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Competitive Pressures and Multiple Births in Infertility Treatment

DOI: 10.31038/AWHC.2020321

Abstract

Background: With the increase in fertility problems and delayed childbearing, demand for infertility treatments has been rising. Today, in vitro fertilization (IVF) is the most successful infertility treatment but it is costly. To meet rising demand for infertility treatment many markets have seen an increased entry of infertility clinics. Concerns have been raised of the effect of high per-treatment cost and rising competitive pressures on the outcomes of infertility treatments. The objective of this study is to examine the relationship between competitive pressures and prices charged by clinics for in vitro fertilization treatments as well as the effect of prices and competition on multiple gestations.
Method: This is a retrospective analysis of 2012-2014 clinic-level data in the United States. This study collects in vitro fertilization prices and combines the price data with the ART Fertility Clinic Success Rates Reports published by the Centersfor Disease Control and Prevention (CDC). The Herfindahl–Hirschman Index (HHI) is a widely-used measure of competition within a market. Regression analysis is used to estimate the relationship between HHI and price variables. The effect of prices and competitive pressures on multiple gestations is estimated.
Results: Multivariate regression results show that competitive pressures do decrease prices charged by IVF clinics (p-value<0.1). IVF refund programs that reimburse couples for multiple failures are more likely to be offered in more concentrated markets (p-value<0.05) and larger clinics (p-value<0.01). Lower prices translate into lower multiple rates for younger women (p-value<0.1). Controlling for prices, competitive pressures decrease multiple rates for younger women (below 35 years of age) but increase multiple rates for older women (above 40 years of age) (p-value<0.1).
Conclusions: Lower IVF prices translate into better quality as measured by the rates of multiples for younger women undergoing infertility treatments. Effect of competitive pressures on quality of care is ambiguous especially after we control for treatment cost. For older women such pressures may lead to more embryo transferred and higher rates of multiples. Further research is needed to identify the relationship between competition and quality of medical care in infertility and other markets.

Keywords

Infertility, in vitro fertilization, competition, econometrics

Background

Infertility and in vitro fertilization

About 11 percent of American women 15–44 years of age have difficulty getting pregnant or carrying a pregnancy to term [1]. Today, over 1.7 percent of all infants born in the United States every year are conceived using assisted reproductive technologies (ART) [1]. To meet this increased demand for ART, the number of infertility clinics in the United States has increased from 263 in 1995 when CDC started collecting ART success rate data to 459 in 2014. Today, in vitro fertilization (IVF) is the most successful infertility treatment but it is invasive and costly. IVF involves ovarian stimulation with prescription drugs with close monitoring by the reproductive endocrinologist to prevent overstimulation, ovarian retrieval (an outpatient surgery), fertilizing an egg with sperm outside of a woman’s body and then implanting it in her womb (another outpatient hospital procedure). Since IVF is a process, rather than a single procedure, costs include medications, laboratory tests, physician fees, hospital charges, anesthesia, and embryology lab fees. A full IVF cycle is priced at over $10,000 and a frozen embryo transfer at over $3,000 [2]. In addition, many couples have to go through several IVF cycles to achieve a live birth. CDC data indicates that only 32.98% of IVF cycles resulted in a live birth. High costs of IVF combined with relative low probability of success lead to more aggressive treatments and poor quality outcomes since patients’ immediate financial interests are best met by maximizing their pregnancy chances on each IVF cycle. Such financial incentives lead to patients transferring more than one embryo so as to limit the number of IVF treatments they undergo despite the health risks and long term costs associated with multiple gestations and births. Although IVF is a medical procedure that treats a medical problem of infertility, most private health insurers exclude it from coverage with only a quarter of insurers covering some infertility benefits [3]. To address costs, some states passed insurance mandates that require employers to cover – or offer to cover- infertility treatments. To date, few Americans have sufficient insurance to cover infertility treatments. While the Affordable Care Act extended insurance coverage to millions of uninsured Americans, IVF is not considered an “essential health benefit” under the Act and most insurers do not cover it outside of states where it is mandated.

Another factor that can address high costs of IVF is competitive pressures that lead to price competition among clinics. However, the effect of competition on IVF outcomes is ambiguous. While deciding on transferring another embryo, patients and clinics face short term benefits (higher probability of success and thus fewer IVF cycles) and long-term costs (higher probability of prematurity, C-section costs, other risks associated with higher risk pregnancy). On one hand, more competitive markets lead to lower prices which may allow patients to transfer fewer embryos per IVF cycle thus reducing multiple births. On the other hand, IVF clinics also compete for patients by advertising higher pregnancy rates and concerns have been raised that competitive pressures may lead clinics to transfer more embryos that may allow clinics to advertise higher success rates. This can lead to more multiple births.
This study examines the relationship between competitive pressures that infertility clinics face and health outcomes. We concentrate on one dimension of health outcomes: multiple gestations per ART birth. High costs of IVF procedure lead couples to transfer more embryos which leads to more multiple births (twins, triplets and high order multiples) per ART birth and thus poor quality health outcomes.

Health care providers in infertility markets compete along two dimensions: prices and quality. Due to lack of insurance coverage, price competition is more important in infertility settings relative to other areas of medical care that are better insured. This study attempts to use unique features of infertility market to distinguish between price and quality impacts of competitive pressures.

Competition and quality of health outcomes

Outside of infertility markets, the relationship between market competition and health care outcomes is ambiguous. While some studies show that hospital competition decreases mortality rates [4-7] others find higher mortality rates in competitive markets [8-9].

Empirical studies on mergers that result in accumulation of market power are similarly inconsistent.  For example, Ho and Hamilton show that mergers increase readmission rates but do not affect mortality rates while Hayford finds that hospital mergers are associated with increased treatment intensity and higher inpatient mortality rates [10,11].

Finally, Mutter, Wong and Goldfarb looked at 12 different dimensions of inpatient quality. They find that the effect of competition is not “unidirectional” with some quality measures showing improvements with greater market competition while others remain the same or even decrease [12].

Infertility treatment markets: The effect of competition

With more IVF clinics entering the market, many hypothesize that under competitive pressures doctors will pursue aggressive treatments so that the IVF clinics can advertise higher success rates. Some industry observers even propose limits on competition [13-15]. Few empirical results that exist however do not support these fears. Steiner measured competition as number of clinics in the area and found that competition did not affect pregnancy rates but decreased high order multiples (triplets and higher) [16]. Hamilton and McManus measured competition with a simple dummy variable (1=monopoly, 0-otherwise). They find that competition does not increase multiple birth rate [17]. Henne and Bundorf (2010) did not find a relationship between the number of competitors an infertility clinic has and embryo transfer decisions [10].

Infertility treatment markets: The effect of insurance mandates

Although previous literature does not exist on the effects of competition on prices of infertility treatments, several studies examined the effect of infertility mandates that make infertility treatments more affordable. Universal insurance mandates are associated with greater utilization of ART and other infertility treatments such as ovulation-inducing drugs and artificial insemination [17,19-21]. Schmidt finds that infertility mandates significantly increase first birth rates for older women [22]. The effect of insurance mandates on multiple gestations is ambiguous. On one hand, infertility mandates in New Jersey and Connecticut had no effecton embryo transfers and the rate of multiples [21]. On the other hand, a growing literature shows that infertility mandates improve outcomes of infertility treatments by decreasing treatment intensity and decreasing probability of multiple gestations per ART birth [17,19, 21]. However, Buckles estimates that state infertility mandates do not significantly affect multiple birth rates, they do increase triplet and higher-order births by 26% [24].

Previous literature on the cost and affordability of ART in the United States is limited but Chambers et al. using international data found that a decrease in a cost of an IVF cycle leads to fewer embryos transferred and higher use of single-embryo transfers. Affordability was measured as net cost of a standard IVF cycle relative to annual disposable income for thirty high and upper middle income countries [25].

Contribution to previous research

This study contributes to previous research on several fronts. First, we collect data on prices charged by IVF clinics to measure the effect of prices on multiple births. We also estimate the effect of the so-called money back programs that some IVF clinics offer. Second, we calculate Herfindahl–Hirschman Index (HHI) to measure market competition which shows more variance across markets in current data due to entry. Having both competition index and price data allows us to separate the effect of competition on prices from the effect of competition on quality. Finally, we are able to measure the effect of state insurance mandates while controlling for prices and competitive pressures.

Methods

Data sources

We use two waves 2012 and 2014of ART Fertility Clinic Success Rates Reports. The data is publicly available by Center of Disease Control and Prevention (CDC). The unit of analysis is a clinic performing ART (no patient level data is available). In this study we use data for non-donor fresh IVF cycles only. Thus, we excluded all cycles where an egg donor was used or frozen embryos were used.

All IVF cycles for each clinic were separated into three age groups since embryo transfer guidelines and IVF success rates vary by maternal age: women below 35 years of age, women between 35 and 40 years of age and women above 40 years of age. We use 2012-2014 ART Fertility Clinic Success Rates Report data to construct the following variables: number of IVF cycles by clinic (this variable captures the volume and the size of each clinic), multiple births by clinic and age group, percent of IVF cycles that underwent PGD (preimplantation genetic diagnosis) to test for genetic abnormalities for each IVF clinic, percent ICSI (intracytoplasmic sperm injection) cycles for each IVF clinic and society for assisted reproductive technologies (SART) membership which requires member compliance with strict embryo transfer guidelines.

Market area characteristics came from publicly available state and MSA-level data. Female labor force participation for years 2012 and 2014 was collected by the Bureau of Labor Statistics (BLS) at the state level. Percentage of educated women variable is based on National Center for Education Statistics report.  This data is collected at the state level and captures percent of women with at least a bachelor’s degree. MSA-level income per capita data came from the US Census Bureau. Data on state infertility mandates was obtained from the American Society for Reproductive Medicine. We also control for state-to-state differences in health care prices. We use annual average cost of living index for the health sector as reported by the Missouri Economic Research and Information Center (2015).

Competition index

We use Herfindahl–Hirschman Index (HHI) to measure market competition. The index is constructed based on total non-donor fresh IVF cycles performed for each clinic. Increases in the Herfindahl index generally indicate a decrease in competition and an increase of market power, whereas decreases indicate the opposite.  The index can vary from zero (perfect competition) to 10000 (Monopoly). We use metropolitan statistical area (MSA) as the relevant market for infertility clinics in our sample.

Price variables

State infertility mandates. Although previous studies used insurance coverage as a main price variable, currently few Americans have sufficient coverage for ART. By 2014fifteen states passed infertility mandates of which only eight states (Connecticut, Louisiana, Hawaii, Illinois, New Jersey, Massachusetts, Maryland, and Rhode Island) require all insurance plans to cover IVF. In addition, Arkansas, Montana and Ohio and West Virginia require some plans (all HMO’s or all non-HMO’s) to cover the costs IVF treatments. We use both definitions of the universal mandate to test the sensitivity of our results. It is important to note that even when insurance coverage is provided, the total value of the benefit may be capped at as low as $15,000 or the minimum number of cycles that must be covered may be as low as one [23].

In our definition of mandated infertility benefits, we do not include states like Texas that only require health insurance plants to offer infertility insurance since employers have the right to refuse such coverage. We also exclude states like California that require coverage of all infertility treatments except IVF.

IVF price measures. We supplement our analysis with price data from a health care price transparency website OkCopay. The price variable includes “one cycle of IVF procedure, using your own eggs, without monitoring” (http://www.okcopay.com/). In this study I used prices that included lab fees but not pharmaceutical prices. The data reflects cash prices, which is the charge before insurance.

In addition, many IVF clinics offer money back programs, (sometimes called IVF refund programs or IVF warranty programs) that allow a fixed fee for a number of IVF attempts and if the treatment is not successful, 80%-100% of money is refunded. Thus, couples that are successful on their first or second attempt most likely overpaid in comparison to traditional fee-for-service IVF.  But, this “overpayment” can be thought of as an “insurance premium” for money back, in the event the treatment is not successful. Data on refunds by clinics was collected from published sources (http://ivfrefund.com/about-ivf-refund.html) and verified with individual clinics. A dummy variable was created; it takes the value of 1 if a clinic offers a refund and zero otherwise.

Price data is only available for the 33.5% of clinics in the CDC sample while data on discounts is available for all 916 clinics in our sample.

Limited price information is an important limitation of this study since one might worry that the clinics that provide data to the transparency websites are systematically different from those that do not in a way that would boas the results. This is especially important since when price variable is included, all regressions are run on this selected sample of 307 clinics. To alleviate this concern we did look at the clinics with price information and did not find them to be different from clinics without price information. Separately we looked at markets where price data is available and markets where price data isnot available and did not find significant differences in market characteristics. These results increase our confidence that lack of data did not bias our empirical results.

Table 1 summarizes descriptive statistics. (Table 1)

Table 1. Descriptive statistics for selected variables

Mean

SD

Minimum

Maximum

Multiples rate for women aged under 35

29.50

17.99

0

100

Multiples rate for women aged 35-39

24.76

19.29

0

100

Multiples rate for women aged 40 and above

14.94

26.26

0

100

HHI

4054.27

3238.41

216.86

10000

Price

13,476.89

3,248.45

5,500

25,850

IVF refund

0.0877

0.283

0

1

Insurance mandate

0.171

0.377

0

1

Cost of living (health)

107.091

17.43

87.3

145.3

Volume (number of cycles)

336.73

570.27

1

7648

% PGD

5.43

10.68

0

100

% ICSI

70.96

19.48

0

100

SART membership

.835

0.370

0

1

Per capita income

49800.49

9074.61

15,200

81,068

Population, thousands

2,695,066

5,021,092

85.56

2.01e+07

% women with at least bachelor’s degree

28.34

4.62

17.4

48.6

Female labor force participation

57.81

3.202

42

69.6

Year = 2014

0.502

0.50

0

1

N
N for Price variable

916
307

Descriptive statistics show that IVF clinics markets vary from unconcentrated (HHI<1500) to monopoly (HHI=10000) although an average clinic is located in a highly concentrated market (mean HHI of 4054). As of 2014, none of the markets can be classified as competitive (HHI< 100). Probability of multiple gestations varied from an average of 14.94% for women over 40 years of age to 29.50% for women under 35 years of age. Average price in our sample was $13,477 with 8.77% of clinics offering IVF refunds.

Empirical analysis

To test the effect of HHI on costs and quality of care, two empirical models are used. First, we estimate the effect of HHI on costs:

AWHC-3-2-305-e001

We use IVF clinic price variable and availability of refunds as our main measures of IVF costs (Costi) for clinic i. Coefficient β1 captures the effect of competition in market m, coefficient β2 captures cost of living (health component), β3 captures the effect of state infertility mandates. In Clinic we control for characteristics of individual IVF clinics such as proportion of ICSI and PGD procedures performed as well as size of the clinic (measured by the volume of the IVF procedures). Variable Marketms is a vector of controls for variables that vary across MSA’s and states that might also affect costs. These include: median family income, population, female labor force participation rate, and percentage of women with at least a bachelor’s degree.  Economic theory predicts that more competitive markets should have lower prices. This relationship holds true in healthcare markets as well. Baker et al. showed that more competition among physician practices is related to lower prices for office visits [26]. Melnick et al. (1992) observed the same relationship in hospital markets: “greater hospital competition leads to lower prices” [27]. Given economic theory and previous empirical literature, we expect higher prices in more concentrated markets (positive β1) and more IVF refunds in more competitive markets (negative β1).

Second model estimates the effect of HHI on multiple gestations. We run the model with and without cost variables to gage the effect of the HHI on price and the effect of the HHI on quality competition. In this study, we concentrate on one important dimension of quality for IVF clinics: the rate of multiple births they produce. Multiple gestations are an important risk factor for preterm birth, with 11% of twins, 36% of triplets, and 67% of quadruplets and higher born very preterm (i.e. less than 32 weeks’ gestation), compared with less than 2% of singletons [28]. Preterm birth leads to increased risk for death, long-term neurological disabilities, and extended time in the hospital [29]. A recent study compared outcomes for women undergoing two IVF pregnancies with singletons and women undergoing one IVF twin pregnancy [30]. The neonatal and maternal outcomes were “dramatically” better for women undergoing two singleton pregnancies. IVF twins had higher rates of preterm births, low birth weight, respiratory complications, sepsis, and jaundice. Women delivering twins had higher rates of preeclampsia, preterm premature rupture of the membranes, and cesarean section. The authors proposed to decrease number of embryos transferred by IVF clinics to minimize the risks associated with multiple pregnancies. In our empirical model we use multiple rates per ART birth by maternal age for each clinic as a measure of quality [30].

AWHC-3-2-305-e002

where the dependent variable measures quality of health outcomes for age cohort a for clinic i. Coefficient β1 captures the effect of market competition, coefficient β2 captures costs of the procedure (prices charged by individual clinics and discounts offered by individual clinics), β3 captures the effect of state infertility mandates.  Although state infertility mandates directly affect IVF costs we treat this policy variable separately.

Although we control for market characteristics at both MSA and the state level, one major concern is that there are likely to be unobservable characteristics that are correlated with both the independent and dependent variables that are driving the estimated coefficients in (2). Therefore, we also take advantage of the panel nature of the data and run (2) with fixed effects to better control for unobservable differences.

Results

IVF costs

We estimate Equation (1) to describe the effect of HHI on IVF prices and refunds offered. Results are presented in table 2. (Table 2)

Table 2. Costs of IVF

 

(1)

(2)

Dependent variable

Price

IVF refund

Estimation method

OLS

Probit

 HHI

 0.0321 (0.0174)*

 0.384 (0.174)**

Mandate

0.0544 (0.0421)

0.186 (0.280)

Cost of living-health

 0.0031 (0.00244)

-0.0122 (0.00759)

West

-0.0226 (0.045)

0.842 (0.287)***

Midwest

-0.112 (0.0498)**

0.251 (0.319)

South

-0.104 (0.0502)**

0.790 (0.287)***

% PGD

0.00248 (0.00129)*

 -0.00869 (0.00759)

% ICSI

0.000919 (0.000748)

0.00472 (0.00441)

SART membership

0.0726 (0.0436)*

 -0.202 (0.227)

Volume

-0.00176 (0.0145)

0.526 (0.0899)***

Per capita income

-0.0764 (0.189)

0.454 (0.637)

Population, thousands

 0.0194 (0.00543)***

 0.103 (0.132)

% women with at least bachelor’s degree

-0.449 (0.154)***

-0.967 (0.713)

Female labor force participation

0.622 (0.419)

 2.011 (1.944)

Year = 2014

0.250 (0.170)

-1.78 (0.197)*

N

 303

 894

R2
F
Chi-squared

0.2196
4.00

84.43

Notes: All continuous variables are in log form; Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01

Table 2 shows that more concentrated markets tend to have higher prices, as economic theory predicts. At the same time, IVF refund programs are more likely to be offered in more concentrated markets and in larger clinics. This result is robust to alternative specifications of the model. Health insurance mandates do not significantly affect prices. Other significant variables include regional factors. IVF costs in the northeast are significantly higher relative to Midwest and South. Also, clinics in the South and West are more likely to offer IVF refund relative to Northeast clinics. Prices tend to be higher in more populous areas and lower in areas with more educated women.

Multiple Gestations

The goal of the paper is to examine the effect of determinants of potentially dangerous outcomes from IVF treatments: multiple births. Table 3 presents results of Equation 2 estimates for multiple rates without fixed effects. (Table 3)

Table 3. Multiple births

Dependent variable

 Multiple rate, %

 Age group

<35 year of age

 35-40 years of age

>40 years of age

 HHI

 4.419 (2.51)*

 0.253 (2.73)

-5.72 (2.57)**

Price, thousands

8.68 (4.78)*

0.029 (5.23)

-9.67 (6.79)

IVF refund

-1.93 (4.35)

-1.616 (4.73)

-0.632 (4.15)

Mandate

 3.63 (3.19)

1.18 (3.47)

-1.58 (3.13)

% PGD

 0.0252 (0.101)

-0.206 (0.109)*

0.117 (0.112)

% ICSI

-0.0368 (0.0583)

0.087 (0.067)

0.00438 (0.0608)

SART membership

1.22 (3.35)

1.01 (3.69)

7.17 (3.64)**

Volume

-1.101 (0.993)

 -1.78 (1.09)

1.19 (1.11)

Per capita income

-27.65 (12.59)**

  -14.89 (13.76)

31.02 (11.96)***

Population, thousands

 2.001 (2.009)

  1.59 (2.19)

-5.73 (2.12)***

% women with at least bachelor’s degree

10.39 (14.-5)

-8.78 (15.72)

-26.77 (14.90)*

Female labor force participation

 -38.94 (31.96)

22.36 (35.03)

44.05 (36.13)

West

-3.08 (3.42)

-3.64 (3.73)

-3.14 (3.65)

Midwest

-0.711 (4.53)

-8.57 (4.95)*

-7.01 (4.90)

South

-4.12 (4.01)

-7.62 (4.39)*

2.86 (4.32)

Year = 2014

-15.50 (13.39)

-15.66 (14.54)

22.16 (13.98)

N

294

288

184

R2

 0.217

0.218

0.235

F

2.20***

4.77***

3.65***

Notes: Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01; All continuous dependent variables are in the log form

Results in Table 3 show that effect of competition on multiple gestations is ambiguous. On one hand, competition decreases multiples through lower prices and through quality competition for women under 35 years of age. Although price variable is not important for women above 35 years of age, younger women are more sensitive with higher prices leading to more multiples for this age group. Without price variables more concentrated markets result in more multiples. Once we control for cost variables, significance  of  HHI decreases although remains positive and significant at p<0.10. Overall for younger women both price and quality competition is important. For older women (over age of 40) the effect of price and other cost measures is not significant. Thus, for this age group the effect of competition is due to quality competition alone and more concentrated markets actually lead to more multiple gestations. For women between 35 and 40 years of age, regional variables and PGD procedures are more important at determining multiples rates than economic variables.

Table 4 presents equation (2) estimates with individual clinic fixed effects. (Table 4)

Table 4. Multiple births estimates with fixed effects

Dependent variable

 Multiple rate, %

 Age group

<35 year of age

 35-40 years of age

>40 years of age

 HHI

0.304 (0.175)*

 -4.09 (7.72)

-8.84 (4.65)*

Price, thousands

8.57 (4.71)*

8.05 (18.29)

-16.22 (13.70)

IVF refund

-32.37 (11.08)***

9.79 (14.06)

-6.39 (9.35)

Mandate

 4.001 (17.69)

-7.15 (18.47)

-13.22 (14.23)

% PGD

-0.344 (0.584)

0.211 (0.645)

-0.877 0.377)**

% ICSI

-0.168 (0.146)

0.148 (0.163)

0.245 (0.117)*

SART membership

-0.691 (10.48)

1.46 (11.45)

12.79 (9.76)

Volume

-0.172 (2.44)

 -0.857 (2.89)

0.514 (1.83)

Per capita income

-69.79 (39.86)*

  51.91 (42.83)

56.91 (27.98)*

Population, thousands

 -1.03 (5.92)

  -4.46 (6.22)

-9.64 (4.68)*

% women with at least bachelor’s degree

-9.005 (50.95)

-55.62 (53.44)

-83.48 (46.67)*

Female labor force participation

48.58 (135.61)

54.33 (142.47)

215.21 (159.13)

Year = 2014

8.91 (38.04)

14.94 (40.04)

53.09 (30.09)*

N

291

285

184

R2

 0.145

0.076

0.0733

F

2.26***

3.77***

3.76***

Notes: Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01; All continuous dependent variables are in the log form

Results in table 4 are consistent with results that were observed without fixed effects. Table 4 shows that IVF refund programs significantly decrease multiple gestations for younger women although do not seem to affect multiple rates for women over 35 years of age.

Table 5 below summarizes how HHI coefficient changes with and without price controls. (Table 5)

Table 5. Effect of competition

Dependent variable

 Multiple rate, %

 Age group

<35 year of age

 35-40 years of age

>40 years of age

HHI coefficient without price, but with clinic characteristics, market and fixed effects controls

0.481 (0.187)***

4.34 (2.48)*

-4.55 (4.86)

 HHI coefficient with price, but with clinic characteristics, market and fixed effects controls (from Table 4)

0.304 (0.175)*

 -4.09 (7.72)

-8.84 (4.65)*

Table 5 finds that the effect of competitive pressures decreases when we control for prices in magnitude but remains significant for women below 35 years of age. For women over 40 years of age coefficient becomes negative and significant. Therefore, competitive pressures may affect quality differently for women of different age groups.

Overall results in tables 4 and 5 show that effect of competition changes with cost controls and may improve health outcomes for younger women but increase multiples for older women.

This study finds that health insurance mandates lead to fewer multiples (results omitted) but once we control for costs of the IVF, health insurance mandates are not statistically significant.

Discussion

Policy implications

The most important economic issues in the US IVF markets are: 1) barriers to access due to high prices and 2) health outcomes. Our empirical analysis confirms the existing consensus that competition lowers prices and lower prices translate into fewer multiples especially for younger women. Once we control for IVF costs, the effect of competition on multiple gestations is ambiguous and depends on the age of the patients.We also found fewer IVF discounts in more competitive markets. Thus, the overall effect of rising competitive pressures on health outcomes is not necessarily negative as previous literature suggests.

On one hand, competition policy is controversial in health care, compared to its use in other markets due to multiple market failures [31]. On the other hand, nothing about the unique features of health care industry suggests that market power is socially beneficial [32]. Despite expressed concerns that under competitive pressures doctors will be hard pressed to compete for patients by allowing more aggressive IVF treatments to boost clinic success rates, empirical results of this study show that this does not always hold true. At least for younger women, competitive pressures lead to fewer multiples by decreasing costs and through quality competition. Also, competitive pressures may be most helpful at improving access and equity when patients are faced with decreasing insurance funding for fertility treatments [33].

Patients searching for IVF clinics are faced with several factors they have to consider: price per cycle, success rate and multiple rate that clinics report. CDC and many IVF clinics make long-term consequences of IVF publicly available and patients are able to make comparisons of clinics by the multiples rates that they produce. This may be an important quality dimension that clinics use to attract prospective patients.

Limitations of the study

To separate the effect of competitive pressures on prices from its effect on quality, this study used the best available price data for IVF clinics to capture the cost of one fresh non-donor cycle of IVF procedure, without monitoring and pharmaceuticals. Unfortunately, this data was not available for all clinics. We did our best to verify and supplement the data but at this IVF prices with hospital and embryology lab charges are not attainable for many US clinics. Thus, low sample size is a problem. Our estimates of the effect of HHI on quality for the entire sample (without controlling for prices) show that competition leads to better quality for women under 40 and is not significant for older women. However, such estimates do not isolate the effect of prices from the effect of quality competition. As price data is becoming more available to consumers, future research is necessary to look at different ways in which competitive pressures affect prices and overall patient welfare.

This study uses only two years of available data. Although looking at a change in HHI over a longer time period may yield better results, price data is not available before 2012. As we accumulate price data to aid patients searching for health care providers, the effect of increasing over time competitive pressures that IVF clinics face can be estimated.

We use MSA as our definition of infertility market area. Since IVF is not an emergency procedure, many couples are able to search outside of their MSA area. Medical tourism allows an increasing number of Americans to cross international borders to obtain health care at a lower price and comparable quality. One may consider the entire world to be the market. In this study we assume that medical tourism is limited and most infertile couples search within their MSA.

Conclusions

This study found that lower IVF prices translate into better health outcomes as measured by the rates of multiples for women undergoing infertility treatments. Further research is needed to identify the relationship between competition and prices as well as competition and health care outcomes. With rising demand for infertility treatments, policy makers must consider the effect of ART funding on prices as well as the effect such funding has on quality and patients’ welfare in ART markets.

References

  1. Centers for Disease Control and Prevention (2016) [Crossref]
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  3. Devine K, Stillman RJ, DeCherney A (2014) The Affordable Care Act: Early Implications for Fertility Medicine.  FertilSteril101:1224-1227. [Crossref]
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Gastrointestinal Clear Cell Sarcoma Tumour of the Caecum: Case Report and Review Literature

DOI: 10.31038/CST.2020514

Abstract

Background: Clear Cell Sarcoma Gastrointestinal Tumour (CCSGIT) is a rare malignant soft tissue sarcoma which is exceptionally localized in the caecum. Due to its nonspecific symptoms the diagnosis is often late and prognosis is poor. The definitive diagnosis requires a combination of morphological, immunohistochemical and molecular techniques, with positive S100 protein marker and negative for melanocytic markers. Genetic studies show EWSR1 rearrangements in all the cases. Surgical resection is the prior treatment, as neither radiotherapy nor chemotherapy appears to be effective, with average 2-year survival after thediagnosis.

Cases Summary: We present two patients, a 41 year-old male and a 36 years-old female, who presented with acute intestinal pain and obstruction, rectal bleeding and anaemia. Both of them underwent an urgent hemicolectomy. The presence of a S100 positive protein and ESWR1 rearrangements in immunochemical and molecular studies confirmed the CCSGIT diagnosis. Postoperative chemotherapy was administrated in both cases. Both patients required a second surgery: In the first patient the second surgery was required for resection of residual aortomesenteric metastatic nodes, and hepatic metastases on the second patient. Both patients died, 4 and 12 months respectively after surgical treatment.

Conclusion: CCSGIT is a distinctive soft tissue sarcoma with nonspecific gastrointestinal symptoms, late diagnosis and poor prognosis. It mainly affects young adults and the incidence of metastatic disease at the time of diagnosis is high. Its diagnosis is based on the presence of positive S100 protein and EWSR1 gene rearrangements. The Melan A, HMB-45 and C-kit are negatives. Early diagnostic and therapeutic strategies are required to provide the best clinical care leading to long-term survival. These reported cases describe two CCSGITs of primary caecum origin; which can contribute to the development of future targeted therapies as well as offering epidemiological evidence on prevalence and prognosis.

Keywords

Caecum, C-kit, Clear cell sarcoma, EESR1 genetic rearrangements, HMB-45, Malignant gastrointestinal sarcoma, Melan A, surgical treatment, S100 protein

gCore tip: Clear cell sarcoma of gastrointestinal tract is a very rare and infrequent tumour. Classically, it can be confused with other similar tumours such as melanocytic tumours, neuroectodermaltumours and gastrointestinal stromal tumours (GIST). Their immunohistochemical characteristics are based on the presence of a positive S100 protein and negative markers for HMB-45, Melan A and GIST (CD117, DOD-1 and CD34). Other important characteristics for the diagnosis of this tumour are positive EWSR1 gene rearrangements by FISH technique studies. Frequently, the CCSGITs affect children and young adults. They are highly aggressive tumours that commonly reoccur with widespread metastatic nodal and visceral disease, even after treatment. The most frequent intestinal locations are the stomach or small bowel. Colonic location and specifically the caecum is rarely described in the literature. Nowadays the only treatment is surgical resection. However, the prognostic is bad and the overall global survival at 3 years is very low. In the future, it is possible that new targeted therapies would offer a possible better prognostic for patients with this rare sarcoma disease.

Introduction

Clear Cell Sarcoma of Gastrointestinal Tumour (CCSGIT) is a rare malignant neoplasm that originates in the wall of the stomach, small intestine or large bowel. This type of tumour is more frequent in paediatric ages and young adults, and was first described in subcutaneous tissue, tendons and aponeurosis [1-4]. In 1993, Ekfors et al. reported the first case of primary gastrointestinal CCS arising in the duodenum tract4. As of today only about 40 cases have been reported and most of these originated in the stomach and small bowel. Exceptionally, only four cases have been described in primary colon origin [5-8]. In this report we present two cases of CCSGIT originated in the ascendant colon (caecum), with an exceptional clinical occlusive presentation. We carried out a literature review with special emphasis on all diagnostic and therapeutic considerations.

Case Reports

Between 2015 and 2020 two patients, a 36 year-old female and a 41 year-old male, presented clinical signs of intestinal obstruction. Both showed abdominal pain and distension, history of rectal bleeding and anaemia. In both of them the abdominal CT scan revealed the presence of a tumour located in the caecum, with infiltration of surrounding fat and thickening of the adjacent peritoneum (fig 1). The CT also detected multiple suspicious metastatic mesenteric nodes that showed pathological uptake in the PET-CT that confirmed peritumoral nodal spread (fig 2). The colonoscopy identified a neoformative process in the caecum and the biopsy was positive for malignant tumour cells with eosinophillic cytoplasm and eccentric nucleus (rabdoid phenotype). Tumour cells were positive for vimentin, keratin AE1/AE3, EMA and S100 protein and negative for keratin CAM 5.2, Melan A, HMB 45, CD45 and DOG-1. A right hemicolectomy with regional lymphadenectomy was performed and reconstruction of the intestine with an ileocolic anastomosis.

CST-5-1-507-g001

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Definitive histopathological studies showed in both cases a caecum tumour with infiltration of the wall and mucosa ulceration with affection of the muscularispropia layer and the adjacent adipose tissue. The tumour showed extensive vascular and perineural invasion nests with pseudopapillary focal pattern with a predominance of epithelial cells (with fusiform areas) with eosinophilic cytoplasm that clearly rejected the periphery with prominent nucleoli compatible with a clear cell sarcoma (fig 3). Immunohistochemical studies were positive for S100 protein, CD68 and vimentin and weakly for cytokeratin CAM 5.2, LCA8CD45), DOG-1, C-kit, chromogranin, alpha-actin, desmin, HMB-45, Melan A and myeloperoxidase (fig 4). The study of gene rearrangements by FISH technique was positive for EWSR1 gene in both patients and confirming the diagnosis of Clear Cell Sarcoma (CCS) tumour. The first patient underwent adjuvant chemotherapy treatment with 5 cycles of Adriamycin 75mg/m2 with partial response and persistence of metastatic lymph nodes. Finally, resource surgery with extended mesenteric and paraaortic lymphadenectomy was performed. The new pathological study confirmed extensive residual nodal involvement with the same initial diagnosis of CCS. In the second male patient liver metastases were detected in sequential postoperative CTs and a posterior partial hepatic surgical resection was done. Both patients developed important extensive ganglion and diffuse metastatic disease and died eight and twelve months after surgery.

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CST-5-1-507-g004

Discussion

Clear Cell Sarcoma of Gastrointestinal Tract (CCSGIT) is a very infrequent tumour and until 2015 only 40 reports had been published. However only 16 of this reports described tumours that corresponded with the accepted morphological, structural and immunochemical features of a CCSGIT. The most common localization is the small bowel; the stomach and the colon are more rarely affected [1-6]. CCS is more frequent in paediatric and young to middle age adults with reported median age of 40 years (from 17 to 77) [5,6]. There seems to be an equal distribution between the sexes. The most common signs and symptoms are similar to those attributed to gastrointestinal tumours: abdominal pain, intestinal distension or obstruction, gastrointestinal bleeding and anaemia. The unspecific clinical presentation and consequent delayed diagnosis play a key role in the definitive prognosis [5-10].

This rare tumour is a source of diagnostic dilemma as it shows features of melanocytic differentiation. The main diagnosis technique for accurate diagnosis is based on its histology and immunohistochemistry, but these approaches do not distinguish between malignant melanoma and CCSGIT. CCSGIT has a histological appearance that is strikingly similar to metastatic melanoma, and also needs to be differentiated from Gastrointestinal Stromal Tumours (GIST) and poorly differentiated papillary adenocarcinoma. The tumour cells of CCSGIT are predominantly epitheloid with oval or round nuclei and a variable amount of eosinophillic or clear cytoplasm, as observed in our patients, but a case featuring oncocytic cytoplasm has been reported [10]. The nuclei display an irregular nuclear contour. Nucleoli are inconspicuous but occasionally prominent and basophilic. Necrosis and surface ulceration can be seen. Osteoclast-like multinucleated giant cells are a frequent and consistent finding. Metastatic tumours resemble the primary tumour morphological features, including the presence of osteoclast-like multinucleated giant cells. All the metastatic nodes in our patient with the extended lymphadenectomy showed the same histopathology as the primary tumour.

From an immunohistochemical point of view, it is well accepted that CCSGITs are characterized by strong and diffuse staining for the S100 protein. In addition these tumours tend to lack melanocytic specific markers including HMB-45, Melan A, Thyrosinase and macrophtalmic associate transciptor factor (MITF) [8] and they do not express GIST markers (CD117,DOG1 and CD34) [4]. Another important finding is that the EWSR1 gene rearrangements are present in CCSGITs. Antonescu et al team studied three cases of CCSGI and claimed to be the first to describe a recurrent translocation of EWS (22q12) and CREB1(2q32.3) resulting in EWS-CREB1 fusion: they concluded that these cases may present a gastrointestinal neuroectodermaltumour that expresses neuroectodermal markers and a lack of melanocytic differentiation. However, the existence of rare cases of CCSGIT with EWS-ATF-1 gene fusion that also lack melanocytic differentiation supports the theory of a common histogenesis between the two tumours [6, 11]. In our two patients the tumours were positive for S100 protein and expressed some neuroectodermal markers but lacked melanocytic differentiation. The study of gene rearrangements by FISCH technique was positive for EWSR1 gene in both patients.

In terms of treatment, surgical excision is the main therapeutic and curative approach. However, in the majority of the series, more than 30% patients presented metastatic disease at diagnosis. The adjuvant chemotherapy and/or radiotherapy do not contribute therapeutic benefits. The majority of the patients died before 2 years after diagnosis.

Conclusion

In summary, CCSGIT is a rare tissue tumour, which usually affects tendons and aponeurosis of soft tissues. Very few cases reported this tumour in the gastrointestinal tract (CCSGIT). Among them the caecum is an exceptional localisation. CCSGI is considered an aggressive malignant neoplasm with unfavourable prognosis and most patients die within two years from the diagnosis. Clinical manifestations are very unspecific, such as abdominal pain, acute intestinal obstruction, digestive haemorrhage and anaemia, which delay diagnosis and treatment. The definitive diagnosis is based on immunohistochemicqal and genetic techniques. These studies present a positive S1200 protein with negative melanocytic or GIST markers. The EWSR1 rearrangement gene is observed in all cases. In addition, this is an aggressive sarcoma tumour and has poor prognosis. Surgical resection is the only possible curative treatment, specially if indicated early. In all of these cases the discussion of therapeutic strategies in a multidisciplinary sarcoma committee is necessary.

Acknowledgements

We would like to thank the patients for allowing their cases to be reported.

Competing Interests

The authors certify that there is no conflict of interest with any financial organisation regarding the material discussed in this paper.

References

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The Myth of the Corona Monster

Short Communication

The death toll, collapse of national health systems, and inability to arrest the worldwide spread of the Corona virus may seem in the eyes of the general public a fight against a sophisticated blood thirsty monster. Not only that the current devastating situation may justify such perception, scientific ignorance and fear-borne superstitions amplify the anxiety and lead to imagination of the virus as an unstoppable beast. On top of this, the terminology used in the media pictures the virus as a live creature with ambitious killing intensions.However, this perception is far from being true. First, we should not forget that this virus is a piece of RNA (ribonucleic acid) and not a live creature (creature definition: at least one cell surrounded by a biological membrane). Thus, rather than scaring the public, it could be wise to discuss in simple words the chemical nature of the virus as well as its possible origin and why does it pose a worldwide concern. Second, the redundant declarations and optimistic promises by non-professionals cannot assuage or calm down a scared public. People require logical explanations with at least putative solutions that leave some hope. Third, an international council supported by national committees of medical as well as communication experts is required to lift some pressure and better explain why may we anticipate dissipation of the virus. Such explanations can capitalize on the description of strategies and means to combat future viral as well as microbial threats, and also illustrate how previous horrible pandemics finally dissipated.

No doubt, globalization of economy and transportation along with explosion of human population enhance disease spread. We have learnt nowadays that borders closure and police and army regulations not necessarily stop this spread. Hence, in the absence of appropriate vaccine and efficient curing drug, the strategy that held sway thus far was isolation of people, cities, and entire districts. Despite this seemingly successful strategy in China and South Korea, the increasing death toll in Europe and the US implies that the world is not ready and probably unable to overcome this frightening situation. Considering a horrifying possibility of a worse future biological threats, it is critical to develop preventive and curing means, directed by the World Health Organization and supported by national brain-storming committees. Such efforts should consider development of multi-potent vaccines (e.g. monoclonal antibodies directed against viral families and based on common sequences or structural entities. The putative feasibility of such idea is currently reflected on efforts to protect infected patients by administration of purified serum derived from cured patients that survived the viral attack. The success of this initiative may be limited if the Corona virus interaction with human cells differs from that of other members of this viral family (SARS and MERS). Another putative possibility might rely on the viral need for an enzyme (polymerase) enabling multiplication of its RNA genome. Arrest of polymerase activity might stop viral propagation, but it may concomitantly affect the host. Therefore, we should seek for a way to eliminate viral propagation with minimum effect on the host. Here we may capitalize on the vast difference in RNA polymerase activity for viral multiplication compared to the lower activity rates required by the host. This difference may be exploited to arrest viral propagation in an approach similar to the so called ‘pulse-chase’ experiments in biochemistry. In these experiments a radioactive isotope (usually 14C or 32P) is used for a short duration to label freshly synthesized macromolecules (proteins, nucleic acids), and then is washed out, enabling follow up of the fate of the labeled molecules. A similar approach may be adapted to arrest polymerase activity by an inhibitor administered for short time intervals, each entailed by drug washout or dilution. Favipiravir (T-705; 6-fluoro-3-hydroxy-2-pyrazinecarboxamide) is an example of an antiviral drug that selectively inhibits the RNA-dependent RNA polymerase of influenza and some related viruses. It might be beneficial to examine whether such a drug or other existing drug derivatives would also affect the Corona polymerase.

None the less, it should be emphasized that such medical approach does not mean that infected individuals and populations should not be isolated to eliminate virus spread, as is practiced presently worldwide.The dangers to humanity imposed by biological threats put a big question-mark on the advantages of globalization. Have we approached the stage where over-populated world along with globalization endanger our existence? Sadly, as long as international conflicts lead to violence and the world is busy in developing new mass-destructive warfare, including biological weapons, humanity is exposed and under threat. Surprisingly, despite the fear, only little has been done to prevent and withstand such global disasters. Allegorically, human populations and international relationship are reminiscent of a bacterial culture growing in a flask. As long as the cells have sufficient resources to thrive, their growth is exponential. However, when density cannot be tolerated and the life supporting resources decline, many cells die and other would survive by feeding on degradation products of the dead (plateau in the growth curve). Then in the absence of sufficient resources the culture begins to collapse (decline of the growth curve) and most cells die. Would humanity extinct one day in a similar fashion?.Another questionable point is how and where was the Corona virus created. Since it is not a live creature, its progenitor belonged most likely to the SARS or MERS viral families, as indicated by the 72.8 similarity of their nucleic acid sequences. Since DNA and RNA are always prone to some rate of mutations that are either detrimental or corrected by various internal mechanisms, the question is whether such natural rate of mutations may explain the creation of Covid-19. Since the Covid-19 RNA sequence differs approximately 27% from other members of the SARS family, the natural rate of mutations can hardly explain its formation unless it happened under strong selective pressure and recombination events allowing substitution of entire RNA sequences. Since the virus is just a chain of nucleic acids, it is hard to consider a feedback mechanism responsible for such genetic capability. This raises a strong suspicion that the Corona virus has not been created by random genetic events. If true, the most rational conclusion would be that the strong selective pressure and recombination events that led to the formation of Covid-19 were directed by human hands, and insufficient control measures allowed the escape of the viral product out of its experimental niche. Not only that such a conclusion is terrible, the continuation of arms race and development of mass destructive biological weapons may seem to an extraterrestrial visitor the most foolish direction taken by mankind.

What is the most effective mouthwash in patients infected with covid-19 to minimize possible transmission by saliva? Update.

DOI: 10.31038/JDMR.2020315

Abstract

Objectives: To study if some antiseptic agent rinse can reduce the viral load of COVID-19 in the infected patients to minimize its virulence in respiratory tract, and therefore the contagious.

Materials and Methods:To analyze of scientific articles published in the last months, about the use and effectivity of some mouthwash against COVID-19 and write an update.

Results: Rinses, as an adjunctive measure for containing the COVID-19 transmission, are important to keep in mind, but there are very few articles on COVID-19 that cover mouthwashes.

Conclusions: A concentration of 1% – 1.5% hydrogen peroxide solution or 1% – 0.2% povidone-iodine seem to be an effective mouthwash to reduce the viral load in oral cavity of COVID-19.

Clinical Relevance: Due to COVID-19 pandemic, we are suffering, and growing information about this virus, questions about which antiseptic rinse to use to decrease the viral load is essential.

Keywords

COVID-19; dentistry, chlorhexidine, povidone iodine, antimicrobial mouth rinse, antimicrobial mouthwash.

Introduction

The zoonotic virus named 2019-nCoV or COVID-19, belongs to the Coronaviridae family, it is probably outbreakstarted with Chinese horseshoe bats (Rhinolophussinicus) [1], and although pangolism was initially thought of the most likely intermediate host [2], the publication on 20th February 2020 of the genetic analysis on the BioRxiv Server has showed that the conclusion was rushed.

An epidemic of coronavirus disease started in 2019, in Wuhan (China), and during a short period of time it is causing an outbreak of pneumonia known as severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) [3, 4].

From 31th December 2019 to 18th April 2020, 2197593 cases of COVID-19 have been reported (in accordance with the applied case definitions and testing strategies in the affected countries), including 153090 deaths (191726 infected, and 20043 deaths in Spain), and it has been recognized in 207 countries and territories around the world [5, 6], and the worst is that the number of confirmed cases and deaths continues increasing until today [3].

The predominant expression of ACE2 in the lower respiratory tract is believed to have determined the natural history of SARS as a lower respiratory tract infection. All patients were initially diagnosed by RT-PCR from oro- or nasopharyngeal swab specimens [7].

Nasopharyngeal and oropharyngeal samples were collected throughout the clinical course in all infected patients, with no statistically significant differences found in either viral loads or detection rates between the two samples. The earliest swabs were taken on first day of symptoms, with symptoms often being very mild or prodromal. All swabs from all patients taken between days 1 to 5 tested positive. The average virus RNA load was 6.76×105 copies per whole swab until day 5 (maximum, 7.11X108 copies/swab). Swab samples taken after day 5 had an average viral load of 3.44×105 copies per swab and a detection rate of 39.93%. The last positive-testing swab sample was taken on day 28 post-onset. Average viral load in sputuTypical COVID-19 signs and symptoms include fever, cough, and shortness of breath [11]; potential atypical symptoms assessed included sore throat, chills, increased confusion, rhinorrhea or nasal congestion, myalgia, dizziness, malaise, headache, nausea, vomitiing and diarrhea [12-14].m was 7.00 x 106 copies per mL (maximum, 2.35×109 copies per mL) [8].

Apart from respiratory pathology, around one-fourth to one-third of the hospitalized patients in Wuhan (China), developed serious complications, such as arrhythmia and shock, and were therefore transferred to the intensive care unit (ICU) [9, 10].

Typical COVID-19 signs and symptoms include fever, cough, and shortness of breath [11]; potential atypical symptoms assessed included sore throat, chills, increased confusion, rhinorrhea or nasal congestion, myalgia, dizziness, malaise, headache, nausea, vomiting and diarrhea [12-14].

People of all ages are vulnerable to this new infectious disease, however elderly people and the existence of underlying comorbidities as cardiovascular disease, diabetes, hypertension, immunosuppression or hospitalization in the ICU [15], have a worse prognosis [10, 16]. According to the average age, in the early stage of the outbreak in Wuhan, it was 59 years [17], very similar to the data provided in Spain that, in 16th March 2020, with 710 analyzed cases, the median age was 51 years [18, 19], although the deaths were in 67.2% in elderly more 80 years old, in according Italian dates [20].

Crisis management in emergent public health event is a global problem and a difficult thesis for researchers worldwide, highlighted by World Health Organization for its vital importance to public sanitation and health, life quality and survival [21, 22].

In many infectious diseases, from bacterial or viral origin, affect the respiratory tract, and therefore with the presence of pathogens in saliva, mouthwashes have been used to reduce the viral load. The chlorhexidine (CHX) is an broad spectrum antiseptic the most used daily in a dental clinic. However, there are many others on the market but, which is the best to out down the viral load? These rinses, are effective of the new viruses as COVID-19? The aim of this article is to analyze the published bibliography to know which mouthwash is effective to reduce the viral load of COVID-19 in the infected patients to minimize its virulence and therefore transmission person-person.

Material and Methods

This is not a systematic review but an update about the use of rinses to reduce de viral load in oral cavity of COVID-19, and try to analyze which is the most effective to avoid the transmission patient-dentist or vice versa.

I looked for the publications in the last months that deal with coronavirus.

Results and Discussion

Mode of transmission is based, initially animal-to human and nowadays in sustained human-to-human spread [1]. The COVID-19 was recently identified in saliva of infected patients, and the 2019-nCoV sequence could be also detected in the self-collected saliva of most infected patients even not in nasopharyngeal aspirate, and serial saliva specimens monitoring showed declines of salivary viral load after hospitalization [23].

This coronavirus can remain suspended in aerosols and retain infectivity for long periods with the possibility for to be inhaled or transmitted via direct contact with conjunctival, nasal, or oral mucosa of oral healthcare personnel (OHCP) or cross-contamination between patients. Although, some authors explain that spread of SARS-CoV-2 through aerosols or vertical transmission (from mothers to their newborns) has to be confirmed yet [24].

There are three different pathways for COVID-19 to present in saliva: firstly, in the lower and upper respiratory tract that enters the oral cavity together with the liquid droplets frequently exchanged by these organs; secondly, in the blood can access the mouth via crevicular fluid, an oral cavity-specific exudate that contains local proteins derived from extracellular matrix and serum-derived proteins [25, 26]. Finally, another way for coronavirus happens in the oral cavity is by major- and minor-salivary gland infection, with subsequent release of particles in saliva via salivary ducts, suggesting that salivary gland cells could be an important source of COVID-19 in saliva [26, 27]. In other words, the saliva droplets to be considered as a fundamental concept is the transmission of the virus [28].

It is now believed that its interpersonal transmission occurs mainly via respiratory droplets (cough, sneeze, droplets from Plügge) and contact transmission through nasal or ocular mucosa (The Chinese Preventive Medicine Association 2020), many times generated during dental clinical procedures is expected [26]. In addition, there may be risk of fecal-oral transmission, as researchers have identified SARS-CoV-2 in the stool of patients from China and the United States Protocol of prevention.

Dental procedure generated aerosol is a potential source of cross-contamination in the dental office. In addition, to containing common oral bacteria it may include pathogenic bacteria, such as Mycobacterium tuberculosis or Legionella pneumophilia, and viruses such as HIV, hepatitis B or C virus, herpes simplex virus, influenza virus [29], and especially the virus that currently causing a global pandemic, COVID-19.

A recent study indicates that copper and paper can allow the virus to survive from 4 to over 24 hours. On the other hand, the infectious charge can be drastically reduced only after at least 48 hours for steel and 72 hours for plastic [30]. For this reason, it’s more urgent to implement strict and efficient infection control protocols for dental practices and hospitals in countries/regions that are (potentially) affected with COVID-19, strict and effective infection control protocols are urgently required [3, 29].

Researchers calculated the mean incubation to be 6.4 days (ranges 2.1 to 11.1 days). It was estimated for travellers from Wuhan with confirmed 2019-nCoV infection in the early outbreak phase, using their reported travel histories and symptom onset dates. This is essential to epidemiological case definitions, and is required to determine the appropriate duration of quarantine [31]. Protection measures are needed to fight against COVID-19.

This emerging pandemic and its severe outbreak in the Italian population have induced the Italian Government first and then the European Union and in many countries of the world, to promote drastic impact measures to “flatten the curve” of the COVID-19 infection and in turn avoid health systems (in particular, intensive care units) being overwhelmed, resulting in fewer deaths [32]. The limitation of people circulating outside their home, social distance the stoppage of almost all working activities and the request to the population to use protective masks and gloves have the main goal of minimizing the likelihood that people who are not infected come into contact with others who are already infected and probably still asymptomatic [33]

Healthcare workers and other patients in the hospital are in close contact with patients with symptomatic and asymptomatic COVID-19, and for this reason they are at higher risk of SARS-CoV-2 infection.

As always happens, healthcare professionals have been immediately involved in the national emergency, overworking, often day and night: unfortunately, small numbers of them have also become infected, and some have tragically died [28].

In the early stage of the epidemic, in an analysis of 138 hospitalized patients with COVID-19 in Wuhan, 41% were presumed to have been infected in hospital, including 29% health care workers and 12% patients hospitalized for other reasons [10].

As of 14th February 2020, a total of 1.716 health care workers in China were infected with SARS-CoV-2, consisting of 3.8% affected patients [10]. Actually, (4th April, 2020), in Spain the healthcare workers infected are about 6.500 [34].

According to these statements Spagnolo et al. [28], wrote in an article that, on 15 March 2020, the New York Times published an article entitled “The Workers Who Face the Greatest Coronavirus Risk”, where an impressive schematic figure described that dentists are the workers most exposed to the risk of being affected by COVID-19, much more than nurses and general physicians. For this reason, the dentists are often the first line of diagnosis, as they work in close contact with patients.

There should be action protocols, based on both existing guidelines and published research on the principles and practices to achieve control of dental infections, mainly addressing the characteristics of nosocomial infection, and SARS, in dental care settings, and providing recommendations on patient evaluation and infection control protocols in dentistry [3].

According to all these arguments, Meng at al. [29] published an article with relevant guidelines and research, recommending management protocols for dental practitioners and students in (potentially) affected areas, introducing the essential knowledge about COVID-19 and nosocomial infection in dental settings. For this reason, [29] established a protocol, since January 24, according to which they should only be attended at the School and Hospital of Stomatology, patients with emergent dental treatment need, under the premise of adequate protection measures. Procedures that are likely to induce coughing should be avoided (if possible) or performed cautiously [35].

Aerosol-generating procedures, such as the use of a 3-way syringe, should be minimized as much as possible. Moreover, rubber dams [36], and the use of saliva ejectors with a low volume or high volume can reduce the production of droplets and aerosols, or spatter in dental procedures of emergency  [28, 37].

If an intraoral X-ray for a correct diagnosis is needed, a panoramic radiography or cone beam (CBCT), are appropriate alternatives during the outbreak of COVID-19, because the radiographic plate can stimulate saliva secretion and coughing [36].

Efficient infection control can prevent the virus from further spreading, which makes the epidemic situation under control. The most important protective measures according toChinese experts consensus are: hand-cleaning- and medical-glove-related hand protection, mask- and goggles-related face protection, UV-related protection, eye protection, nasal and oral mucosa protection, outer ear and hair protection [37].

For this reason, and knowing that the risk of cross infection may be high among patients and oral healthcare practitioners in oral healthcare settings [3, 29], population must keep in mind the requirement of a close contact between healthcare workers and infected patients to collect nasopharyngeal or oropharyngeal samples, the possibility of a saliva self-collection can strongly reduce the risk of COVID-19 transmission [26].

Dental practice should be postponed at least 1 month for convalescing patients with SARS or infected with COVID-19. [29, 38].

Since the viral load contained in the human saliva is very high, rinses with antiseptic mouthwashes can only reduce the infectious amount but are not able to eliminate the virus in the saliva [29, 39]. Active virus replication in the upper respiratory tract puts the prospects of COVID-19 containment in perspective [7].

In this sense, a few important concepts would be useful to briefly report and discuss here or raise future research.

To reduce viral load, Samaranayake et al. [38] and the General Council of Dentists of Spain [40], based on the study of [39], recommended that the patient should must rinse during 1 minute, with a mouthwash of 1% hydrogen peroxide solution 1% o de 0.2% povidone-iodine (PVP-I) before urgent treatment [40], because for over 60 years, PVP-I formulations have been shown to limit the impact and spread of infectious diseases with potent antiviral, antibacterial and antifungal effects [41].

The solution 3% hydrogen peroxide was used by author such as Nobahar et al. [42] in the prevention of VAP, obtaining good results in reducing the bacterial load and recommend its use in routine care for the prevention of this type of pneumonia. Nevertheless, [43] that applied 1.5% hydrogen peroxide solution with a suction brush after applying 0.12% CHX oral solution using swab, in patients hospitalized in ICU, they did not get statistically significant differences comparing with the group control.

According to PVP-1, other authors, such as Meng et al. [29], advised that a preoperative concentration at 1% through gargle/mouthwash reduced the viral load in the dental aerosol and in the oral cavity and oropharynx, and consequently, it is an effective way to reduce the risk of experiencing contamination in the dental office. In addition, we must include others hygiene measures needed to reduce the severity of future SARS outbreaks [44].

Marui et al. [45], analyzed the effect of some rinse such as Cetylpyridinium chloride (CPC) 0.05% only or combinated (0.075% CPC, 0.28% zinc lactate, and 0.05% sodium fluoride), essential oils (like tea tree oil), CHX 0.12% or 0.2% and herbal mouthrinse, through the microbiological count of total number of colony-forming units (CFU). This number of CFU had a significant reduction (p<0.05) with a mean of 78.9% with CHX, 61.3% with essential oils and 61.2% with CPC. In this study, the use of a herbal mouthrinse did not result in a significant reduction in the number of CFU compared with the control product [45], however [46] obtained significant antibacterial effects against Staphylococcus aureus and Streptococcus pneumoniae, and for this reason it is an alternative to other rinses.

On the other hand, Koeman et al. [47] obtained satisfactory results when combining CHX with colistin (polypeptide antibiotic effective against resistant bacteria), but both cases used only in the prevention of ventilator-associated pneumonia (VAP). Oral CHX has also not been seen as decreasing the bacterial load of COVID-19, as the Guideline for the Diagnosis and Treatment of Novel Coronavirus Pneumonia (the 5th edition) released by the National Health Commission of the People’s Republic of China concludes that the most used rinses are those of CHX, may not be effective to kill 2019-nCoV.

Bioscience Laboratories (Bozeman, Montana 2016-2019) made a study to compare the virucidal effect of several oral rinses as iodine or CHX, obtaining efficacy to completely inactivate oral pathogens, taking 15 seconds and 30 seconds to inactivate coronavirus, where others products were ineffective [48]. Nevertheless, other studies describe to CLX as a poor and not effective antiviral agent against Coronavirus (Viruses, November 2012, 4, 3044-3068) [49], just as [50], said in their study: the virus is resistant to CHX, and therefore its use is not useful.

[3] described the first typical family case of COVID-19 treated using the Chinese traditional patent medicine Shuanghuanglian oral liquid (SHL), because of poor response to the western medicine. If SHL used extracts of three Chinese herbs, namely, honeysuckle, forsythia, and Scutellariabaicalensis, to treat cold, sore throat, and cough with fever.

The most reviewed articles about COVID-19 do not considered the use of mouth rinses as a measure to reduce viral load and therefore the risk of transmission by Pügge drops from patient to dentist, or vice versa [51, 52].

Conclusion

A concentration of 1% – 1.5% hydrogen peroxide solution or 1% – 0.2% povidone-iodine seems to be an effective mouthwash to reduce the viral load in oral cavity.

To provide legal help, guidance and protocols to the oral medical industry in dealing with public health emergencies is essential. On this way, if traditional Chinese medicine and the use of some herbal rinses have been successful, research should be conducted along these lines. Perhaps we will face other viruses like hartavirus in the near future, and we must be prepared.

Acknowledgments

Health professionals for their continuous fight to stop this pandemic and researchers who are still looking for the vaccine against COVID-19.

Thanks to Chang Chen for translate Chinese texts, and I would like to say thank you, personally, Dra. PíaLópezJornet for encouraging me to continue working and reading scientific literature, even if we are confined in Spain at these moments.

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Genetics of Hidradenitis Suppurativa

DOI: 10.31038/JMG.2020324

Abstract

HidradenitisSuppurativa(HS), also named acne inversa, which is a common chronic inflammatory skin disorder characterized clinically by painful lumps, abscesses and scarring. Thirty-five unique mutations in patients with HS have been identified in three of the genes that encode members of the γ-secretase complex: nicastrin (NCSTN), presenilin 1 (PSEN1), and presenilin enhancer 2 (PSENEN) as well as in POGLUT1, an Endoplasmic Reticulum (ER) O-glucosyltransferase that is involved in Notch signaling. This review summarizes research updates on genetics of HS.

Keywords

Hidradenitis suppurativa, γ-secretase, nicastrin, presenilin

Introduction

Hidradenitis Suppurativa (HS), also named acne inversa, is a common chronic inflammatory skin disorder characterized clinically by painful lumps, abscesses and scarring (OMIM # 142690). The prevalence of HS in the population is 0.10%, or 98 per 100,000 persons in the United States (US) [1,2] and three times more common in female patients (73.8% women) than male patients (26.2% men), 3-fold greater in African Americans and 2-fold greater in biracial populations than in the overall population [1]. Antibiotics, anti-inflammation regiments, acne washes and medicines, and surgical procedure are the premirary current treatment options [3]. Major surgery demonstrated improvements in the HS patients’ overall work and daily activity impairment [4]. However, the disease progression often causes scars leading immobility, markedly affecting quality of life in severe patients who have poor responses to treatments [5].

The etiology of HS is associated with multi-factoralsincuding genetics and others. HS increased an independent risk of all-cause mortality [6]. Obesity, smoking, family history and environmental factors such as diet, are known to be associated with the HS disease pathogenesis. Obesity is linked to skin barrier function, sebaceous glands and sebum production, sweat gland, lymphatics, and collagen structure and function, wound healing, microcirculation and macrocirculation [7]. Obesity and smoking increase the HS incidence [8] [9]. HS patients classified as Hurley III HS were 28% more likely to be smokers and obese [10] and four times more likely to be obese compared to the general population by meta-analysis of case-control studies in Asia, Europe, and the US [11]. One-third (31%) of the HS patients who eliminated smoking or made dietary alterations including a reduction in gluten, dairy, refined sugars, tomatos, or alcohol showed improvement in HS clinical symptoms [12]. Patients with HS were at higher risk for long-term opioid use compared with controls [13].

HS lesion counts are increased with low serum zinc and vitamin D levels. Supplementation of zinc, vitamin D, vitamin B12, or exclusion of dairy or brewer’s yeast reduced lesion resolution. Bariatric surgery often causes weight loss which may lead to HS improvement but oftenresults in more severe malnutrition thatworsens or even leads to new HS onset post bariatric surgery [11]. The complement (C) system wasfound to be significantly down-regulated in the HS skin and blood transcriptomes and the HS blood proteome [81]. Porphyromonas species, which are able cleave inactive C5 into C5a, have been identified in the HS microbiome.  C5a levels in serum and tissue correlate with disease activity and degree of neutrophilic infiltrates in HS, suggesting that complement inhibition is a promising and potential therapeutic target for HS [82]. HS lesions showed 83% bacterial culture anaerobes compred to 53% of control samples, and milleri group streptococci and actinomycetes in 33% and 26% of cases, respectively [83]. Microarray analysis demonstrated that HS lesional skin samples had significantly decreased expression of enzymes involved in generating ceramide and sphingomyelin, increased expression of enzymes that catabolize ceramide to sphingosine, and increased expression of enzymes involved in converting ceramide to galactosylceramide and gangliosides, which suggests that sphingolipid metabolismi saltered in HS lesional skin comparedwith normal skin [86]. In HS patients, the serum and HS skin lension levels of chitinase-3-like protein 1 (YKL-40) were significantly elevated, suggesting that YKL-40 maybe one of the biomarkers of HS [87].

HS patients demonstrate a significantly higher heart rate in the HS groups than in the population [14]. HS often co-existed with psoriasis. Compared to patients with psoriasis alone, HS patients with psoriasis were significantly younger and had a higher prevalence of obesity and smoking [15].

Macrophages in HS infiltrates release a variety of pro-inflammatory cytokines such as interlukins and tumornecrosis factor α (TNFα), exacerbating the inflammation. Obesity and smoking contribute to macrophage dysfunction [9]. Elevated expression of TNFα has been identified in skin lesions, such as skin tunnels, of HS patients alongwith a clustering of interleukins (IL‐8, IL‐16, IL‐1α and IL‐1β) [68] [69]. Gene-sets related to Notchsignalling and Interferonpathwaysweredifferentiallyactivated in HS lesionalcompared to non-lesional skin [80].

Adalimumab is a TNFα inhibitor which has been used in both USA and Europe for treating HS patients. Adalimumab reduced flare, showed a higher efficacy on nodules-abscesses than on draining tunnels and increased the number of patients achieving a Hidradenitis Suppurativa Clinical Response [91]. By a Genome-Wide Association Study (GWAS) analysis one single Linkage Disequilibrium (LD) block in the BCL2 gene was significantly associated with adalimumab response (lead Single-Nucleotide Polymorphism [SNP] rs 59532114). Meanwhile, a correlation of the most strongly associated SNP minor allele with increased BCL2 gene and protein expression in hair follicle tissues was observed with bioinformatic analysis and functional genomics experiments [66]. HLA alleles may affect the treatment response in HS patients treated with adalimumab. Threre were three protective HLA alleles (HLA-DQB1*05, HLA-DRB1*01, and HLA-DRB1*07) less prevalent and two risk HLA alleles (HLA-DRB1*03 and HLA-DRB1*011) more abundant in HS patients developing anti-drug antibodies to adalimumab than these not [67].

Genes Linked to HS

Genetics is assciated with the pathogenesis of HS. One third of HS patients have a family history with an autosomal dominant inherentance trait [16] which pattern suggests a single gene disorder. Thirty-five unique mutations in patients with familial or sporadic HS have been found in genes encoding three of the four genes comprising the γ-secretase complex: nicastrin (NCSTN), presenilin 1 (PSEN1), presenilin enhancer 2 (PSENEN)  [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] and in POGLUT1, an Endoplasmic Reticulum (ER) O-glucosyltransferase involving in Notch signaling [33] with a diversity of mutation types in Caucasian, Chinese, Japanese, Indian or African ethnic origin (Table 1) [34][35]. NCSTN possesses majority (74%, 26/35) of the mutations (6 missenses, 8 nonsenses, 6 frameshifts, and 6 in splice sites resulted in frameshift or in-frame deletions). A single frameshift PSEN1-P242LfsX11 mutation was detected in PSEN1[21]. Six mutations were found in PSENEN (18%, 6/34) (3 frameshifts, 1 nonsense, 1 splicing, 1 missense). Two mutations were in POGLU1 (1 nonsense, 1 splicing).  NCSTN-R117X and Q568X were identified in more than one ethnic population and multiple families; the rest HS-linked mutations are private to each HS family or subject. NCSTN-c.1799delTG is a two-base deletion that leads to a nonsense change L600X, while 2 splicing site mutations in NCSTN, c.582+1delG p. F145fs_X54 and c.1551+1G>A p.A486_T517del result in frame-shifts while the other 4 splicing mutations cause in-frame deletions (Table 1) [34]. HS-associated mutation types in NCSTN, PSEN1, PSENEN andPOGLU1 are missense 20% (7/35), nonsense 29% (10/35), frameshift 29% (10/35) and splicing site changes 22% (8/35).

Table 1.Mutation spectrum of NCSTN, PSEN1, PSENEN and POGLUT1 in HS patients

ID

Mutation category

Nucleotide Change

Amino Acid Change

TM

Ethnic origin

Reference

NCSTN

1

Missense

c. 223G>A

p.V75I

Yes

Chinese

36

2

c.553G>A

p.D185N

Yes

Caucasian

17

3

c.632C>G

p.P211R

Yes

Chinese

18

4

c.647A>C

p.Q216P

Yes

Chinese

36

5

c.944C>T

p.A315V

Yes

Chinese

19

6

c.1229C>T

p.A410V

Yes

Chinese

20

7

Nonsense

c. 349C>T

p.R117X

No

Chinese,
Caucasian,
African

21
20
22

8

c.477C>A

p.C159X

No

Chinese

23

9

c.497C>A

p.S166X

No

Chinese

24

10

c.1258C>T

p.Q420X

No

Chinese

94

11

c. 1300C>T

p.R434X

No

Caucasian

25

12

c. 1695T>G

p.Y565X

No

Chinese

18

13

c.1702C>T

p.Q568X

No

Caucasian
Japanese

95

14

c.1799delTG

p.L600X

No

Indian

26

15

Frameshift

c.210_211delAG

p.T70fsX18

No

Chinese

27

16

c.487delC

p.Q163SfsX39

No

Chinese

21

17

c.687insCC

p.C230PfsX31

No

Indian

26

18

c.1752delG

p.E584DfsX44

No

Chinese

21

19

c.1768A>G

p.590AfsX3

No

Caucasian

25

20

c.1912_1915delCAGT

p.S638fsX1

No

Caucasian

35

21

Splice Site

c.582+1delG

p. F145fs_X54

No

Japanese

95

21

c.996+7 G>A

p.L282_G332del

Yes

Caucasian

17

23

c.1101+1 G>A

p.E333_Q367del

Yes

Caucasian

28

24

c.1101+10 A>G

p.E333_Q367del

Yes

African

17

25

c.1352+1 G>A

p.Q393fs_X9

No

Chinese

27

26

c.1551+1G>A

p.A486_T517del

No

Chinese

21

PSEN1

27

Frameshift

c.725delC

P242LfsX11

Chinese

21

PSENEN

28

Frameshift

c.66delG

p.F23LfsX46

Chinese

21 29

29

c.66_67insG

p.F23VfsX98

Caucasian

17

30

c.279delC

p.P94SfsX51

Chinese

21

31

Nonsense

c.168T>G

p.Y56-101Pdel

Caucasian

30

32

Splicing

c.167-2A>G

p.G55-101Pdel

Chinese

31

33

Missense

c.194T>G

p.L65R

Chinese

31

POGLUT1

34

Nonsense

c.814C>T

p.R272*

Caucasian

32

35

Splicing

c.430‐1G>A

p.K246_392Ldel

Caucasian

33

HS patients who carry a mutation in NCSTN, PSEN1, PSENEN or POGLUT1 display severe or typical symptoms of HS lesions [36][17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32][33]s. HS patients who carrying a PSENEN or POFUT1 mutation also have co-ocurrent Dowling–DegosDisease (DDD) syndrome), an abnormally dark skin coloring condition (hyperpigmentation) [32] [37] [38] [30] [33] while mutations in NCSTN and PSEN1 occur in patients with HS only. There were 2.8 -fold patients with complex HS demenstating increase in pathogenic variants of an innate immunity regulator pyrin (also known as marenostrin, MEFV) compared to the healthy controls in the general Turkish population [39].

Structures of HS-Linked Genetic Mutations

The putative functions of the HS-linked mutations were analyzed by in silico analysis of using a variety of programs. By SWISS-MODEL, most of the HS-linked nonsense, frameshift, and splice site mutations resulted in marked 3D structural changes, and a C-terminal end frameshift mutation NCSTN-E584DfsX44 led to a striking 3D structural change while another nearby downstream frameshift mutation NCSTN-p.590AfsX3 (6 amino acids apart) caused only a minor 3D change [34]. This finding suggests that this NCSTN-E584DfsX44 mutation is likely located at a critical site for NCSTN conformation [34]. By PolyPhen-2, SNP & Go and Proven prediction, among 6 NCSTN missense mutations, NCSTN-P211R and Q216P were most deleterious; PolyPhen-2 predicts that V75I is probably damaging and D185N, A315V and A410V are predicted to have benign or neutral effects. 62% (16/26) of NCSTN mutations are nonsense or frameshift mutations that causes a truncation of the protein product. Structurally, NCSTN contains a large extra cellular domain and a single TM [40], that is located at amino acid position 670-692. 39% (10/26)  of NCSTN mutations (6 missense mutations and 4 splicing site mutations) retain the TM region, while 61% (16/26) of other NCSTN nonsense, frameshift mutations and c.582+1delG [17] and c.1352+1 G>A (experimental confirmed) [27] lose the TM domain to become cytosolic proteins that cannot enter the cell to initial signaling (Table 1). Among 4 splicing site mutations that do not affect TM regions, 3 potentially affect two key NCSTN substrate recruitment sites Gry333 and Tyr337. The p. L282_G332del occurs next to a residue of the NCSTN substrate recruitment site G333; and E333_Q367del and E333_Q367del completely abolish the 2 NCSTN substrate recruitment sites Gry333 and Tyr337 [40], which suggest that these NCSTN mutations affect important substrate recruitment structures. 50% (3/6) of the NCSTN splicing site mutations affect substrate recruitment [34].

Post Translation of HS-Linked Genetic Mutations

NCSTN mutatioNS Y565X occurs on a tyrosine phosphorylation site and R434X occurs on a glycosylation site. NCSTN-R434X disrupts the protein immediately before Asn435, one of the two NCSTN prominent glycans Asn55 and Asn435 [40]. 21% (5 of 24) of the NCSTN mutations, NCTSN-P211R, L600X, C230PfsX31, P590AfsX3 and F145fs_X54 occur at cysteine residues participating in disulfide bonds [41] [42]. Six potential NCSTN ubiquitination sites are predicted:  K78, T127, K386, K403, K591 and K597. Six residues in NCSTN undergo sumolyation: G146, S341, K386, P423, T459, and D476. NCSTN-P590AfsX3 occurs immediately before the predicted ubiquitination site K591 and abolishes two ubiquitination sites – K591 and K597. F145fs_X54 abolishes sumolyation site G146. Both NCSTN- E333_Q367del and E333_Q367del abolish sumolyation site S341. NCSTN-T70fsX18 and R117X abolish all the ubiquitination and sumolyation sites and C159X and S166X abolish four of the six ubiquitination sites and five of the six sumolyation sites [34]. The C-terminal end frameshift mutation NCSTN-E584DfsX44 resulted in a striking 3D structural change suggesting that this mutation is likely located at a critical site for NCSTN conformation [34]. Ubiquitiation and sumoylation are involved in post-translational modification. A large number of NCSTN mutations affect predicted ubiquitiation and sumoylation sites, suggesting that post-translational modification might contribute to HS pathogenesis.

HS-Linkled Mutational Effect

HS associated mutations in NCSTN are predicted to cause a loss of function as a result of frameshift and premature translation termination and a loss of  the TM domain, to affect NCSTN substrate recruitment sites, to cause a loss or creation of new ligand binging sites, and to alter post-translational modifications and disulfide bonds [41] [42], all of which support the notion that the NCSTN mutations result in significantly reduced levels of NCT and reduced γ-secretase-mediated processing of Notch and signaling in the skin [43].  Silencing of the keratinocyte NCSTN by CRISPR-Cas9 in both the keratinocyte cell line HEK001 and an embryonic kidney cell line HEK293 showed a significantly increased expression of genes related to the type I interferon response pathway [44]. NCSTNWild Type (WT) were upregulated in myeloid cells including monocytes, macrophages and non-lymphoid dendritic cells [35]. NCSTN knockdown in HaCaT cells impaired γ-secretase activity and proliferation and differentiation of keratinocytes. Expression levels of several γ-secretase substrates involved in the Notch pathway were significantly attenuated in NCSTN-silencing HaCaT cells and the lesion from a HS patient. Phosphoinositide 3-kinase (PI3K) as well as AKT and its activated form pAKT were markedly elevated in NCSTN-silencing HaCaT cells [23]. NCSTN mutations led to decreased miR-30a-3p levels, which negatively regulated RAB31 expression. Moreover, enhanced RAB31 levels accelerated degradation of activated EGFR, leading to abnormal differentiation in keratinocytes. Familial HS patients and mouse knocked out for Ncstn showed impaired EGFR signaling and epidermal differentiation [45].

However, testing four NCSTN-missense mutations, V75I, D185N, P211R, and Q216P for their effects on mediating Notch processing and signaling demonstrated a vague role of HS-linked NCSTN mutations in HS pathogenesis. The NCSTN-V75I, D185N, and P211R mutants can function in Notch signaling in vivo; in contrast mutant Q216P failed to rescue Notch processing and nuclear signaling [46]. Mouse models where components of the ¡-secretase with resultant Notch dysregulation have been knocked out have resulted in the development of dermal cysts and histological features of follicular occlusion [21][47] although these models rapidly developed multiple squamous cell carcinomas,which is not consistent with the typical progression of HS [47]. These findings suggest that although NCSTN-V75I, D185N, and P211R and some other NCSTN mutations have a significant role in the pathogenesis of the disease, this role is through a mechanism(s) other than impaired Notch signaling.

A single frameshiftPSEN1-P242LfsX11 mutation is predicted to truncate the PS1 protein after the 5th TM domain at the cytosolic region of the N terminal, which would markedly alter the 3D structure of PS1. PSENEN contains three TMs, at amino acid positions 18-38, 60-80 and 85-101. The PSENEN N-terminus is cytoplasmic, followed by two short helices that dip into the membrane [40]. All the PSENEN mutations occur within TM regions: frameshift mutations F23LfsX46 and F23VfsX98 delete all 3 TM regions, while P94SfsX51 disrupts TM region 3. Nonsense Y56-101Pdel and c.167-2A>G splicing site mutations lead to similar disruptions of TM regions 2 & 3. The missense mutation PSENEN-L65R laysin the TM 2 region and is predicted to be deleterious. POGLUT1 is located in the lumen of the endoplasmic reticulum. Both POGLUT1-R272* and C.430-1G>A, K246* lead to an early termination of protein synthesis. POGLUT1-R272* is located in the C-terminal domain and results in a truncated form of POGLUT1 with partial loss of the C-terminal domain. The splicing site c.430‐1G>A mutation was identified in exon 4 of the POFUT1 gene in patients with HS and DDD syndrome, which potentially generates aberrant splicing with loss of functionality [33]. POGLUT1 is predicted to possess 17 ligand binding sites of interactions with chain A. Hydrogen bonds include A.Y117, A.S152, A.R158, A.R158, A.D196, A.V197, A.V197, A.L199, A.V214, A.A215, A.A215, A.S217, A.F218, A.R219, A.R219 and salt bridges: A.R158 and A.R219. Both POGLUT1- c.430‐1G>A (K246*) or R272* completely abolish ligand binding function and show significant alteration of global quality estimate by Qualitative Model Energy Analysis (QMEAN) values:  POGLUT1-WT:-71; POGLUT1- c.430‐1G>A (K246*): 0.90; and R272* 0.45, indicating a greater deviation in mutant forms from the POGLUT1-WT [34].

A higher and prolonged TNFα expression and differential gene expression of four cytokine or chemokines than that of PS1-WT in response to LPS stimulation was observed in overexpression of the HS-associated PSEN1 mutation PSEN1-P242LfsX11 in PMA-differentiated macrophages [34]. Of  the overexpressing PSEN1-WT and PSEN1-P242LfsX11 induced under-expressed genes [34],  LIF and CSF2 are essential for the proliferation and differentiation of hematopoietic progenitor cells into granulocytes and macrophages [48] [49], IL12 is critical for the activation and maintenance of immune responses [50], and BMP2 regulates stem cell activation in the process of hair follicle regeneration in the dermis [51]. Theincreased expression of proinflammatoryTNFα and the decreased expression of LIF, IL12B, CSF2, BMP2 and other genes associated with the overexpression of PSEN1-P242LfsX11 may promote inflammatory processes, impair the activation/maintenance of immune cells and reduce hair follicle regeneration [34]. HS patients with a PSEN1 mutation may benefit greatly from TNFα inhibiting agents such as infliximab, adalimumab, rituximab, and ustekinumab, in particular after anti-inflammatory regimens fail to control the disease process.

PSEN1 has pleiotropic nature [52]. PSEN1 is linked to early-onset familial Alzheimer’s Disease (AD) (OMIM # 104300), a neurodegenerative disorder and the most common form of dementia in the elderly [53]. A single frameshiftPSEN1-P242LfsX11 mutation was detected in familial HS patients [21]. More than 185 missense or inframe deletion mutations and promoter variants in PSEN1 have previously been found in patients with familial AD (http://www. alz.org/) and sporadic Dilated Cardiomyopathy (DCM) [54], and 685 genes have been associated with AD (www.alz.org). The familial HS patients with PSEN1-P242LfsX11 mutation did not show the symptoms of AD [21]. Significant differential expression of ErbB4, SCNB1, and Tie1 was observed in HS lesional skin, and of EphB2, EPHB4, KCNE1, LRP6, MUSK, SDC3, Sortilin1 were observed in blood specific to AD [55]. AD-associated PSEN1 mutations alters the -secretases cleavage of β-APP to increase Aβ 42/40 ratio resulting in Aβ plague formation and related AD pathology [21]. Overexpression or silencing of presenilin caused cardiac dysfunction in Drosophila [56]. Overexpression of PSEN1-P242LfsX11 in zebrafish embryos enhanced Notch signaling but did not affect γ-secretase cleavage of APP [57], which suggests that the involvement of the PSEN1 mutation in HS pathogenesis also has a mechanism that is independent of γ-secretase activity. Different from the effectiveness of administration of TNFα inhibitor Adalimumab in the treatment of HS patients, administration of the TNFα modulator etanercept in AD patients demonstrated no apparent effect on cognitive functioning, though TNFα has been implicated in the pathogenesis of AD [58] [59]. In AD patients, only one side of each TM helix in PS1 is affected, the hot spot of Leu219, Glu222, Leu226, Ser230, Met233, and Phe237 are placed on the same side of TM5 [40] while the HS-linked PSEN1-P242LfsX11 is on the other side of TM5 in PS1. This distribution or structure of AD-linked PSEN1 mutation is significantly different from HS-linked PSEN mutations which may indicate functional importance.

POGLUT1 is an Endoplasmic Reticulum (ER) O-glucosyltransferase that adds glucose moieties to serine residues in EGF-like repeats, such as NOTCH intracellular domain [60]. Mutations in POGLUT1, including W4X, R218X, R279PfsX3 and R279W, have been previously described in unrelated caucasian patients with Dowling-Degos disease (DDD) [32] [37] [38]. Mutations in POGLUT1 caused an approximately 50% weaker POGLU1 expression in patient lesional skin compared to controls, by immunohistologic staining for POGLUT1 [38]. In addition, a missense mutation in POGLUT1 was identified with patients with muscular dystrophy. Muscles from patients demonstrated decreased Notch signaling, dramatic reduction in satellite cell pool and a muscle-specific α-dystroglycanhypoglycosylation not present in patients’ fibroblasts, suggesting a Notch-dependent pathomechanism for this novel form of muscular dystrophy [60]. Mutations in PSENEN are also identified in DDD patients [30]. Evidence has suggested the association between decreased Notch activity and POFUT1 mutations [61]. The finding of POGLUT1 mutations in patients with HS-DDD syndrome indicates aberrant Notch signaling is involved in both HS and DDD pathogenesis. Notably, mutations in POGLUT1 and NCSTN are linked to dysregulation of Notch signaling which might also contribute to small vessel disease, as well as to vascular cognitive impairment [62].

Epigenetics of HS-Linked Genes

Significant epigenetic modifications were observed in HS skin lensions [63]. mRNA of all the studied genes were significantly under-expressed in lesional HS skin compared to healthy skin by RT-PCR analyses of The Expression of Translocation (TET) and Isocitrate Dehydrogenase (IDH) family genes in the lensional skins of HS patients, suggesting that epigenetic changes occur in HS tissue and that aberrant expression of the DNA hydroxymethylation regulators may play a role in the pathogenesis of HS [63]. HS was associated with a 1.69-fold increased odds of diabetes; however, the absolute risk difference was small and is probably not clinically relevant [64]. A significant overexpression of miRNA-155-5p, miRNA-223-5p, miRNA-31-5p, miRNA-21-5p, and miRNA-146a-5p was observed in lesional HS skin compared to healthy controls, suggesting that these miRNAs may be potential disease biomarkers and therapeutic targets for HS [65].

Acknowledgments

This work was supported by the National Institutes of Health [R01AG014713 and R01MH060009 to R.E.T; R03AR063271 and R15EB019704 to A.L.]; National Science Foundation [NSF1455613 to A.L] and the Cure Alzheimer’s Fund [to R.E.T].

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Cyber Hybrid Warfare: Asymmetric threat

DOI: 10.31038/NAMS.2020315

Abstract

Cyber hybrid warfare has been known since antiquity, it is not a new terminology nor a new practice. It can have an effect even more than a regular conventional war. The implementation of the cyber hybrid war aims to misinform, guide and manipulate citizens, disorganize the target state, create panic, overthrow governments, manipulate sensitive situations, intimidate groups, individuals and even shortened groups of the population, and finally to form an opinion according to the enemy’s beliefs. Creating online events designed to stimulate citizens to align with the strategy of governments or the strategy of the enemy government is a form of cyber hybrid warfare. The cyber hybrid warfare falls under the category of asymmetric threats as it is not possible to determine how, and the duration of the cyber invasion.The success or not of a cyber hybrid war depends on the organization, the electronic equipment, and the groups of actions they decide according to the means at their disposal to create the necessary digital entities. Finally, the cyber hybrid warfare is often used to show online military equipment aimed at downplaying its moral opponent.

Introduction

The cyber hybrid warfare also includes DeepFake, a practice mentioned in Christos Beretas previous research. The cyber hybrid war aims to disrupt and hurt the adversarial state in an organized and targeted manner, mainly regarding the organizational structure of the target state and its functioning.Digital media are used to intimidate citizens, target specific groups of people, disseminate false news between political and military leadership in order to spread hatred and resentment on both sides, to divide the people, and finally the fall of the government, followed by the anger and indignation of the people. The cyber hybrid warfare is not only and exclusively applied during a period of natural war, it is a kind of war that can be waged for years and of course in times of peace. It is difficult for citizens in a cyber hybrid war to understand the truth and lies.A well-organized cyber hybrid war is difficult for people to recognize as the facts presented are so convincing that it is impossible to recognize them as false. The ways to avoid and protect against such a war are numerous and require knowledge, experience, alertness, high morale, courage and professionalism to deal with such a cyber threat from its birth.Sovereign states around the world are using the cyber hybrid warfare to blackmail, trap, mislead, both foreign governments and citizens, achieving remote results without the use of physical violence and natural disasters. The cyber hybrid war has come to stay, and it is an emerging form of war – the pressure of the strong against the weak or better of the organized states against the disorganized. As mentioned above, a great DeepFake video is capable of stirring up enormous panic and hatred in a society. It is an asymmetric threat that is increasing day by day.

Characteristics

The cyber hybrid war is an asymmetric threat that is defined when an entity uses electronic means to disturb the peace or spread panic in the target state and launch hostilities or uproot social groups residing in it. A fake video, for example, that will be sent to targeted social groups is capable of sparking riots in the crowd with demonstrations and violence. By reading this one can easily understand the reader that the cyber hybrid war is the result of an entity preceding its onset.This entity is the digital asymmetric threat which if not handled properly then evolves into a cyber hybrid war. The cyber hybrid war is not tantamount to an isolated practice, that is, it is not a common attack on the adversarial state; rather, it consists of organized methods that are often impossible to identify, such an attack may include social media, online press, videos and hostilities from different events, etc.The difference between a cyber hybrid war and conventional warfare is that except there are no killings and conflicts, there is a constant low-level influx of information affecting the target state. That is, it does not follow the logic that an event has occurred, a number of people have risen and then the digital invasion process has ended, on the contrary, the digital presence is continuous and stable at the same level as possible.

Advanced stages of a cyber hybrid war include practices such as misinformation aimed at the financial loss of the target state, intra-country turmoil from pro-country groups that launched the cyber hybrid war to compel its citizens to withdraw. for the purpose of financial loss or even the overthrow of the government.In a cyber hybrid war, the invaders’ practical ways of attacking are not one-sided but two-sided, which means that in one field they can decrease and increase in another, for example a false bent can be seen in social media news and on the contrary the volume of fake videos is growing too.A cyber hybrid war is often won when combine electronic and physical attacks in the target state, which means that in the target state it requires the penetration of disturbing elements in order to revolt and destroy the target state’s infrastructure and economy.This includes increasing crime, which will then be used in the media and social media by the adversary state as a means of corrupting the target country with the ultimate aim of reducing its reputation, spreading fear to other countries. aimed at restricting travelers, other countries’ security reviews, further financial burden, withering and global isolation.

The success or not of a  cyber hybrid war in addition to the proper organization, hardware, and staff, requires and sufficient funding for the whole venture, funding is a key success factor, with insufficient funding the result will be the opposite, as it will unprofessionalism has emerged, and it is easy for social groups to understand that this is fake news, which is equivalent to project failure and redesign.Funding can come exclusively from the state that organizes the cyber hybrid threat, it can come from friendly countries in it, as well as from organizations that are scattered around the world, usually when a cyber hybrid war is funded by organizations around the world, the communication takes place through social media or smart phone applications that offer anonymous messaging services. At this point it should be noted that there is no formal single practice or specificity in the form of steps that need to be taken to be considered a threat as a cyber hybrid threat, so there is no legal framework defining the steps that characterize that this is a threat to the target state to take legal actions, the legal framework is incomplete and that is something that countries that are waging such wars are very aware of and they are washed.

As technology evolves, asymmetric threats increase as states with sufficient funding and equipment are able to wage such wars on a large scale, which is why the cyber hybrid wars will intensify. That is why governments and security agencies around the world are trying to organize and shield themselves against the cyber hybrid war, now knowing that its impact is greater than even conventional warfare.Preparing, organizing, and preventing such attacks are the basic prerequisites for dealing with the threat. This entails writing and implementing a cyber security policy that outlines the conditions, steps to be taken, education, definitions, and how to handle such incidents.The security policy should be updated annually and adapted to the needs and the level of risk that exists per period. It must adequately specify how government agencies must act in a period of digital asymmetric threat. Allied countries need to formulate a common cyber policy so that dealing with a digital asymmetric threat is unified. It is of no use to allies and friendly countries not to implement a common strategy against digital asymmetric threats. Friendly organized countries can easily trap the enemy and destroy the plans.

Conclusion

The cyber hybrid war is made up of several entities that, depending on the smooth functioning of all entities, are judged to be successful or unsuccessful. It is an asymmetric threat, no one can know the length or the size of the area it will take place. It is a kind of war that with the development of technology will see significant development. An important factor in success is financial support and therefore the amount of money each state is willing to spend to design and implement a credit cyber hybrid war. A well-organized and implementable cyber hybrid warfare can cause severe damage to a conventional one. It is not necessary for a cyber hybrid war to be designed exclusively by wealthy and developed countries, such a war can be created by any state that has the knowledge, money, and organization to mount an asymmetric threat. In the cyber hybrid war, the chances of convicting states for war crimes are minimized, as in the cyber hybrid war there is no clear legal framework defining the methods of intruders.Identifying a digital threat is difficult due to the complexity of its actions; identifying and neutralizing a cyber hybrid threat requires knowledge and experience of such threats. Some countries in the world have developed methods and teams to detect and manage such threats, but the measures they take to protect them are found to be incomplete and not fully effective and the reason is the rapid development of technology that new methods and techniques are constantly being discovered.Finally, as has been said above, the best defense is the organization of friendly states to provide a single aid and formulate a unified security policy that will lead to massive isolation of cyber hybrid threats. Unified repression by friendly countries against such attacks is the best organized defense against hybrid threats.

References

  1. Christos Beretas(2020)DeepFake – Another One Cyber Threat.
  2. Andreas Krieg, Jean-Marc Rickli(2019) Surrogate Warfare: The Transformation of War in the Twenty-First Century.
  3. Andrew Fevery(2018) Hybrid Warfare.

Coronavirus (COVID-19): Mode of Action that Raises Questions

DOI: 10.31038/NAMS.2020314

Opinion Article

This article is a personal opinion article and nothing more.

We are all living in the last days a state of panic wherever we are in the world. This panic is justified and owe it to the well-known Coronavirus pandemic (COVID-19) as it is officially called. The virus causes from mild to very severe symptoms, such as acute respiratory infection, that is, ARF pneumonia(AcuteRespiratoryFailure). Symptoms of the virus start from a cough, fever with tithing slowly, tiredness, and shortness of breath.

So far there is no vaccine or antibody that kills the virus. The treatments are based on antibodies created to treat the flu and pneumonia. Experimental tests of cocktail antibiotics are also used which act on a case-by-case basis in conjunction with the patient’s physical condition, concomitant illness, and age.

The way of virus actions have triggered a number of questions that I’m sure they will be of concern to you, whether you have been involved or have not found answers Important questions remain unanswered, such questions are:

• The first patient how has been infected by the virus?

• In the country where the virus first appeared, did they allow the sale of animals that had been used as experimental animals before?

• Is allowed  to sell laboratory cloned animals?

• Is it permissible to import from outside of the country laboratory created cloned animals?

• Is there evidence that animals or seafood , have the virus spread or been infected?

• Are there any announcements or publications from government sources about the study, safety and protection against such corona-viruses in the past?

• Does virus analysis show mutations based on the corona-virus structure?

Focusing on time actions of the virus, again causes questions, ranging from 2 to 14 days with an average of 5 days. Sound like the virus have hooks and try to get into the human body. By adding amino acids, a virus that could threaten humans could easily mutate.

Sound like the virus enters the human body, and after it enters, stays there and shows signs of existence after a few days, this could be concealed in such a way to protect itselfto not detected and kill it early before infect the human body, also by this way may hide the exact date of infection, so that the place of infection is not easily detected.

Analyzing the above reminds me a bit of the way HIV works, where after about a week those infected with HIV show flu or simply cold symptoms, then the symptoms subside and the carrier stays asymptomatic for years, spreading ignorant the virus.

Considering all of the above, to behave the way COVID-19 might behave, this virus may be made in the laboratory, as a biological weapon that was either accidentally escaped, or applied as a test under real conditions, or for some purpose, by whom; unknown.People who believe it is a biological weapon could think of two scenarios, the first being a real-life test, and the second being that the virus escaped from a laboratory by accident in an experimental animal or a worker.

Whatever the reality is, I hope very soon all of this will be over and everything will return to normal in our lives.

References

  1. PhD Candidate in Cyber Security (Innovative Knowledge Institute) Paris, France.
  2. Member of Alpha Beta Kappa Honor Society, Alpha of Ohio, USA.

Treatment f organophenolic and organoaromatics from textile wastewater using NiCO2O4 doped Bi2O2CO3 nanocomposite

DOI: 10.31038/NAMS.2020313

Abstract

The textile wastewaters could not be treated effectively with conventional treatment processes due to high polyphenol and aromatic compounds and colour content. In this study, by doping of NiCO2O4 to  Bi2O2CO3 the generated NiCO2O4to Bi2O2CO3nanocomposite was used for the photocatalytic oxidation of COD components (CODtotal, CODdissolved, CODinert), color, organophenols and organoaromatic compounds from a textile industry wastewaters (TW) at different operational conditions such as, at different photooxidation times (5 min, 15 min, 30 min, 60 min, 80 min and 100 min), at diferent NiCO2O4ratios (0.5wt% , 1wt%, 1.5wt%, 2wt%), at different NiCO2O4 / Bi2O2CO3nanocomposite concentrations (1, 5, 15, 30 and 45 mg/L), under 10, 30, 50 and 100 W solar irradiations, respectively. The maximum CODtotal, CODinert, total flavonols, total aromatic amines (TAAs) and color photooxidation yields were 99%, 92%, 91%, 98% and 99% respectively, under the optimized conditions, at 30 mg/L Ni/BiO nanocomposite with a Ni mass ratio of 1.5 wt% under 50 W UV (ultraviolet) light, after 60 min photooxidation time, at 25°C. The photooxidation yields of kaempferol (KPL), quercetin (QEN), patuletin (PTN), rhamnetin (RMN) and rhamnazin (RHAZ) from flavonols and 2-methoxy-5-methylaniline (MMA), 2,4-diaminoanisole(DAA); 4,40-diamino diphenyl ether (DDE), o-aminoazotoluene (OAAT), and 4-aminoazobenzol (AAB) from polyaromatic amines were > 82%.The pollutants of textile industry wastewater were effectively degraded with Ni doped BiO nanocomposite.

Keywords

Flavonols; Nickel cobaltite NiCO2O4 nanocomposite; bismuth subcarbonate (Bi2O2CO3) nanocomposite; Photooxidation; Polyaromatic amines; Ultraviolet (UV) light irradiation.

Biographical notes

Delia Teresa Sponza is a Professor at the Department of Environmental Engineering, Engineering Faculty, Dokuz Eylül University,İzmir, Turkey. She graduated her MSc and PhD degrees from Dokuz Eylül University, Turkey, in Environmental Engineering. Her research interests are environmental microbiology,environmental sciences and toxicity. She has published a number ofresearch papers at the national and international journals.

Rukiye Oztekin is a Researcher at the Department of Environmental Engineering, Engineering Faculty, Dokuz Eylül University, İzmir, Turkey. She graduated her MSc and PhD degrees from Dokuz Eylül University, Turkey, in Environmental Engineering. Her research interestsinclude environmetal sciences and toxic industrial wastewater treatment.

Introduction

Textile industry is one of those industries that consume large amounts of water in the manufacturing process [1] and, also, discharge great amounts of effluents with synthetic dyes to the environment causing public concern and legislation problems. Synthetic dyes that make up the majority (60–70%) of the dyes applied in textile processing industries [2] are considered to be serious health risk factors. Apart from the aesthetic deterioration of water bodies, many colorants and their breakdown products are toxic to aquatic life [3] and can cause harmful effects to humans [4,5]. Several physico-chemical and biological methods for dye removal from wastewater have been investigated [6-8] and seem that each technique faces the facts of technical and economical limitations [7]. The traditional physical, chemical and biologic means of wastewater treatment often have little degradation effect on this kind of pollutants. On the contrary, the technology of nanoparticulate photodegradation has been proved to be effective to them. Compared with the other conventional wastewater treatment means, this technology has such advantages as: (1) wide application, especially to the molecule structure-complexed contaminants which cannot be easily degraded by the traditional methods; (2) the nanoparticles itself have no toxicity to the health of our human livings and (3) it demonstrates a strong destructive power to the pollutants and can mineralize the pollutants into carbondipxide (CO2) and water (H2O) [9].

Bi2O2CO3 has gained much attention due to its promising photocatalytic activity for wastewater treatment [10-12]. Although Bi2O2CO3 has been widely studied in the photocatalytic degradation of wastewater, little attention has been poured to investigate the microwave catalytic performance of Bi2O2CO3 for microwave catalytic oxidation degradation of wastewater, up to now. At the same time, the magnetic NiCO2O4 has intriguing advantages, such as excellent microwave absorption performance, low cost, magnetically separable property, and high stability [13]. To the best of our knowledge, NiCO2O4-Bi2O2CO3 composite as microwave catalyst for degradation o more semiconductor photocatalysts have been found to be capable of photocatalytic degradation of organic macromolecular contaminants in wastewater [14, 15]. Therefore, photocatalytic degradation has become the most environmentally friendly, energy-saving, and efficient water pollution treatment method. In view of the fact that the traditional photocatalysts (such as TiO2) have large band gap energy and low response to visible light, their application is greatly limited. Among these miconducting photocatalysts, bismuth molybdate (Bi2MoO6) as a ternary oxide compound of Aurivillius phase becomes one of the promising materials. This is because it has a unique layered structure sandwiched between the perovskite octahedral (MoO4)2sheets and bismuth oxide layers of (Bi2O2)2+ [16-18]. Its dielectric property, ion conductivity, and catalytic performance have obvious advantages in bismuth-based semiconductors [19, 20]. Nevertheless, the light absorption property of the pure Bi2MoO6 primarily appears in the ultraviolet light region, which is only a small part of the solar spectra. Meanwhile, it presents a high recombination rate of electronhole
pairs in the process of photocatalytic reaction [21]. Therefore, researchers have improved the performance of Bi2MoO6 by means of
morphology controlling, semiconductor compounding, and doping modification [22]. Among these measures, doping has proven to be an effective method to ameliorate the surface properties of photocatalysts and enhance photocatalytic performance.

It was reported that carbon-doped Bi2MoO6 exhibited significantly enhanced and stable photocatalytic properties compared with Bi2MoO6 [23], which carbon replaced the O2anion in the lattice of Bi2MoO6, resulting in lattice expansion and grain diameter reduction, enhancement of specific surface area [24]. prepared Graphene-Bi2MoO6 (G-Bi2MoO6) hybridphotocatalysts by a simple one-step process, and an increase in photocatalytic activity was observed for G-Bi2MoO6 hybrids compared with pure Bi2MoO6 under visible light. Xing et al., (2017) reported the photocatalytic activity of 0.5% Pd–3C/BMO was robustly enhanced about 5-fold for Rhodamine B (RhB) degradation within 40 min under UV + visible light irradiation and 29-fold for O-phenylphenol (OPP) degradation within 120 min under visible light irradiation in comparison with pristine Bi2MoO6, respectively. [25] prepared a B-doped Bi2MoO6 photocatalyst with hydrothermal method by using HBO3 as a dopant source. It was found that B-doping increases the amount of Bi5+ and oxygen vacancies, so that the visible light absorption of catalyst is stronger, and the band gap energy is lower, which significantly improves the photocatalytic activity of Bi2MoO6. [26] successfully synthesized sulfur-doped copper-cobalt bimetal oxide by coprecipitation method, which significantly improved the catalytic performance and stability of the catalyst. [27] fabricated Bi2MoO6 surface co-doped with Ni2+ and Ti4+ ions through an incipient-wetness impregnation technology and calcination method, with the results suggesting Ni2+ and Ti4+ codoping increases visible-light absorption by Bi2MoO6 and promotes the separation of photogenerated charge carriers. Density functional theory calculations and systematical characterization results revealed that Biself-doping could not only promote the separation and transfer of photo generated electron-hole pairs of Bi2MoO6 but also alter the position of valence and conduction band without changing its preferential crystal orientations, morphology, visible light absorption, as well as band gap energy [28, 29] synthesized pure and various contents of Ce3+ doped Bi2MoO6 nano structures by a facile hydrothermal method. The 0.5%Ce3+ doped Bi2MoO6 exhibitsthe best photocatalytic activity of 96.6% within 20 min for RhB removal.

The photocatalytic performance of NiCO2O4-doped Bi2MoO6 nanoparticles has not been investigated extensively for the removals of aromatics and polyphenols from a textile industry. In this work, the phsicochemical properties of NiCO2O4 doped Bi2O2CO3 nanocomposite was investigated using microscope (SEM), transmission electron microscopy (TEM), Fourier transform infrared spectroscopy (FT-IR), X-ray photoelectron spectroscopy (XPS), photoluminescence spectra (PL), N2 adsorption–desorption, elemental mapping, Raman and diffused reflectances pectra (DRS) analysis. The photocatalytic oxidation of pollutant parameters [COD components (CODtotal, CODdissolved, CODinert), flavonols (kaempferol, quercetin, patuletin, rhamnetin and rhamnazin), polyaromatic amines (2-methoxy-5-methylaniline, 2,4-diaminoanisole, 4,40-diamino diphenyl ether, o-aminoazotoluene, and 4-aminoazobenzol) and color] from the TW at different operational conditions such as, at increasing photooxidation times (5 min, 15 min, 30 min, 60 min, 80 min and 100 min), at diferent Ni mass ratios (0.5wt% , 1wt%, 1.5wt%, 2wt%), at different Ni-BiO photocatalyst concentrations (1, 5, 15, 30 and 45 mg/L), at different pH ranges (4, 6, 8, 10) under 10, 30, 50 and 100 W UV light irradiations, respectively, were investigated .

Materials and methods

Raw wastewater

The characterization of raw TW was given in Table 1.

Table 1. Characterization values of TW at pH=5.7 (n=3, mean values ± SD). (SD: standard deviation; n: the repeat number of experiments in this study).

Parameters

Values

Minimum

Medium

Maximum

pH

5.00 ± 0.18

5.27 ± 0.19

6.00 ± 0.21

DO (mg/L)

1.30 ± 0.05

1.40 ± 0.05

1.50 ± 0.05

ORP (mV)

85.00 ± 2.98

106.00 ± 3.71

128.00 ± 4.48

TSS (mg/L)

285.00 ± 9.98

356.00 ± 12.46

430.00 ± 15.05

TVSS (mg/L)

192.00 ± 6.72

240.00 ± 8.40

290.00 ± 10.15

CODtotal (mg/L)

931.70 ± 32.61

1164.60 ± 40.76

1409.20 ± 49.32

CODdissolved (mg/L)

770.40 ± 26.96

962.99 ± 33.71

1165.22 ± 40.78

TOC (mg/L)

462.40 ± 16.18

578.00 ± 20.23

700.00 ± 24.50

BOD5 (mg/L)

251.50 ± 8.80

314.36 ± 11.00

380.38 ± 13.31

BOD5/CODdis

0.26 ± 0.01

0.33 ± 0.012

0.40 ± 0.014

Total N (mg/L)

24.80 ± 0.87

31.00 ± 1.09

37.51 ± 1.31

NH4-N (mg/L)

1.76 ± 0.06

2.20 ± 0.08

2.66 ± 0.09

NO3-N (mg/L)

8.00 ± 0.28

10.00 ± 0.35

12.10 ± 0.42

NO2-N (mg/L)

0.13 ± 0.05

0.16 ± 0.06

0.19 ± 0.07

Total P (mg/L)

8.80 ± 0.31

11.00 ± 0.39

13.30 ± 0.47

PO4-P (mg/L)

6.40 ± 0.22

8.00 ± 0.28

9.68 ± 0.34

SO4-2 (mg/L)

1248.00 ± 43.70

1560.00 ± 54.60

1888.00 ± 66.10

Color (1/m)

70.90 ± 2.48

88.56 ± 3.10

107.20 ± 3.75

Flavonols (mg/L)

30.9 ± 1.08

38.6 ± 1.35

46.1 ± 1.61

Flavonols

Kaempferol

4.2 ± 0.20

5.7 ± 0.2

7.2 ± 0.3

Quercetin

7.3 ± 0.26

9.2 ± 0.32

11.1 ± 0.4

Patuletin

8.3 ± 0.30

10.3 ± 0.36

12.2 ± 0.43

Rhamnetin

6.0 ± 0.21

7.2 ± 0.25

8.4 ± 0.3

Rhamnazin

5.1 ± 0.18

6.15 ± 0.22

7.2 ± 0.25

TAAs (mg benzidine/L)

891.84 ± 31.21

1038 ± 36.33

1183.8 ± 41.43

Polyaromatics

2-methoxy-5-methylaniline

128.5 ± 4.5

134.6 ±  4.71

140.6 ± 4.92

2,4-diaminoanisole

250.2 ± 8.76

275.8 ±  9.7

301.3 ± 10.6

4,40-diamino diphenyl ether

146.54 ± 5.13

156.0 ± 5.5

165.4 ± 5.8

o-aminoazotoluene

265.4 ± 9.3

293.6 ± 10.3

321.7 ± 11.3

4-aminoazobenzol

101.2 ± 3.54

178 ± 6.23

254.8 ± 8.92

Chemical structure of flavonols and poliaromatics present in the TW

The structure of flavonols in the TW was shown in Figure 1. The structure of polyaromatics in the TW was given Figure 2.

NAMS-3-1-305-g001

Figure 1. Chemical structure of flavonoids in the TW.

NAMS-3-1-305-g002

Figure 2. Chemical structure of polyaromatics in the TW

Preparation of photocatalysts

Ni-doped BiO nano particles were prepared by co-precipitation method using nickel nitrate hexahydrate [Ni(NO3)2.6H2O] (Analytical grade, Merck ) and Bismuthnitrate hexahydrate [Bi(NO3)2·6H2O] (Sigma, Aldrich) as the precursors of nickel and bismuth, respectively. Ni(NO3)2.6H2O and sodium carbonate anhydrous (Na2CO3) were dissolved separately in double distilled H2O to obtain 0.5 mol/Lsolutions. Nickel nitrate solution (250 mL of 0.5 mol/L) was slowly added into vigorously stirred 250 mL of 0.5 mol/L Na2CO3 solution. Nickel nitrate in the required stoichiometry was slowly added into the above solution and a white precipitate was obtained. The precipitate was filtered, repeatedly rinsed with distilled H2O and then washed twice with ethanol. The resultant solid product was dried at 100°C for 12 h and calcined at 300°C for 2 h. BiO particles were also prepared by the same procedure without the addition of nickel nitrate solution. The doping Ni mass ratios of Bismuth are expressed as wt%.

X-Ray diffraction (XRD) analysis

XRD patterns of the samples are going to carry out using a D/Max-2400Rigaku X-ray powder diffractometer operated in the reflection mode with Cu Ka (λ = 0.15418 nm) radiation through scan angle (2θ) from 20° to 80°.

Scanning electron microscopy (SEM) analysis

The morphological structures of the Ni-BiO nanocomposites before photocatalytic degradation with UV light irradiations and after photocatalytic degradation with UV by means of a SEM.

Fourier transform infrared spectroscopy (FTIR)analysis

The FTIR spectra of Ni, BiO and Ni-BiO samples were measured with FTIR spectroscopy measurements.

Photocatalytic degradation reactor

A 2 L cylinder kuvars glass reactor was used for the photodegradation experiments in the TW under different UV powers, at different operational conditions. 1000 mL TW was filled for experimental studies and the photocatalyst were added to the cylinder glass reactor. The photocatalytic reaction was operated with constant stirring during the photocatalytic degradation process. 10 mL of the reacting solution were sampled and centrifugated (at 10000 rpm) at different time intervals.

Used chemicals

Ni(NO3)2.6H2O (Analytical Grade, Merck, Germany) and Bi(NO3)3·6H2O (Analytical grade, Merck, Germany) were used as nickel and bismuth sources, respectively. Na2CO3 was purchased from Merck (Analytical grade). Helium, He(g) (GC grade, 99.98%) and nitrogen, N2(g) (GC grade, 99.98%) was purchased from Linde, (Germany). Kaempferol (99%), quercetin (99%), patuletin (99%), rhamnetin (99%), rhamnazin (99%), 2-methoxy-5-methylaniline (99%), 2,4-diaminoanisole (99%), 4,40-diamino diphenyl-ether (99%), o-aminoazotoluene (99%), 4-aminoazobenzol (99%) were purchased from Aldrich, (Germany).

Analytical methods

pH, T(°C), ORP, DO, BOD5, CODtotal, CODdissolved, total suspended solids (TSS), Total-N, NH3-N, NO3-N, NO2N, Total-P and PO4-P measurements were monitored following the Standard Methods 2310, 2320, 2550, 2580, 4500-O, 5210 B, 5220 D, 2540 D, 4500-N, 4500-NH3, 4500-NO3, 4500-NO2 and 4500-P [30]. Inert COD was measured according to glucose comparison method [31]. The samples were analyzed by high pressure liquid chromatography (HPLC) with photodiode array and mass spectrometric detection using an Agilent 1100 high performance liquid chromatography system consisting of an automatic injector, a gradient pump, a Hewlett–Packard series 1100 photodiode array detector, and an Agilent series 1100 VL on-line atmospheric pressure ionization electrospray ionization mass spectrometer to detect flavonols namely kaempferol, quercetin, patuletin, rhamnetin, rhamnazin and polyaromatics namely, 2-methoxy-5-methylaniline, 2,4-diaminoanisole, 4,40-diamino diphenyl-ether, o-aminoazotoluene, 4-aminoazobenzol, respectively. All the  metabolites were measured in the same HPLC by mass spectrometric detections. Operation of the system and data analysis were done using ChemStation software, and detection was generally done in the negative ion [M − H]– mode, which gave less complex spectra, although the positive ion mode was sometimes used to reveal fragmentation patterns—especially patterns of sugar attachment. Separation of flavonol components was made on a Vydac C18 reversed phase column (2.1 μm dia. × 250 mm long; 5-μm particle size). Columns were eluted with acetonitrile-water gradients containing 0.1% formic acid in both solvents. The quality of the raw (un-treated) and photooxidated wastewater were determined by measuring the absorbances of the supernatans at wavelengths varying between 200 nm, 250 nm, 300 nm, 350 nm and 540 nmusing an Aquamate Termoelectron Corporation UV-vis spectrophotometer.

Measurement of photonic efficiency (lr) of Ni doped BiO

The relative photonic efficiency of the catalyst is obtained by comparing the photonic efficiency of Ni-doped BiO with that of the standard photocatalyst (BiO). In order to evaluate lr, a solution of 1-Methylcyclopropene-MCP (40 mg/L) with a pH of 10 was irradiated with 100 mg of BiO and Ni-doped BiO for 60 min. From the degradation results, Ir was calculated as follows (Eq. 1).

NAMS-3-1-305-e001

Operational conditions

Under 10-30-50 and 100 W  UV light powers the photocatalytic oxidation of the pollutant parameters in the TW at different operational conditions such as at increasing Ni mass ratios in the Ni-BiOnanocomposite(0.5wt% , 1wt%, 1.5wt%, 2wt%), at increasing photooxidation times (5 min, 15 min, 30, 60 min, 80 min and 100 min), at different Ni-BiOphotocatalyst concentrations (1, 5, 15, 30 and 45 mg/L), under acidic, neutral and basic conditions, respectively.

All the experiments were carried out following the batch-wise procedure. All experiments were carried out three times and the results were given as the means of triplicate sampling with standard deviation (SD) values.

Results and analysis

XRD Analysis results

The powder XRD patterns of BiO and Ni-doped BiO with different lanthanum mass ratios are shown in Figure 3. The XRD patterns of all the Ni-doped BiO catalysts are almost similar to that of BiO, suggesting that there is no change in the crystal structure upon Ni loading. This also indicates that Ni+2 is uniformly dispersed on BiO nanoparticles in the form of small Ni2O2 cluster. However the Ni-doped samples have a wider and lower intense diffraction peaks than pure BiO. Moreover, the XRD peaks of Ni-doped BiO continuously get broader with increasing the Ni loading up to a mass ratio of 2%wt.

NAMS-3-1-305-g003

Figure 3. XRD patterns of BiO and Ni doped BiO (a) pure BiO, (b) 2 wt% Ni doped BiO, (c) 0.5wt% Ni doped BiO, (d) 1.0wt% Ni doped BiO, and (e) 1.5wt% Ni doped BiO.

SEM Analysis results

The morphology of nanocomposite particles is analyzed by SEM. Figure 4 shows that the nanocomposite material is partly composed of clusters containing composite nanoparticles adhering to each other with a mean size of around 20-80 nm before photooxidation process (Figure 4a) while the size increased to 24-86 nm after photooxidation (Figure 4b) with intermediates and remaining not photodegraded pollutants.

NAMS-3-1-305-g004

Figure 4. SEM micrographs of pure and nickel modified BiO, (a) pure BiO at 25°C, (b) Ni doped BiO at 25°C.

FTIR Analysis results

Figure 5 shows the FTIR spectrum of BiO and Ni-doped BiO, BiO powder synthesized under laboratory conditions. The peak between 400 and 700 cm-1 give the information of Bi–O and Ni–Bi–O on the FTIR spectra. The peak at 437–455 cm-1 give the information about stretching vibration of crystalline hexagonal zinc oxide (Bi–O stretching, vibration) and the peaks from 902 to 1020 cm-1 are attributed to the bond between lanthanum and oxygen (Ni–O). The broad peak between 3400 to 3900 cm-1 indicate the OH groups, due to the H2O which indicates the existence of atmospheric H2O adsorbed on the surface of nanocrystalline powder. An absorption band and a peak have been observed at 2350 cm-1, respectively, which arises from the absorption of atmospheric CO2 on the metal cations.

NAMS-3-1-305-g005

Figure 5. FTIR Spectra of pure BiO and Ni-doped BiO nanoparticles, with different concentration of dopant

Results and Discussions

Effect of increasing Ni-BiOnanocomposite concentrations on the removals of TW pollutants

The effects of increasing Ni-BiO nanocomposite concentrations (1 mg/L, 5 mg/L, 15 mg/L, 30 mg/L and 45 mg/L), on the photocatalytic oxidation of polutant parameters in the TW was investigated. The preliminary studies showed that the maximum removal of COD with 20 mg/L Ni-BiO nanocomposite was 89% with 70 min photooxidation time at pH=7.8 with 40 W UV power (Data not shown). Based on these yields the operational conditions for photocatalytic time were choosen as 60 min at a power of 50 W and at a pH of 8. The maximum photocatalytic oxidation removals for all pollutants in the TW were observed at 30 mg/L Ni-BiO nanocomposite concentrations, at pH=8.0, after 60 min photooxidation time and at 25°C at a power of 50 W (Figure 6). Removal efficiencies slightly decreased at 45 mg/L Ni-BiO nanocomposite concentration, because over load of surface area of Ni-BiO nanocomposites (Figure 6). This limiting the power of UV irradiation. Lower photo-removal efficiencies was measured for 1, 5, and 15 mg/L Ni-BiO concentrations due to low surface areas in the nanocomposite. On the contrarily, the surface area is high at 30 mg/L Ni-BiO nanocomposite concentrations. Therefore, the maximum photodegradation yield was observed in this nanocomposite concentration. The CODtotal, CODinert, total flavonols, total aromatic amines and color removals increased linearly as the Ni-BiO nanocomposite concentrations were increased from 1 mg/L up to 5 mg/L, to 15 mg/L, and up to 30 mg/L, respectively (Table 2 and Figure 6). Furher increase of nanocomposite concentration to 45 mg/L affect negatively the all the pollutant yields. The reason for this is the optimum amount of catalyst increases the number of active sites on the photocatalyst surface, which in turn increase the number of OH and superoxide radicals (O2 ●) to degrade pollutant parameters (COD components, flavonols, polyaromatics, color). When the concentration of the catalyst increases above the optimum value, the degradation decreases due to the interception of the light by the suspension [32]. reported that as the excess catalyst (turbidity) prevent the illumination of light, OH, a primary oxidant in the photocatalytic system decreased and the efficiency of the degradation reduced accordingly. Furthermore, the increase in catalyst concentration beyond the optimum may result in the agglomeration of catalyst particles; hence, the part of the catalyst surface becomes unavailable for photon absorption, and thereby, photocatalytic oxidation efficiency decreases [33]. Maximum CODtotal, CODinert, total flavonols, TAAs and color removal efficiencies were obtained after 60 min photooxidation process with yields of 99%, 92%, 91%, 98% and 99%, respectively, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W power and at 25°C (Figure 6). Flavonols such as kaempferol, quercetin, patuletin, rhamnetin, rhamnazin removal efficiencies were 87%, 88%, 90%, 87% and 85% respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration and at 25°C temperature (Table 2). Polyaromatic amines such as, 2-methoxy-5-methylaniline, 2,4-diaminoanisole, 4,40-diamino diphenyl ether, o-aminoazotoluene, 4-aminoazobenzol removal efficiencies after photooxidation process were 93%, 95%, 87%, 84% and 82%, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 2).

NAMS-3-1-305-g006

Figure 6. Removal efficiencies of CODtotal, CODinert, total flavonols and TAAs at Ni-BiO=1 mg/L, BiO=5 mg/L, BiO=15 mg/L and BiO=30 mg/L.

Table 2. Effect of increasing Ni-BiO nanocomposite concentrations on the TW during photooxidation process after 60 min, at 50 W UV irradiation, at pH=8.0, at 25°C.

Parameters

Removal efficiencies (%)

Ni-BiO concentrations (mg/L)

1
mg/L

5
mg/L

15
mg/L

30
mg/L

45
mg/L

CODtotal

51

65

84

99

79

CODinert

45

63

78

92

76

CODdissolved

50

64

82

98

80

Color

62

69

85

99

83

Total flavonols

40

58

79

91

72

Flavonols

Kaempferol

35

57

72

87

65

Quercetin

36

61

73

88

67

Patuletin

37

62

79

90

74

Rhamnetin

38

56

72

87

64

Rhamnazin

34

53

71

85

66

TAAs

58

75

81

98

77

Polyaromatics

2-methoxy-5-methylaniline

55

66

83

93

79

2,4-diaminoanisole

54

71

79

95

73

4,40-diamino diphenyl ether

52

58

68

87

63

o-aminoazotoluene

49

65

75

84

72

4-aminoazobenzol

47

62

76

82

70

Kaempferol metabolies such as, 3-O-[2-O,6-O-bis(α-L-rhamnosyl)-( β-D-glucosyl] quercetin, 3-O-[6-O-(α-L -rhamnosyl)-( β-D-  glucosyl]quercetin, 3-O-{2-O-[6-O-(p-hydroxy-trans-cinnamoyl)-{ )-, β-D-glucosyl]- á-L-rhamnosyl}kaempferol decreased from 5.7 mg/L to 0.86 mg/L, from 5.7 mg/L to 1.08 mg/L, from 5.7 mg/L to 1.25 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 3). Quercetin metabolites such as, 3-O-[6-O-( α-L -rhamnosyl)- )-(β-D-glucosyl]quercetin, 3-O-{2-O-[6-O-(p-hydroxy-trans-cinnamoyl)-( β-D -glucosyl]– á-L-rhamnosyl}quercetin reduced from 9.2 mg/L to 1.28 mg/L, from 9.2 mg/L to 2.30 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 3). Patuletin metabolites such as, (E)-ascladiol, (Z)-ascladiol dropped off from 10.3 mg/L to 1.55 mg/L, from 10.3 mg/L to 1.85, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 3). Rhamnetin metabolites such as, methyl quercetin, tetrahydroxy-7-methoxyflavone decreased from 7.2 mg/L to 1.15 mg/L, from 7.2 mg/L to 1.44 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 3). Rhamnazin metabolites such as, Rhamnazin-3-0-β-D-glucopyranosyl-(l →5)- α-L-arabinofuranoside, Rhamnazin-3-O-β-D- glucopyranosyl-(l—»5)-[β-D-apiofuranosyl-(-1→2)]-α -L-arabinofuranoside reduced from 6.5 mg/L to 1.42 mg/L, from 6.5 mg/L to 1.66 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 3).

Table 3. The metabolites of flavonols in the TW.

Flavonoids

Flavonoids metabolites

Influent concentrations (mg/L)

Effluent Concentrations (mg/L)

Removal efficiencies (%)

Kaempferol

3-O-[2-O,6-O-bis(α-L-rhamnosyl)-( ß-D-glucosyl]-quercetin

5.7

0.86

85

3-O-[6-O-(α-L -rhamnosyl)-( ß-D-  glucosyl]quercetin

5.7

1.08

81

3-O-{2-O-[6-O-(p-hydroxy-trans-cinnamoyl)-{ )-, ß-D-glucosyl]- á-L-rhamnosyl}kaempferol

5.7

1.25

78

Quercetin

3-O-[6-O-(α-L -rhamnosyl)- )-( ß-D-glucosyl]quercetin

9.2

1.28

86

3-O-{2-O-[6-O-(p-hydroxy-trans-cinnamoyl)-( ß-D -glucosyl]– á-L-rhamnosyl}quercetin

9.2

2.30

75

Patuletin

(E)-ascladiol

10.3

1.55

85

(Z)-ascladiol

10.3

1.85

82

Rhamnetin

Methyl quercetin

7.2

1.15

84

Tetrahydroxy-7-methoxyflavone

7.2

1.44

80

Rhamnazin

Rhamnazin-3-0-ß-D-glucopyranosyl-(l →5)-α-L-
arabinofuranoside

6.15

1.42

77

Rhamnazin-3-O-ß-D- glucopyranosyl-(l—»5)-[ß-D-apiofuranosyl-(-1→2)]-α -L-arabinofuranoside

6.15

1.66

73

2-methoxy-5-methylaniline metabolite such as, 5-nitro-o-toluidine decreased from 134.6 mg/L to 36.34, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 4). 2,4-diaminoanisole such as, 4-acetylamino-2-aminoanisole, 2,4-diacetylaminoanisole reduced from 275.8 mg/L to 22.06 mg/L, from 275.8 mg/L to 38.61 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 4). 4,40-diamino diphenyl ether metabolites such as, N,NI-diacetyl-4,4I-diaminobenzhydrol, N,NI-diacetyl-4,4 I –diaminophenylmethane dropped off from 156 mg/L to 28.08 mg/L, from 156 mg/L to 40.56 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 4). o-aminoazotoluene metabolites such as, hydroxy-OAT (I), 4′-hydroxy-OAAT,  2′-hydroxymethyl-3-methyl-4-aminoazobenzene, 4, 4′-bis(otolylazo)-2, 2′ -dimethylazoxybenzene decreased from 293.6 mg/L to 58.72 mg/L, from 293.6 mg/L to 79.27 mg/L, from 293.6 mg/L to 85.14 mg/L, from 293.6 mg/L to 117.44 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L La-ZnO nanocomposite concentration at 50 W  UV power and at 25°C (Table 4). 4-aminoazobenzol metabolites such as phenylhydroxylamine, nitrosobenzol reduced from 178 mg/L to 39.16 mg/L, from 178 mg/L to 44.5 mg/L, respectively, after 60 min photooxidation time, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power and at 25°C (Table 4).

Table 4. The metabolites of polyaromatic amines in the TW.

Polyaromatic amines

Polyaromatic amines metabolites

Influent concentrations (mg/L)

Effluent Concentrations (mg/L)

Removal efficiencies (%)

2-methoxy-5-methylaniline

5-nitro-o-toluidine

134.6

36.34

87

2,4-diaminoanisole

4-acetylamino-2-aminoanisole

275.8

22.06

92

2,4-diacetylaminoanisole

275.8

38.61

86

4,40-diamino diphenyl ether

N,NI-diacetyl-4,4I-diaminobenzhydrol

156

28.08

82

N,NI-diacetyl-4,4 I -diaminophenylmethane

156

40.56

74

o-aminoazotoluene

hydroxy-OAT (I)

293.6

58.72

80

4′ -hydroxy-OAAT

293.6

79.27

73

2′ -hydroxymethyl-3-methyl-4-aminoazobenzene

293.6

85.14

71

4, 4′-bis(otolylazo)-2, 2′ -dimethylazoxybenzene

293.6

117.44

60

4-aminoazobenzol

Phenylhydroxylamine

178

39.16

78

Nitrosobenzol

178

44.5

75

[34] researched the photocatalytic activity of pure and Ni+2-doped BiO samples for the degradation of Rhodamine B (RhB). The effect of Ni+2 doping concentration on the photocatalytic activity of RhB wasalso investigated. 9 g/L Ni+2-doped BiO with a mass ratio of 2wt% had high photocatalytic efficiency [34]. 4-nitrophenol degradation was studied in the presence of Ni doped BiO nanoparticles with a Ni mass ratio of 4% [35]. 78.26% 4-nitrophenol removal was observed the aforementioned nanocomposite after 195 min photodegradation time and at 30 W  UV light irradiation at pH=8 [35]. 68.57% Acid Yellow 29 55% Coomassie Brilliant Blue G250 and 37.27% Acid Green 25 degradations was obtained after 120 min of irradiation in the presence of 0.9% Ni-doped BiO, at 500 W UV light irradiation, under atmospheric oxygen, at 25°C, respectively [36]. The color and pollutant yields obtained in our study exhibited higher yields compared to the studies given above with low Ni-BiO nanocomposite concentrations.

Effect of increasing Ni mass ratios on 30 mg/L Ni doped BiO nanocomposite for photodegradation of TW pollutants

Were researched the effects of different La mass ratios (0.5wt%, 1wt%, 1.5wt% and 2wt% ) in 30 mg/L Ni-BiO nanocomposite concentrations on the photooxidation yields of all pollutants in the TW during photooxidation experiments. Maximum CODtotal, CODinert, total flavonols, TAAs and color removal efficiencies were 99%, 92%, 91%, 98% and 99%, respectively, after 60 min photooxidation time, at pH=8.0, at 1.5wt% Ni mass ratio and at 25°C (Table 5 and Figure 7). Removal efficiencies increased as the Ni mass ratio in the Ni doped BiO nanocomposite were increased from 0.5wt% to 1wt% and to 1.5wt%. Maximum removal efficiencies was measured at 1.5wt% Ni mass ratio in the nanocomposite. The photocatalytic degradation efficiency of BiO nanoparticles increases with an increase in the Ni loading and shows a maximum activity at 1.5 wt%. Then decreases in photooxidation yield was observed on further Ni doping (to 2 wt%). The reason of this can be explained as follows: excessive amounts of dopants can retard the photocatalysis process, because excess amount of dopants deposited on the surface of BiO increases the recombination rate of free electrons and energized holes, thus inhibiting the photodegradation process. Hence, further increase in Ni doping to 2wt% results in the decrease of photocatalytic degradation efficiency.

Table 5. Effect of increasing Ni mass ratios on the TW during photooxidation process after 60 min, at 50 W UV irradiation, 30 mg/L Ni-BiO nanocomposite concentrations, at pH=8.0, at 25°C.

 

Parameters

Removal efficiencies (%)

Ni mass ratios (%)

0.5wt%

1wt%

1.5wt%

2wt%

CODtotal

46

71

99

80

CODinert

40

69

92

74

CODdissolved

45

70

98

78

Color

57

76

99

81

Total flavonols

35

64

91

75

Flavonols

Kaempferol

30

63

87

68

Quercetin

31

67

88

69

Patuletin

32

68

90

75

Rhamnetin

33

62

87

68

Rhamnazin

30

60

85

67

TAAs

53

81

98

77

Polyaromatics

2-methoxy-5-methylaniline

50

72

93

69

2,4-diaminoanisole

49

77

95

75

4,40-diamino diphenyl ether

47

64

87

64

o-aminoazotoluene

44

71

84

70

4-aminoazobenzol

41

70

82

66

NAMS-3-1-305-g007

Figure 7. Removal efficiencies of CODtotal, CODinert, total flavonols and TAAs at 0.5wt%, 1wt%, 1.5wt%, and 2 wt% Ni mass ratio.

The synthesized Ni-doped BiO catalyst possesses smaller particle size distribution than pure BiO nanoparticles. Apart from their small size, as Ni+2 was doped in BiO, more surface defects are produced as reported by [37]. Consequently, the migration of the photo-induced electrons and holes toward surface defects is reasonable [37]. Thus, the separation efficiency of the electron–hole pairs of Ni-doped BiO with more oxygen defects should be more than that of the pure BiO nanoparticles. Therefore, the enhancement in the photocatalytic degradation efficiency of Ni doping BiO increases due to small particle size and higher defect concentration compared to BiO alone.

UV absorbances of Ni-doped BiO

The UV–vis absorption spectra of BiO and Ni-doped BiO are shown in Figure 8. It can be clearly seen from Figure 8. The maximum absorbance shifts is 410 nm for pure nano BiO while the maximum absorbance of Ni-doped BiO with a Ni mass ratio 0.5wt% is observed at a wavelentgh of 380 nm. The wave of absorbance of Ni-doped BiO also increases gradually with increasing the Ni loading and is much higher as compared to that of pure BiO. This could be mainly attributed to the quantum size effect as well as the strong interaction between the surface oxides of Bi and Ni. These observations strongly suggest that the Ni doping significantly affects the absorbance properties.

NAMS-3-1-305-g008

Figure 8. UV-vis absorption spectra of Ni doped BiO catalysts

The strong UV band gap emission (375–395 nm) results from the radiative recombination of an excited electron in the conduction band with the valence band hole. The broad visible or deep-trap state emissions (410–440 nm and 540–580 nm) are commonly defined as the recombination of the electron-hole pair from localized states with energy levels deep in the band gap, resulting in lower energy emission. These deep-trap emissions indicate the presence of defects or oxygen vacancies of BiO nanostructures [38]. Since the band gap excitation of electrons in BiO or Ni-doped BiO with 254 nm can promote electrons to the conduction band with high kinetic energy, they can reach the solid-liquid interface easily, suppressing electron–hole recombination in comparison with 365 nm. Hence, the observation of low rate at 254 nm is therefore unexpected [39]. The UV band gap emission of Ni-doped BiO nanostructures was increased between 380 and 410 nm after the photocatalytic process of pollutant parameters. The results show that 1.5 wt% Ni-doped BiO has maximum activity as compared to other photocatalysts.

Effect of increasing photooxidation time on the photooxidation yields of pollutants in the TW

Six different photooxidation times (5 min, 15 min, 30 min, 60 min, 80 min and 100 min) was examined during photocatalytic oxidation of the pollutants in the TW. To determine the optimum time for maximum removals these pollutant parameters in the TW. The maximum photocatalytic oxidation removals was observed at 60 min photooxidation time, at pH=8.0 using 30 mg/L Ni doped BiO with a La mass ratio of 1.5wt% at an UV power of 50 W (Figure 9). The removals of CODtotal, CODinert, total flavonols, total aromatic amines and color were found to increase linearly with increase in retention time from 5 min up to 80 min. A further increase in retention time to and 100 min lead to a decrease in yields of pollutant parameters. In other words the removal efficiencies of pollutant parameters (COD components, flavonols, polyaromatics, color) decreased for photooxidation time > 60 min since at long irradiation times since the surface energy of Ni doped – BiO decreases [40]. The photooxidation can form small molecules such as H2O, carbonmonoxide (CO), CO2 and benzene etc. after long irradiation; it will lead to the decrease of the polar groups and the oxygen content of pollutant surface. The dispersive component of surface energy, the density of polymer surface has great influence on dispersivity of pollutants in the TW. However, the rate of photodegradation of Ni doped-BiO blends increases with the increase of irradiation time, and is higher than that of photocrosslinking after long irradiation time, leading to the decrease of the density of the polymer surface and the dispersivity of COD, dyes and other pollutants to Ni doped–BiO [41]. The photooxidation can form small molecules such as H2O, CO, CO2 and benzene etc. after long irradiation; it will lead to the decrease of the polar groups and the oxygen content of polymer surface, therefore the dispersivity decreaeses resulting in low photooxidation yields [41]. Aromatic and phenolic metabolites which would adsorb strongly onto titania surface and block significant part of photoreactive sites.

NAMS-3-1-305-g009

Figure 9. Removal efficiencies of CODtotal, CODinert total flavonols and TAAs after 5, 15, 30, 60, 80 and 100 min retention times.

The maximum CODtotal, CODinert, total flavonols, total aromatic amines and color removal efficiencies were 99%, 92%, 91%, 98% and 99%, respectively, after 60 min photooxidation time, at 1.5 wt% Ni mass ratio in 30 mg/L Ni-BiO nanocomposite concentration, at pH=8.0 and at 25°C under 50 W irradiation (Table 6). Also, flavonols such as kaempferol, quercetin, patuletin, rhamnetin, rhamnazin removal efficiencies were 87%, 88%, 90%, 87% and 85%, respectively (Table 6). The photooxidation removals of polyaromatic amines such as, 2-methoxy-5-methylaniline, 2.4-diaminoanisole, 4.40-diamino diphenyl ether, o-aminoazotoluene, 4-aminoazobenzol were 93%, 95%, 87%, 84% and 82%, respectively, after 60 min at pH=8.0 and at 25°C (Table 6). Kaempferol, quercetin, patuletin, rhamnetin, rhamnazin concentrations decreased from 5.7 to 0.741 mg/L, from 9.2 to 1.104 mg/L, from 10.3 to 1.03 mg/L, from 7.2 to 0.936 mg/L, from 6.15 to 0.923 mg/L, respectively. 2-methoxy-5-methylaniline, 2.4-diaminoanisole, 4.40-diamino diphenyl ether, o-aminoazotoluene, 4-aminoazobenzol concentrations decreased from 134.6 to 9.422 mg/L, from 275.8 to 13.79 mg/L, from 156 to 5.46 mg/L, from 293.6 to 10.28, from 178 to 6.23 mg/L, respectively.

Table 6. Effect of increasing photooxidation time on the TW during photooxidation process, at 50 W UV irradiation, at pH=8.0, 30 mg/L Ni-BiO nanocomposite concentrations, 1.5 wt% Ni mass ratio, at 25°C.

 

Parameters

Removal efficiencies (%)

5
min

15 min

30
min

60
min

80
min

100 min

CODtotal

56

69

87

99

99

99

CODinert

50

67

81

92

92

92

CODdissolved

55

68

85

98

98

98

Color

67

74

88

99

99

99

Total flavonols

45

63

82

91

91

91

Flavonols

Kaempferol

40

61

75

87

86

86

Quercetin

41

65

77

88

86

85

Patuletin

41

66

81

90

89

89

Rhamnetin

43

61

74

87

85

84

Rhamnazin

39

58

72

85

84

84

TAAs

63

78

84

98

98

98

Polyaromatics

2-methoxy-5-methylaniline

60

71

86

93

93

92

2,4-diaminoanisole

59

75

82

95

94

94

4,40-diamino diphenyl ether

57

62

71

87

79

78

o-aminoazotoluene

55

69

78

84

82

80

4-aminoazobenzol

51

62

75

82

81

79

The color yields obtained in this study for TW are higher than the studies given below: [42] investigated the effects of Bi0.95Ni0.05O and Bi0.90Ni0.10O on the treatment of Methylene Blue (MB) dyestuff removal under 18 UV irradiation for 1 h. 81% color yields were observed for the aforementioned Ni-Bi-O nanocomposites, respectively [42]. [43] found 80% color yields based on Reactive Black 5 after 60 min irradiation time under 90 W irradiation using Bi-Ni nanocomposite.

Effect of increasing UV powers on the yields of pollutants in the TW

In this study, four UV light powers were used (10 W, 30 W, 50 W and 100 W) to detect the optimum UV irradiation power for maximum photo-removal of the pollutant parameters in the TW using 30 mg/L Ni doped BiO nanocomposite with a Ni mass ratio of 1,5%w. The maximum photocatalytic oxidation removals was observed at 50 W  UV light irradiation, at pH=8.0, after 30 min photooxidation time and at 25°C (Table 7 and Figure 10). The CODtotal, CODinert total flavonols, total aromatic amines and color were found to increase linearly with increase in UV light irradiation from 10 W, up to 30 W, up to 50 W, respectively (Table 7 and Figure 10). Further increase of UV power up to 100 W did not affect positively the pollutant yields. Maximum CODtotal, CODinert, total flavonols, TAAs and color removal efficiencies after photooxidation process were 99%, 92%, 91%, 98% and 99%, respectively, for the aforementioned operational conditions (Figure 10). Flavonols such as kaempferol, quercetin, patuletin, rhamnetin, rhamnazin removal efficiencies were 87%, 88%, 90%, 87% and 85%, respectively, after 60 min photooxidation time, at 50 W  UV light, at pH=8.0, at 30 mg/L Ni-BiO nanocomposite concentration and at 25°C (Table 7). Polyaromatic amines such as, 2-methoxy-5-methylaniline, 2, 4-diaminoanisole, 4, 40-diamino diphenyl ether, o-aminoazotoluene, 4-aminoazobenzol removal efficiencies after photooxidation process were 93%, 95%, 87%, 84% and 82%, respectively (Table 7).

Table 7. Effect of increasing UV light irradiations on the TW during photooxidation process after 60 min, at 30 mg/L Ni-BiO photocatalyst concentration, at pH=8.0, at 25°C.

Parameters

Removal efficiencies (%)

UV light irradiation

10 W

30 W

50 W

100 W

CODtotal

49

82

99

97

CODinert

43

76

92

90

CODdissolved

48

81

98

96

Color

60

83

99

99

Total flavonols

38

76

91

90

Flavonols

Kaempferol

33

70

87

87

Quercetin

34

71

88

86

Patuletin

35

78

90

89

Rhamnetin

36

70

87

87

Rhamnazin

33

71

85

85

TAAs

56

79

98

96

Polyaromatics

2-methoxy-5-methylaniline

53

81

93

92

2,4-diaminoanisole

52

77

95

93

4,40-diamino diphenyl ether

50

66

87

86

o-aminoazotoluene

47

73

84

81

4-aminoazobenzol

45

71

82

80

NAMS-3-1-305-g010

Figure 10. Removal efficiencies of CODtotal, CODinert, total flavonols and TAAs at 10 W, 30 W, 50 W and at 100 W.

The UV power determines the extent of light absorption by the semiconductor catalyst at a given wavelength. During initiation of photocatalysis, electron–hole formation in the photochemical reaction is strongly dependent on the optimum light intensity [44]. In this study, as the UV power increase from 10 W up to 50 W might favor a high-level surface defects, which account for the increase in the defect emission relative to the UV emission as reported by [39]. Higher UV powers > 50 W decrease the defects in the surface of the nanoparticle by disturbing the active holes.

Effect of increasing pH values on the pollutant yields in the TW

The effects of increasing pH values (4.0, 6.0, 8.0 and 10.0) on the photocatalytic oxidation of polutant parameters in TW was examined by considering the solubility of BiO nanoparticles in acidic as well as in highly basic solutions. The maximum photocatalytic oxidation removals was obtained at pH=8.0, after 60 min photooxidation time with a Ni mass ratio 1.5wt% using 30 mg/L Ni-BiO nanocomposite concentration at 50 W  UV power (Table 8 and Figure 11). In acidic medium, less photocatalytic degradation of pollutant parameters (COD components, flavonols, polyaromatics, color) was observed. The extent of photocatalytic degradation of polutant parameters was found to increase with increase in initial pH to 8.0 and a decrease in maximum photocatalytic degradation was found at pH 10. The possible explanation of this is that the pH at zero point charge (zpc) of BiO is 9.0 ± 0.3 [45]. Below pH 8.0, active sites on the positively charged catalyst surface are preferentially covered by pollutant molecules. Thus, surface concentration of the polutant parameters (COD components, flavonols, polyaromatics, color) is relatively high, while those of OH and OH are low. Hence, photocatalytic degradation decreases at acidic pH. On the other hand, above pH 8.0, catalyst surface is negatively charged by means of metal-bound OH, consequently the surface concentration of the polutant parameters (COD components, flavonols, polyaromatics, color) is low, and OH is high. In addition, polutant parameters are not protonated above pH 8.0. The electrostatic repulsion between the surface charges and Ni doped BiO nanocomposite hinders the amount of polutant parameters and the adsorption, consequently surface concentration of the polutant parameters decreases, which results in the decrease of photocatalytic degradation at pH 10.0. In conclusion, pH 8.0 can provide moderate surface concentration of polutant parameters which react with the holes to form OH.

Table 8. Effect of increasing pH values on the TW during photooxidation process, at 50 W UV irradiation, after 60 min, at 25°C.

 

Parameters

Removal efficiencies (%)

pH values

pH=4.0

pH=6.0

pH=8.0

pH=10.0

CODtotal

53

74

99

72

CODinert

47

72

92

70

CODdissolved

52

73

98

71

Color

64

79

99

77

Total flavonols

42

68

91

66

Flavonols

Kaempferol

37

66

87

64

Quercetin

38

70

88

68

Patuletin

39

71

90

69

Rhamnetin

40

66

87

64

Rhamnazin

45

62

85

60

TAAs

60

83

98

81

Polyaromatics

2-methoxy-5-methylaniline

57

76

93

74

2,4-diaminoanisole

56

80

95

78

4,40-diamino diphenyl ether

54

67

87

65

o-aminoazotoluene

52

74

84

72

4-aminoazobenzol

50

65

82

63

NAMS-3-1-305-g011

Figure 11. Removal efficiencies of CODtotal, CODinert, total flavonols and TAAs at pH=4.0, pH=6.0, pH=8.0, pH=10.0.

Photocatalytic oxidation mechanisms of Ni doped BiOnanocomposite

The higher activity of Ni doped BiO can beattributed to successful e–h+ separation and production of ●O2 and OH. Ni-modified BiO sample manifests the highest efficiency, which may be explained by the highest number of O2 vacancies (related to the different charge and electronegativity of Ni and Bi ions) and as a result of stronger adsorption of OHions onto the BiO surface [46]. This favors the formation of OH by reaction of hole and OH. The OH and photogenerated ●O2has extremely strong non-selective oxidants lead to the degradation of the organic pollutant at the surface of Ni modified BiO [41]. The photocatalytic degradation mechanism starts with the illumination of BiO nanoparticles and production of electron–hole pairs in Eq. (2):

NAMS-3-1-305-e002

Major roles of metal ions in this study are to increase the concentration of BiO on the surface of the catalyst and to prolong the individual life-time of electrons and holes and hence, inhibit their recombination. The ability of Ni+3 to scavenge photogenerated electrons is as follows: (Eq. 3):

NAMS-3-1-305-e003

However, stabilities of Ni+3 ions may be disturbed in their reduced forms (Ni+2). This can be achieved by transferring the trapped electron to O2 [Eq. (4)]:

NAMS-3-1-305-e004

The produced O2● is responsible from the generation of OH, known as highly reactive electrophilic oxidants [Eqs. (5-7)]:

NAMS-3-1-305-e005-6-7

In the meantime, photogenerated holes may react with H2O molecules and produce OH (Eq. 8):

NAMS-3-1-305-e008

The color removal by photooxidation of dyes reactions were given in Eqs (9-14):

NAMS-3-1-305-e009-14

Thus, loading of metal ions such as Ni on the surface of BiO matrix can suppress the recombination of photoinduced charge carriers either with only electron capture ability or with steps forward to produce OH. For Ni–BiO, electron accepting ability, production of more OH, the highest surface roughness value and the higher dark adsorption capacity result in pronounced photoactivity. The decay profile of the products includes the subsequent attacks of OH, known as highly reactive electrophilic oxidants. The main reaction pathway (60% of OH) is the addition of the OH to the double bond of the azo group, resulting in the rapid disappearance of color; however, addition to the aromatic ring also occurs (40% of OH) [47, 48]. Further OH attacks and the increment in OH concentration in the solution increase the yield of OHadduct in the degradation progress of each product. The opening of the dye aromatic rings due to consecutive oxidation reactions leads to low-molecular weight compounds [49].

Photonic efficiency of Ni doped BiO

In order to evaluate the relative photonic efficiency (Ir), a solution of MCP (40 mg/L) adjusted to pH 10 was irradiated with 100 mg BiO (Merck) and Ni-doped BiO, separately. The relative photonic efficiencies of light of wavelengths 254 and 365 nm for BiO and Ni-doped BiO are presented in Table 9. For comparison, the relative photonic efficiency of TiO2 is also presented in Table 9. The relative photonic efficiencies of Ni-doped BiO are greater as compared to those of BiO and TiO2, revealing the effectiveness of metal-doped systems. It is also interesting to note that the relative photonic efficiency for Ni-doped BiO for light of wavelength 254 nm are much higher as compared to that for 365 nm. The results are in good agreement with degradation and mineralization studies. Comparing the high efficiency of Ni doped BiO catalysts with standard BiO and TiO2 catalyst, the photocatalytic efficiency of 1.5 wt% Ni-doped BiO is higher as compared to that of BiO and TiO2 and other Ni doped BiO nanacomposites.

Table 9. Comparison of relative photonic efficiencies in the photodegradation of pollutants in TW by BiO and Ni-doped BiO photocatalysts (*)

 

Parameters

Relative photonic efficiency (Ir)

256 nm

370 nm

Pure BiO

1.01 ± 0.001

0.79 ± 0.01

0.1wt% Ni–BiO

1.09 ± 0.01

0.93 ± 0.01

0.5 wt% Ni–BiO

1.28 ± 0.02

0.94 ± 0.01

1.0wt% Ni–BiO

2.59 ± 0.01

2.22 ± 0.01

1.5wt% Ni–BiO

2.98 ± 0.01

2.25 ± 0.01

2wt% Ni–BiO

1.02± 0.01

1.98 ± 0.01

Commercial BiO

1.02 ± 0.01

1.02 ± 0.01

TiO2

1.38 ± 0.01

1.03 ± 0.01

(*): pH 5; UV = 8 lamps; ë = 254 and 365 nm; 50 W UV power, 60 min photooxidation time

Reusability of Ni doped BiO

As shown in Figure 12, after the first cycle of photocatalytic oxidation within 60 min, 99% of the Ni doped BiO with a mass ratio of 1.5wt% was recovered. After three cycles, the phoooxidation ability of Ni doped BiO nanocomposite was retained at 93% of the original value. After 8th cycles the nanocomposite was reatined at 80%. One of the reasons for the slight decline in photooxidation is that the surface of the reused photocatalysts may exist with some low residual substances which did not occupy the photocatalytic sites and did not block the adsorption. The presence of Ni significantly changed the binding site of the pollutant molecules. It is possible that the oxygen atom in Ni-BiO was bound to the dopant Ni [50]. The speedily recovering of the photodegradation capacity of Ni doped BiO for pollutans photodegradation will benefit to their photocatalytic activity.

NAMS-3-1-305-g012

Figure 12. The reusability of Ni doped BiO

Conclusions

By using 30 mg/L Ni-BiO with a Ni mass ratio of 1.5w% the CODtotal, CODinert, flavonols, polyaromatics and color were photodegraded with yields as high as 82-99% within 60 min photooxidation time, at 25°C under 50 W  UV power, at pH=8.0. The addition of Ni to BiO lead to enhance the photocatalytic activity by increasing the total surface area. The flavonoids and polyaromatic amines and their metabolites in the TW were firstly determined photodegraded with high rates and photonic efficiency using 30 mg/L Ni-BiO with a Ni mass ratio of 1.5w% at pH 8.

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Abundance, Composition and Spatial Distribution of Marine Plastic Litter in Sea Surface Waters Around Cap Corse

DOI: 10.31038/NAMS.2020312

Abstract

Marine litter is a widespread problem affecting all the oceans of the world. Plastics represent around 90% of marine litter, and it is estimated that there are between 15 and 51 trillion plastic particles floating on the surface of the oceans. The objectives of this study are to: (i) identify and characterize the main categories of floating items sampled in surface waters off the Cap Corse peninsula, (ii) provide estimates of the occurrence of floating items in this area, and (iii) get an overview of the potential areas of litter accumulation. We highlighted a heterogeneous distribution of floating litter as the plastic density characterizing the area between Bastia and Macinaggio (27 027 items/km2) was, on average, 2.31 times higher than the density estimated between Macinaggio and Pino (11 688 items.km2). Several studies highlighted that spatio-temporal variability of plastic densities and sizes of plastics (micro, meso, macroplastics) could be tightly linked with hydrodynamics and wind regime, distance to land, coastal human population and maritime traffic. Beyond the need to further raise awareness, providing more evidences and information regarding such marine pollution may hopefully foster urgent management strategies, whereby the most effective mitigation strategy implies reducing the input at its source.

Keywords

Plastic, marine litter, manta-net, Mediterranean Sea.

Introduction

Marine litter is a widespread problem affecting all the oceans of the world. Plastic pollution has gained attention by scientists and public perception in the last decade [1, 2]. Plastics represent around 90% of marine litter [3], and it is estimated that there are between 15 and 51 trillion plastic particles floating on the surface of the oceans [4].Global plastic production increased from 5 million tonnes in 1950 to 322 million tonnes in 2015 [5] It is considered that, on average, around 80–90% of ocean plastic comes from land-based sources, including via rivers, with a smaller proportion arising from ocean-based sources such as fisheries, ships and aquaculture. Plastic inputs from land to ocean was estimated to represent at least 4.8 to 12.7 million tonnes in the year 2010 [6]. Because of their abundance, durability and persistence, marine plastics constitute today a major threat to the marine environment [7].

The most visible impacts of marine plastics are the ingestion, suffocation and entanglement of hundreds of marine species, including species listed on the IUCN Red List as near threatened or above [8]. Microplastics (less than 5 mm in diameter), in particular, have recently become a source of concern, as their ingestion has been observed in a wide variety of taxa including zooplankton, marine invertebrates, fish, turtles, seabirds, and marine mammals [9–11]. Once ingested, microplastics can cause starvation, alterations in intestinal functions, a reduction in feeding capacity, energy reserves and reproductive output [12]. Also, contaminated preys can be consumed by predators leading to the transfer of plastics accross trophic levels [13]. Moreover plastics are polymers that may contain a large variety of chemical additives and contaminants, including organic pollutants and endocrine disruptors, that pollute the environment [14] and can be harmful to marine biota [15, 16].

Floating marine litter also plays an important role in the spread of marine or terrestrial organisms, including the dispersal of invasive species that may pose a threat to local ecosystems [17]. Also, the hydrophobic nature of plastics stimulates the formation of biofilms and allows the establishment of numerous organisms, called “epiplastic” organisms, which constitute a new marine ecosystem called “plastisphere”[18]. It can host different groups, in particular microbial organismsincluding pathogenic viruses or bacteria but also fungi, algae, molluscs, cnidarians, and crustaceans [19–21]. The surge in the number of litter introduced into the marine environment currently offers a great variability of objects that may serve as « novel habitat » or as « hitch-hiking raft »  [22, 23].

In addition to causing harm and threatening marine ecosystems, marine litter, especially plastic, can also negatively affect human wellbeing, food security and socioeconomic sectors such as tourism, aquaculture, fishing and navigation [24-26].

The Mediterranean Sea is considered as a biodiversity hotspot [27], besieged by multiple human pressures. Indeed, its shores are home to around 10% of the world’s coastal population and around 100 million people live within 10 km of the coast [28]. Moreover, the Mediterranean basin is one of the busiest shipping routes in the world and receives the waters of densely populated watersheds, e.g. the Nile, the Ebro, the Po [29]. It is therefore not surprising that the basin is nowadays described as one of the areas most affected by marine litter in the world, whereby the average density of plastic as well as its frequency of occurrence throughout the basin were comparable to accumulation zones in ocean gyres [29–31]. In Europe, various regulatory directives have been put in place to limit and reduce this pollution, such as the Marine Strategy Framework Directive (MSFD). In order to define the concept of « Good Environmental Status », the MSFD proposed 11 descriptors including descriptor n° 10 describing good status for marine litter as follows: “Properties and quantities of marine litter do not cause harm to the coastal and marine environment” [32]. Also new knowledge on this topic may have impact in the implementation of other environmental regulations such as the new European Strategy for Plastics in a Circular Economy (COM/ 2018/028 final), which has recently agreed on banning certain single use plastic (SUP) items.

To develop and validate indices of ecosystem status or pollution, it is necessary to have access to areas with low human impact and then validate them along local pressure gradients [33]. Corsica, is a privileged area in the North-Western Mediterranean. It is at the centre of one of the most touristic regions in the world still sheltered from heavy pollution of anthropic origin. This area should come closer to the concept of Good Ecological Status in terms of pollution by plastic marine litter. Our study intends to provide further information on marine litter regarding the northeastern waters of Corsica, part of the Cap Corse and Agriate Marine Natural Park (PNMCCA). This area is also comprised within the Pelagos Sanctuary, a large marine area subject to an agreement between Italy, Monaco and France for the protection of marine mammals.

In detail, the objectives of this study are to: (i) identify and characterize the main categories of floating items sampled in surface waters off the Cap Corse peninsula, (ii) provide estimates of the occurrence of floating items in this area, and (iii) get an overview of the potential areas of litter accumulation.

Material and method

In August 2019, the Corsican Blue Project team carried out a marine litter sampling campaign  within the perimeter of the Cap Corse and Agriate Marine Natural Park (PNMCCA). A total of six manta-net tows were conducted along the coast of the Cap Corse peninsula between Bastia and Pino, including three transects along the eastern coast (Bastia-Macinaggio) and three transects along the northwestern coast (Pino-Macinaggio). The manta-net, characterized by a rectangular opening of 86 x 46 cm and a net opening of 330 μm, was deployed at the surface beyond the boats’ wake at an average speed of 2.2 to 2.4 knots and for about 30 min per tow. General characteristics of each transect were recorded. After each sampling, the entire net was thoroughly rinsed with seawater from the opening to the collection bag to ensure that all the debris were concentrated in the cod end before being retrieved.

Collected samples were sent for analysis to the STARESO (STAtion de REcherches Sous-marines et Océanographique) research station.In the laboratory, the samples were rinsed with seawater on a 300 μm sieve.Then the mesh was rinsed with tap water and the sample was collected. Sampling consists of direct extraction from the environment of items that are recognizable by the naked eye. Several steps have been taken to separate the litter from the biological matrix and water [34]. Litter was manually separated from natural debris by removing the largest pieces of biological material (leaves, algae, wood …) and rinsing them with water that underwent a second sorting to avoid any loss of debris [35]. Items that were visually identified as litter were collected using fine forceps and then counted. To avoid misidentification and underestimation of microplastics it is necessary to standardize the plastic particle selection, following certain criteria to guarantee proper identification [34]. Plastics were identified according morphological characteristics and physical response features (e.g. response to physical stress; microplastics were bendable or soft, colors) [34, 36]. Identified plastic items were measured over their largest cross-section (total length) in order to be classified into three categories: microplastics (<5 mm), mesoplastics (5-200 mm) and macroplastics (> 200 mm) [37]. Plastic items were also classified, as proposed by [21], into six categories according to their visual characteristics:

1. Fragment: this category is generally the most abundant. They are rigid, thick, with sharp, pointed edges and an irregular shape. They can be of different colors.

2. Film: they also appear in irregular shapes, but compared to the fragments, they are fine and flexible and generally transparent.

3. Pellet: they are generally from the plastics industry. These are irregular round shapes, about 5 mm in diameter. They are generally flat on one side and can be of different colors.

4. Granule: they have a regular round shape and generally smaller, around 1 mm in diameter. They appear in natural colors (white, beige, brown).

5. Filament: these are, with the fragments, the most abundant type of particles. They can be short or long, with different thicknesses and colors.

6. Foam: they most often come from large particles of polystyrene foam. They have a soft, irregular shape and are white to yellow in color.

The surface of the surveyed area was estimated by multiplying the observation width by the transect distance, and litter density (items/km2) was calculated by dividing the items count with the surveyed area surface [29].

Results and discussion

In this study, plastic litter was encountered in 100% of the hauls made off Cap Corse, representing a total of 238 itemsand a mean density of 19357 items/ km2.

We highlighted a heterogeneous distribution of floating litter as the plastic density characterizing the area between Bastia and Macinaggio (27 027 items/km2) was, on average, 2.31 times higher than the density estimated between Macinaggio and Pino (11 688 items.km2) (Fig.1). Several studies highlighted that spatio-temporal variability of plastic densities and sizes of plastics (micro, meso, macroplastics)could be tightly linked withhydrodynamics and wind regime [31, 38], distance to land [29, 39], coastal human population [40, 41] and maritime traffic [23]. In our case, the difference in densities found between the regions Bastia-Macinaggio and Macinaggio-Pino, could be consistent with coastal human population pressurewhereby the area with an estimated higher density is located close to Bastia, a city of more than 44 000 inhabitants.As an example, a sampling campaign conducted in the Ligurian Sea, mainly along the French continental coast, reported that highest densities were found in front of Nice [40]. Corsica has been identified as a reference area where contamination by microplastics was lower compared to other regions off the French Mediterranean coasts (e.g. Antibes, Marseille, Toulon) [42].

NAMS-3-1-304-g001

Figure 1. Average concentration of plastic litter, expressed as debrits per km2, in surface water off Cap Corse.

Moreover, the area between Corsica and Elba has been identified as displaying the highest natural marine debris concentration throughout the Central Western Mediterranean, suggesting therefore that the area is under great influence of terrigenous input [43]. However, the identification of the source of the collected litter remains challenging without the consideration of dispersion models, and items being subject to surface water circulation [44] may drift from their source of input. Indeed, studies investigating on debris transport and dispersion due to marine circulation strongly suggest that floating litter might drift during periods ranging from a few weeks to several years before eventually sinking or beaching [45]. Taking into account thatthe Tyrrhenian Sea has been identified as an important accumulation zone [23] and that the eastern coast of Corsica  is under the influence of the Tyrrhenian sea current which flows along the Italian coast before entering the Corsica channel [46] it is very likely that the area between Bastia and Macinaggiois supplied by debris drifting northwards.

It remains particularly challenging to compare our litter concentrations with those reported inother studies given the large variety of sampling methodologies. However, based on the same sampling methodology, sampled in the northern coast of Corsica, at the same season and at a rather similar distance to land, and concentrations were found to be in a same order of magnitude, ranging from tens of thousands to hundreds of thousands of items per square kilometer [30, 31, 40] (Table 1). However, in our case, densitieswere overall lower, andhigherdensities in the Bay of Calvi might be linked tothe different demographic pressures. Indeed, during summer season, population in Calvi may rise up to 60 000 inhabitants while the northwestern part of Cap Corse does not have such large population centre. However, these densities might also be linked to thedifference inwind stress during the sampling campaign [38], and also, as previously mentionned, to the water circulation properties of the considered coastal areas.

Table 1. Literature data on floating plastic densities for stations along the northen Corsican coast.

Site (NorthernCorsica)

Method

Mesh size (µm)

Density
(items / km2)

Source

Calvi

Manta trawl

333

400 000

[30]

Cap Corse

80 000

Cap Corse

40 000 – 80 000

[31]

Calvi

20 000 – 150 000

[40]

Regarding size classes, 62% of the total number of items was smaller than 5mm (microplastics), 26% measured between 5 and 200mm (mesoplastics), and 12% was bigger than 200mm (macroplastics) (Fig.2). In other words microplastics were 2.4 times more abundant than mesoplastics,and 5.3 times more abundant than macroplastics (> 200 mm).Such proportion is very similar to the study carried out in the Bay of Calvi, reporting that microplastics, mesoplastics and macroplastics accounted for 54%, 28% and 18% of total collected items, respectively [38].

NAMS-3-1-304-g002

Figure 2. Size class of the litter found during the sampling campaign.

Beyond the size-based classification,items were additionnaly classified according to their shape and appearance and it was found that fragments were largely predominant (62%), followed by films (26%), filaments (9%), foams (2%) and pellets (1%) (Fig.3). No granule was found. Such proportion is consistent with previous results reported [39] and it was highlighted that the proportion of fragments was especially important in the north of Corsica compared to other stations throughout the Western Mediterranean Sea [31].

NAMS-3-1-304-g003

Figure 3. Main categories of litter found during the sampling campaign.

While on land, the island of Corsica is currently facing a major litter crisis,  due to overloaded garbage dumps, its coastal marine waters are not exempted from marine litter pollution. In this context and despite a relatively small sampling effort compared to other major sea campaigns, our study provides information regarding the type and occurrence of marine litter and plastics in the local coastal waters off the Cap Corse peninsula. While the average density and types of litter items were in agreement with other comparable studies, we highlighted a potential heterogeneous distribution within the Cap Corse marine waters, with higher densities found in the transects of the eastern coast than in those from the northwestern area of the peninsula. To this, different explanations were proposed, such as terrestrial inputs and the influence of large population centres or the influx of debris through the marine circulation and wind forcing.

Conclusion

We highly advise further marine litter sampling campaigns to be conducted within these waters that are positionned at a bio-geogaphical crossroad where several major currents meet. Moreover such study would be scientifically supported and potentially technically facilitated given the fact that the Cap Corse waters are included within the Cap Corse and Agriate Marine Natural Park and the Pelagos Sanctuary. Field information could, for example, be useful in the risk assessment of whale or mammals exposure to microplastics by validating simulated plastic distribution, in parallel to whale habitat models [47]. Moreover, Corsica is also subject to high tourist flows during summer which also translates into an increment of boating, maritime shipping and passengers transport. It would therefore be advisable to conduct sampling all year round, to highlight any annual variability. This study also intends to promote and encourage further « participatory sciences » by which citizens are involved in data collection, in association with the scientific world.

Beyond the need to further raise awareness, providing more evidences and information regarding such marine pollution may hopefully foster urgent management strategies, whereby the most effective mitigation strategy implies reducing the input at its source.

Acknowledgments

This research was funded by the “Agence de l’eau Rhône Méditerranée Corse” and the “Collectivité de Corse” (CdC), as part of the STARE CAPMED project research.

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Treatment and Management in the Corona Virus Crisis: Think outside the Box While inside the Box

DOI: 10.31038/IDT.2020112

Perspective

I wrote this position paper as someone who wears several hats, each one separately, and primarily, onehat on top of the other. My many personal, family-community, and professional roles overlap and enhanceeach other. In this periodof crisis and challenge, of many difficulties and struggles,new knowledge and new experiences accumulate. In this text, I have chosen to share my personal message, comingfrom weeks of quarantine, and mydiscovery ofadministrative and professional modes of action that were new to me.

In ordinary times, which characteristically have greater degrees of freedom, we often encounter an avoidance approach tochange.The necessary experimentation with unfamiliar modalities/ techniques may even threaten our routine. However, in the face of another reality, there is an opportunity to grow and expand, precisely from a narrow and restricted physical boundary. I found myself in this time in therapeutic and administrative work at the Feeding Clinic, charting new ways andunfamiliar tracks. The deliberations and questionsand observations following my own process are presented below.

From protocol to practice

Protocol is formulatedin routine times, shaped by habits and consistency and based on personal and collective knowledge and experience. These are accompanied by a familiar reality, which at times is nottaken into account.The relevance of accepted practicesdiminishes in times of crisis. Work protocols that have served us well until now require renewal and change, according to the given needs.

We naturally tend to prefer familiar treatment plans and methods, thinking that they will achieve optimal results. However, relianceon conventionalapproaches can lead to missed therapeutic and administrative opportunities that are appropriate for these periods of crisis. As we become more creative and liberated from therapeutic conventions, we can achieve a broad and refreshing newreality-based therapeutic practice. For example, telephone or e-mailsduring the corona crisis can provide a reframing of the situation as well as a calmresponse and guidance on the challenge at hand.

Online treatment and management

The interpersonal encounter is a basic component of therapeutic work in the field of early childhood mental health. The session includes eye contact in which the therapist observes emotional states and the quality of the interaction, based on mimicry and body language. The encounter sometimes invites physical contact .Treatmentina period of quarantine eliminates some elements of nonverbal communication but may well sharpen other therapeutic skills.

The richness and diversity of online treatment depends on the technological means and skills of both the therapist andthe family in treatment. The quality of the therapy is also affected by the economic level and accessible material, which isexpensive. A flexible and open approachmakes remote communication with diverse populations possible and is combined withsensitivityto the populations’ unique character and needs.

The advantages of remote support are both technical, such as a high level of accessibility, and qualitative. For example, in a phone conversation with parents, sensitive and attentive listening can compensate for the lack of eye contact whileways to introduce new foods to a picky eater are presented.

Intake as a diagnostic and therapeutic tool

The face-to-face intake is currently replaced by telephone intake. Many new applicants experiencea high level of distress.In many cases, it is my professionalresponsibility to refer callers to emergency medical centers after consulting with the physician in the community.

Telephone intake for non-urgent callers is usually necessaryfor parents waiting for their children’s acceptance tothe feeding center. The intake is primarily intended to address their feelings of anger, frustration and disappointment. These intense emotions are not necessarily related to the child’s medical condition, and often reflect the parents’ cognitive and emotional state and need for an attentive ear, with or without eye contact.

Anxiety vs. Distress

Parents turn to a feeding center with possible distress in the background. How threatening or disruptive the situation is will affect the situation, as well as the parental resources that are mobilized. Currently, as the level of collective anxiety rises, the internal and private threat is sometimes temporarily reduced. Accordingly, and also because of the life-threatening possibility of increased exposure to Covid-19 virusin the medical center, parents refrain from contacting us unless there isimmediate danger.As therapeutic alternatives are developed; we bolster the parents’ confidence who willthen appreciate conventional therapy when it becomes possible .

Creativity and Productivity

While curiosity is the primary driving force when seeking therapeutic solutions, creativity is the fuel for finding the therapeutic path. There are different examples. For instance, a toddler was initially described on the phone, as refusing to eat. He achieved independent eating and avaried dietafter one therapy (phone) call, which came after a consultation and preliminary information from the educational and rehabilitation staff of the daycare center he attended prior to quarantine with his family.

Thinking outside the box, while being physically inside the box of my home, and physically distant from the patient and his family, led me to enlist family members as modelsfor social eating. The patient’s achievement delighted all those who saw themselves, and rightly so, as partners in his success.

Multidisciplinary team

The uniqueness of our feeding center is the skilled, sensitive, multidisciplinary response that can be individualized and family-oriented under one umbrella. Our staff support and complement each other so that the whole is worth more than the sum ofits parts. At this time, this integrative work continues, in shared thinking and discussion and supportive, encouraging conversations, with the hope of resuming non-virtual work sessions, as the danger passes.

Unpaid leave, layoffs and a reduced workforce at the feeding clinic as in other medical and treatment centers, arevague, unresolved, but solvable. I leave issues to the experts in economics, with the challenge of translating unique therapeutic productivity into the materialworld.

“Talk. Share. Work on youemotionally and psychologically, now is the time.” Dr. Guy Winch believes that the real threat during the Corona virus’s active period is mental. In an article in the Haaretzsupplement (Ayelet Shani, April 10, 2020), he emphasizes the importance of strengthening our coping tools and recommends that the mental health community not give in to helplessness oravoidance.

The routine of our lives can bring calm and stability, based on familiar and fixed events, their high predictability, clarity and logic. When I realized that the Corona virus had entered my personal and professional life, and might rob me of a stable routine, I understood theneed for a response anchored in the new reality.

This understanding led toa therapeutic thought process using methods nottypically included in early childhood mental health. The new reality has also sharpened my understanding of unique ways of managing and maintaining workrelationshipsin my work as coordinator of a multidisciplinary therapy center.

The work methods described above, adapted to extraordinary disruption, are also important for a promptresponse to non-urgent inquiries. Other cases are currently referred to emergency medical units, according to need and the recommendation of community doctors.

I warmly embrace the recommendation of psychologist Dr. Guy Winch. I do not succumb to helplessness . I invite in energized thinking and shared action in the current situation and believe that new insights are beginning to emerge.