matrix just created comprises one column for each of the elements, or precisely 36 columns to ‘code’ the independent variables, the 36 elements.

The matrix contains the number ‘1’ when the element is present in the vignette, and the number ‘0’ when the element is absent from the vignette.

At the end of the input matrix are five columns, corresponding to the dependent variables.

The first pair of response data columns are the two ratings, for interest, and for actual price, and the second pair of response data columns are the two transformed variables, Top3 (either 0 or 100) and Bot3 (either 0 or 100), respectively.

Step 13: Create 113 Individual Models for Top3, and 113 Individual Models for Price, One per Respondent

This is a preparatory step. The individual level models can be readily created because the original experimental design ensured that each respondent would evaluate 48 unique vignettes, created according to a full experimental design. That provision enables the researcher to create an individual-level model for a respondent. The subsequent analysis clusters the 113 respondents twice, first by the pattern of the 36 coefficients of Top3, and then the pattern of the 36 coefficients for price. The clustering is done by k-Means, a well-accepted statistical process which created groups of respondents whose patterns of coefficients are maximally similar within a cluster, and whose patterns of averages of coefficients within a cluster maximally different from cluster to cluster. These clusters are created by k-means clustering, using the distance metric (1-Pearson Correlation). Two respondents are most similar, perfectly related to each other and in the same cluster when the Pearson Correlation calculated from the 36 coefficients is 1.0. Two respondents are most different from each other, and in different clusters, when the Pearson Correlation between them calculated from the 36 coefficients is -1 (perfectly opposite). Three clusters emerged from the clustering of the Top3, and three other clusters emerged from the (separate) clustering of the Price [13,14].

We call these clusters ‘mind-sets’ because they represent the way the respondent thinks about the topic. The respondent may or may not be able to tell the researcher her or his own mind-set, but it will become clear from the study, or later from a tool called the PVI, personal viewpoint identifier.

Step 14 – Extract Three Mind-sets for Top3 (What Interests), and Three Parallel Mind-sets for Price (Pattern of What They will Pay)

Create two sets of models or equations, one for Top3, and one for Price, respectively. The models look the same, except the Price model does not have an additive constant.

Top3 = k0 + k1(A1) + k2(A2) … k36(F6)

Price = k1(A1) + k2(A2) … k36(F6)

Step 15: Uncover the Mind-sets Based on What Interests the Respondent about Craft Beer

Lay out the coefficients for the Top3 model, but do not put in any of the negative coefficients which are 0 or negative. Furthermore, highlight the coefficients which are +8 or above. The rationale for showing only partial data is to ensure that the pattern of coefficients emerges clearly, allowing the researcher to identify the elements which ‘drive’ interest. Putting in 0 and negative coefficients hinders the ability identify the patterns. Furthermore, sort the table by the three mind-sets.

Table 5 shows the additive constant and the coefficients for the total panel and the three emergent mind-sets. For the Total Panel, two elements emerge: A5 (Dark…bittersweet chocolate and coffee flavors, coefficient = 14) and A6 (Sour taste with fruitiness … dark cherry, plum, currants, coefficient =10). One might think that these two KEY elements for craft beer. They are certainly strong elements, but the division of the respondents into three mind-sets reveals different groups with varying preference, and many more opportunities when these groups can be identified and receive the proper advertising for craft beer. The opportunity for business as well as learning will be enhanced by understanding how the respondents divide in the pattern of their preferences, especially when the rating scale is ‘interest’ (question 1).

Table 5: Positive coefficients for the 36 elements for Total Panel and for three mind-sets. Data based on the coefficient for the Top3 value from all respondents in the group.

table 5

Step 16: Uncover the Patterns for Mind-Sets Based on Price the Respondent is Willing to Pay

Lay out the 36 elements for price, sorted by the three emergent mind-sets based on clustering using the price coefficients. Table 6 shows these results. In contrast to Table 5, all prices are shown; although for the patterns one might eliminate a low price, such as $1.60 or less. The choice of what constitutes an irrelevant element is left to the researcher.

Table 6: Coefficients for the 36 elements for Total Panel and for three mind-sets. Data based on the coefficient for Price from all data from respondents in the group.

table 6

Table 6 suggests three groups of respondents whose preferences are less polarized when the groups are constructed based upon the patterns of price (Homo Economicus). The groups certainly different in the price that they are willing to pay for the feature. On the other hand, within a mind-set (homogeneous with respect to price), the nature of the specific elements driving the high price is not clear. The groups are more similar than they are different, based upon the ‘meaning ‘of the elements. This leads us to the conclusion that clustering or segmenting people based economic aspects, such as price, will ‘work’ in terms of delivering statistically meaningful clusters. That is accepted because the clustering is assumed to be done correctly. What is surprising, however, is the difficulty of seeing the dramatically different patterns across the clusters created by the price coefficients. Homo Economicus does exist, and can be demonstrated, but is clearly less interpretable.

Step 17: Create a Method to Discover these Mind-sets in the Population

Mind Genomics reveals mind-sets based upon the pattern of responses to granular information about relatively small, minor topics. As such, the conventional methods used by researchers to create ‘personas’ in the population and assign an individual to one of these persona’s is limited, both by the reality that the topic is usually too small to invest in, and that the research may often be investigating the topic as the first person to do so.

The value of the mind-set is knowledge, which simply remains within the data, but the larger value is to assign NEW PEOPLE to mind-sets, whether to understand people, or more ambitiously to link together behaviors and markers (biological, sociological, behavioral, respectively). All are possible, once there emerges a simple, cost-effective method to assign new people to the mind-sets already discovered.

Table 6 shows a cross-tabulation of mind-sets by gender, and mind-sets by each other (Top3 or acceptor mind-sets versus Price mind-sets vs. Bot3 or rejector mind-sets). The mind-sets cannot be easily predicted from each. Knowing a person’s gender will not predict to which mind-set a person will belong. Table 6 suggests that a male or a female show similar but not identical distributions of membership in the three mind-sets emerging from clustering the coefficients for Top3. Furthermore, looking at the bottom of Table 6 we see three mind-sets separately created for Bot3, the anti-interest pattern, viz., the elements which clearly DO NOT interest the respondent. The membership patterns differ from the membership patterns of Top3, meaning that knowing something about a respondent does not easily predict knowing their mind-set. A different approach needs to be created to assign new people to the mind-sets.

Recent, the authors have suggested that one can create a small set of six questions, based upon the summary data from the study. This is called the PVI, the personal viewpoint identifier. The respondent answers six questions, the questions using the same or similar language to that used to create the mind-sets, the answers presented as a binary scale (NO vs. YES, or similar language). The pattern of the six answers enables the PVI to assign the respondent to the most likely mind-set. The PVI is set up ahead of time, with the underlying mathematics comprising a Monte-Carlo simulation system with added variability to ensure a robust assignment mechanism. The output of the system is feedback to either the researcher or to the user as to the membership in the specific mind-set, as well as the nature of the three mind-sets. Figure 7 shows the web-based form filled out by the respondent. The web-link as of this writing (Winter, 2020) is https://www.pvi360.com/TypingToolPage.aspx?projectid=1262&userid=2018

fig 7

Figure 7: The PVI for craft beer, showing the three classification questions on the left panel (not used by the PVI for assignment), and the six questions on the right panel used for assignment to one of the three mind-sets emerging from Top3 cluster analysis.

Step 18: Discover Pairwise Interactions Using ‘Scenario Analysis’

An ongoing issue in messaging, one which has never been successfully resolved, is to demonstrate on a repeatable basis that ideas interact with each other, either enhancing each other, or suppressing each other. The notion of interaction makes sense when we think about products, especially foods and beverages, where it is the combination that is liked, not the individual ingredients.

In experimental design, and in the approaches used here, the basic notion is that each element is an independent ‘actor’ in the combination. The independence is assured, at least at a statistical level, by creating vignettes where the same elements appear in different combinations so that they are statistically independent of each other. Does the Mind Genomics systemized permutation covering a great deal of the so-called ‘design space’ (potential combinations), enable the researcher to uncover hitherto unexpected synergies or suppressions of pairs of elements?

A simple way to discover these interactions builds them in at the start, creating a design which comprises both linear terms (single elements) and known combinations of elements. With six questions and six answers per question, there are 15 pairs of questions, each pair of questions responsible for 36 combinations. This comes to 540 pairwise combinations in the 6×6 Mind Genomics design used here. For the more recent, preferred 4×4 design (four questions, four answers per question) there are 6 pairs of questions, and 16 possible pairs of answers for each pair of questions, viz., 96 pairwise combinations to create and test. The design effort is simply too great, and the typical conjoint approaches cannot deal with the discovery and evaluation of pairwise interactions (Table 9).

Table 9: Scenario analysis showing how the coefficients of the elements change in terms of Price (Question 2) when the vignette with the element is constructed to have a specific origin provided by Question D.

table 9

The task of uncovering pairwise and even higher order interactions can be made simpler, virtually straightforward in the Mind Genomics paradigm [15-17]. Let us illustrate it by looking for interactions of elements with question D, Source of the craft beer. There are six Sources (D1-D6), and a seventh Source (D0) where no Source is mentioned). We create a new variable, called ByD. The new variable, ByD, takes on the values 0 when the vignette has no mention of a source (viz., D does not contribute an element), and takes on the value 1-6 depending upon which specific element appears in the vignette. Thus, the variable ByD stratifies the data matrix.

One sorts data matrix according to the newly created variable, ByD. One then performs seven OLS regressions, one OLS regression for each of the seven strata, respectively. The independent variables are the remaining elements, viz., all starting elements except elements D1-D6. Thus, the independent variables are 30, rather than 36 (A1-A6; B1-B6; C1-C6; E1-E6; F1-F6).

The OLS regression returns with estimates of the 30 coefficients, for each stratum, specifically the stratum where D=0 (does not appear), where D=1 (local brewery with a great story) …D6 (from Germany). The OLS regression estimates the additive constant and the 30 coefficients when the dependent variable is Top3 (interested), and the 30 coefficients without the additive constant when the dependent variable is Price. Synergisms and suppressions appear when one compares the performance of an element in the absence of source (viz., D=0) vs. the performance of the same element in the presence of a specific source (viz., D=1). Synergism emerges when the coefficient with a source is ‘higher’ than the coefficient estimated in the absence of source (viz., D=0).

Tables 7 and 8 show the three strongest performing elements and the three weakest performing elements for the total panel, first for the dependent variable being Top3 (interest; Table 7) and for the dependent variable being Price (Table 8).

Table 7: Distribution of respondents into mind-sets based upon gender, by Top3 (what interests them), by Bot3 (what does not interest them), and by Price (what they are willing to pay). The patterns of membership differ.

Total Top M3S1 Top3 MS2 Top3 MS3
  Total 113 38 40 35
 
Gender Male 62 19 24 19
Gender Female 51 19 16 16
   
Mind-Set Top3 MS1 38 38 0 0
Mind-Set Top3 MS2 40 0 40 0
Mind-Set Top3 MS3 35 0 0 35
 
Mind-Set Price MS4 35 6 18 11
Mind-Set Price MS5 37 25 4 8
Mind-Set Price MS6 41 7 18 16
 
Mind-Set Bot3S7 47 14 21 12
Mind-Set Bot3S8 32 11 8 13
Mind-Set Bot3S9 34 13 11 10

Table 8: Scenario analysis showing how the coefficients of the elements change in terms of Top3 (interest, Question 1) when the vignette with the element is constructed to have a specific origin provided by Question D.

table 8

a.  The ‘strongest’ performers and the weakest performers are defined by the performance when the coefficients are estimate for the stratum where D=0 (no mention of origin).

b.  The columns are sorted by the sum of the additive constant (for Top3, not for price) and the arithmetic average of the 30 coefficients. The first column is always the coefficients for the case when the source is absent from the vignette.

The scenario analysis generates many numbers. It is easiest to see patterns and interactions by eliminating the zero and negative coefficients, to focus on the effect of the different ‘origins’ shown in the columns on a single element (shown in a row). Tables 7 and 8 show evidence of quite strong interactions in some cases, and quite weak interactions in other cases. It is important to keep in mind that these are only estimates of the possible interactions. The negative coefficients are eliminated so we can see cases when the interactions can be very power in the positive direction (Hoppy … with a high level of bitterness, a basically anti-interest element by itself) synergizing with source (Germany).

The synergisms are clearly far stronger for the elements evaluated on interest (question #1), and far weaker for elements evaluate on price. A cursory look at the six elements studied for price (Table 8) reveals, however, that all six of the elements increase in dollar value when they are associated with country of origin. It is discoveries like this, unexpected, which can lead to a new appreciation of craft beer, especially the way people think about it.

Discussion and Conclusions

The sequence of steps presented here produces an exceptionally rich database of information about the mind of the respondent, a database which is obtained within hours and days, a database whose information is achievable, and who metrics, the coefficients, have ratio-scale values, and are comparable from study to study, from topic to topic, so long as the rating scales are same.

In the spirit of Mind Genomics, the discussion is brief. The data essentially present the whole story. There is no need to plug holes in the literature, to falsify hypotheses and conjectures. There may be hypotheses to be tested with the data, but the data serves as an exploration of a topic, as an understanding of the mind of people respect to something from their ‘everyday’ experience.

Of interest from the point of view of science of the mind and decision making is the difference within the same person when the person deals with price versus when the person deals with emotion. The former, Homo Economicus, is well recognized as an entity in the scientific literature. The latter, Homo Emotionalis, is just beginning to be studied (although consumer researchers have long known about the importance of Homo Emotionalis in decision making. Those in government and public policy are just now beginning to understand the role of emotion and feeling in policy, although it has always been present, recognized perhaps but not acknowledged [18-20].

The logical next steps for Mind Genomics vary by the goal and vision of the researcher. The world of beer, of alcoholic beverages lies open for a concerted research effort. Beyond the world of the knowledge of beer is the marketing, and the benefits conferred on the marketer by knowing the three mind-sets, and how to assign a new person to a mind-set using the PVI. Inserting the PVI into digital marketing, e.g., as a game, might allow the marketer to drive the respondent’s online inquiry into a landing page appropriate for the mind-set.

At the level science, however, we have a paradigm to acquire and analyze data, and a template to store and present the results. One might imagine the happy day in a few years when these studies are done as the standard way of exploring new topics, not so much in a piecemeal way to falsify or not falsify hypotheses, but rather simply to create the aforementioned ‘wiki of the mind’ as a living, dynamic encyclopedia of life as it is experienced.

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