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World Issues, Artificial Intelligence, and People’s Minds – Bringing Structured Internet in Gaza

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DOI: 10.31038/ASMHS.2023711

Abstract

The paper presents a new way to understand problems in a rapid, transnational fashion. The approach defines a problem, uses artificial intelligence to select our aspects of the problem which ‘tell a story’, and then uses artificial intelligence to select four answers to each question. These sixteen questions are combined by experimental design into permuted sets of 24 vignettes, each vignette set up for a unique experimental design with the desired mathematical properties, valid at the level of a single individual.. Within an hour, the same study was run in 14 countries, 20 respondents per country. The analysis shows how OLS (ordinary least squares regression)creates ‘grand models’ showing how the different answers (elements) drive two types of responses (emotional, rational, respectively), and how other information about the respondents (country, gender, age) can be used to augment the knowledge by revealing the part-worth contribution of each of the 14 countries, two genders, and five age groups. The approach also lends itself to uncovering mind-sets in the population. As a demonstration, the approach was run in one evening with 280 respondents analyzed in a few hours, showing the potential for creating early-stage knowledge-driven databases to explore any topic of human decision making.

Keywords

Schizophrenia; Typical antipsychotic drug; Atypical antipsychotic drug; Extrapyramidal symptoms; Tardive Dyskinesia; Medication induced movement disorder

Introduction

A cursory look of any newspaper, any news channel, or of course conversations among friends will quickly reveal the focus of people on the problems of the world. Not only do one’s personal problems clamor for discussion, but also problems that seem to be insolvable. These ever-present problems become the grist for conversations, most of which do not lead anywhere. We might say about world problems the same thing that Mark Twain said about the weather, namely ‘everyone talks about it, but no one does anything about it.’

Of course, whereas we realize the futility of talking about problems that we cannot solve, billions of dollars are spent by countries, by international bodies such as the United  Nations, and  by many hundreds, if not thousands, of NGO’s (non-governmental organizations). These organizations study the problem, often seemingly doing so ad infinitum, make recommendations, and occasionally actually implement their recommendations.

What is missing in much of these efforts is a rapid way of getting suggestions about solving the problems, doing so inexpensively, rapidly, with some sense of the response of real people to the policies and actions recommended. By the foregoing we mean simply that the standard long methods may be the traditional way to deal with these problems, but today’s methods to understand people’s points of views, really their minds, and to measure their responses to alternative ideas, potential solutions, has developed into a technology that asks for use dealing with world problems.

Part of the problem may be traced back to the world of academics, and specifically to the world of science as the scientist deals with issues of human behavior and human opinion. The academic world has evolved to look for the hallmarks of solid, possibly irrefutable evidence, such evidence emerging from ‘tight’ research protocols, hypothesis statement at the start of the study, and powerful statistics to ensure that the research either confirms the ingoing hypothesis, or falsifies it [1]. There is room for observational research, and even the use of statistics to substantiate the findings, but there observational research is often considered ‘less scientific,’ more a matter of educated observation than real science.

In the middle of this divided world, strong science on the one side guided experiments, and observations research on th other, enters the emerging science of Mind Genomics. The objective of this emerging science is to use simple, but powerful experiments to understand how people make decisions. Mind Genomics itself comprises simply the creation of experimental designs specifying combinations of messages, creation of these combinations by combining phrases (test stimuli), evaluation of these combinations by people, and then the estimation of what each messages does to drive the rating assigned by a person (respondent) to the different combinations.

The original vision of Mind Genomics was to create an easy-to- use research template, one which allow the researcher to quantify the importance of the different messages as drivers of human judgment. Mind Genomics was created from the realization that when it comes to the way people make judgments, it is often counterproductive and simply wrong to present ideas/messages to a person, one at a time, make a measurement (e.g., respondent rating importance). Messages are not experienced one at a time, out of context. Experiences comprise combinations of features. It is better to imitate experience through combinations which are ‘somewhat more real’ than to force people to judge one idea at a time.

Mind Genomics and Its Augmentation by Artificial Intelligence

Mind Genomics is an emerging science with origins in psychology, statistics, and consumer research. The objective of Mind Genomics is to quantify how people make decisions about the world of the everyday.

We are accustomed to human interest stories about decision making, especially when there is a surprise factor, such as the fact that we tend to believe what agrees with our prejudices (so-called confirmation bias), and that we can get a good idea of the number pieces of candy in a big bowl by averaging the guesses of many hundreds of thousands of people (so-called wisdom of the crowd). These are interesting stories, sometimes surprising, sometimes not, but they are not particularly useful for decision making just being stories. The stories are interesting, but more important are methods to arrive at how people think about topics.

Mind Genomics approaches the topic of thinking about an issue using simple methods, specifically showing a person a combination of features, getting a rating of that combination, doing the same ‘operation’ many times with different combinations, and finally estimating the contribution of each item in the combination, each particular message. Mind Genomics works by creating specific combinations of features, rather than combining them at random. The features are combined by what statisticians call an ‘experimental design’. The design specifies the different combinations. By creating specific combinations viz., those prescribed by the experimental design, I becomes possible to estimate the number of ratings points contributed by each message or element.

The third contribution, consumer research, tells us how to run the study, how to present the information to the respondent, how to make the topic seem like a survey, and how to look at the answers from the point of view of a person’s everyday mind. Consumer research moves beyond traditional psychology, the science, and towards the specifics of psychology in the life of the everyday

The actual process of Mind Genomics has been explicated in various papers, some going back almost 20 years [2,3]. The approach is not new. What has evolved has been the recognition of practical issues, such as the need to have simple, short experiments, with quick set up, quick execution, rapid and automatic statistical analysis, and ‘next steps to make the results come alive after the research has been done and reported. The rationale for speed and low cost emerges from the history of applications by author Moskowitz over the past twenty five years. It has become obvious during the evolution of Mind Genomics that it is difficult to develop ideas (viz., thinking), that the world of research has become overly accepting of ‘slow and steady but absolutely correct’, and that more often than not the design of a study takes so long for technical and personal reasons that the real miracle is that the study is executed at all. Quite often the process implodes because it’s difficult to think of the test stimuli, reach consensus, and then agree upon the test specifics. The notion of DIY, do-it-yourself research is now becoming increasing well accepted, but as far back as 22 years ago the notion of a DIY version of Mind Genomics was already presented to the public, and evidence of implementation presented at that time [4].

Mind Genomics emerged from the world of application, from the world of realistic timelines, and from a world where those who needed the technology really make good use of it, rather than those who were simply interested in a technology to burnish one’s resume. It is in this spirit that the current study was run, a spirit of exploring ideas, not the spirit of ‘filling a hole’ in the literature [5] but rather to explore new limits on what could be done.

The process of Mind Genomics is straightforward, following these steps.

  1. Select a topic. The topic should involve human decision making at some level, because the Mind Genomics project will focus on the different aspects of the way people make decisions.
  2. For the topic select four The questions should tell a ‘story’. It is at this step that research often breaks down, simply because in today’s world education and scientific research fail to teach people about how to ask questions which tell a story. The increasingly narrow focus on specifics, viz. intellectual reductionism, which manifests itself as researchers become more focused, more sophisticated, narrows the scope of the topic until the researcher cannot really ‘feel’ the bigger picture as a motivation for the study. People do understand the bigger picture, but often have a difficult time filling out the picture.

For those new to a topic, the Mind Genomic program (www. BimiLeap.com) incorporates an AI component called Idea Coach. The researcher who wants coaching and AI to set up the four questions writes a small paragraph about the topic and what is being sought, doing so in a specific screen on the program. The AI then returns with up to 30 questions. It is best to involve Idea Coach several times, and then select the four questions which best tell the story in questions. Idea Coach need not remain shackled with one description. The researcher can invoke Idea Coach several times with the same basic description, obtaining different questions, and can also change the description.

For each question, the researcher is instructed to provide four answers to each question. Typically  the task of providing answers   to questions ends up being a great deal easier than generating the questions in the first place. This difference may well be due to the way people are educated. Students are taught to answer questions, the questions being provided by a second party. For those individuals who wish to avail themselves of the built in access to AI, one can request Idea Coach to provide sets of up to 15 answers to each question. Again, one can interrogate the AI several times to get a sense of the different possible answers.

The researcher now writes a short introduction to the topic, so that the respondent will understand what is being presented. This orientation will appear on each page, introducing the test stimulus. As shown below, the introduction is deliberately made to be short, conveying little information. The rationale for the short, incomplete introduction is the desire to have the specific test phrases generate the primary communication. The orientation can be thought of as a way of creating coherence among the test stimuli.

The research has the option to ask up to eight questions, each question offering up to eight answers, with the respondent instructed to select the ‘appropriate’ one answer for each question. These classification questions allow the respondent to define the respondent in terms of WHO the respondent is, what the respondent THINKS about a topic, and what the respondent DOES. These eight questions, along with standard questions of gender and age enable the researcher to understand the respondent in terms of standard types of questions.

Underlying the Mind Genomics program is a built-in experimental design, specifically created to allow different numbers of independent variables. The underlying experimental designs, developed and patented by author HRM are set up so that they can be permuted [6], viz., different ‘daughter designs’ be created, each having the same underlying mathematical structure. These daughter designs are structurally identical, having a specific number of independent variables (the questions), an equal number of levels (the answers), all of the answers being present an equal number of times. The design for the study presented here comprises four questions, four answers for each question, and 24 combinations. The combinations are called vignettes. Each vignette comprises 2-4 answers, at most one answer from a question. The design ends up with each answer (aka ‘element’) appearing five times in 24 vignettes, absent 19 times. Each question thus contributes to 20 vignettes, and does not contribute to four vignettes. The result is that the vignettes are incomplete, allowing for the use of OLS (ordinary least squares) regression [7], and the estimation of the absolute values of the coefficients.

One of the key issues is research is the desire to minimize random variability in the experiment, and by doing so let the actual ‘signal’ come through, instead of the signal being lost in the ‘noise’. Typically, this is done by having many measurements of the same stimuli, viz., many people evaluating the same set of vignettes. That strategy is called replication to reduce variation, and comes from the world of statistics. Mind Genomics works in a different manner, more in the spirit of the MRI (magnetic resonance imaging). The aforementioned experimental design, comprising 24 vignettes, is set up to allow     the analysis of the data from one respondent. The desire now is to strengthen the signal. Another way to strengthen signal is to take different pictures, in the way that the MRI does. Mind Genomics allows for those different pictures, by the strategy of permuting the experimental design, without changing the mathematical properties. Permutation means simply moving around the labelling of answers. In the original design an answer could have been called A1. The underlying experimental design combines these answer as described above, to create a set of 24 combinations. Permutation allows the creation of an entirely different set of vignettes, albeit with the same mathematical properties. These desirable properties are that the 16 elements (answers) are statistically independent of each other, and that the data from each respondent can be analyzed separately by OLS regression. As we will see below, these properties provide a unique opportunity to increase the power of the data to reveal patterns with relatively few respondents.

  1. The researcher creates a set of rating questions on a Likert scale. The scale is anchored at both ends to evaluate feeling on an ‘aspect’ felt by the respondent upon reading the test stimulus (e.g., 5 = agree 1 = disagree; 5 = will be successful vs. 1 = will not be successful). It is in the structure of the rating scale that allows the respondent to communicate one’s feeling about the test stimuli. In recent studies, author HRM has used a number of two dimensional scales, allowing the researcher to explore the topic more deeply. The two dimensional scale is structured as follows:

    2. i)   5 = Yes for Aspect 1 AND Yes for Aspect 2

    ii)  4 = Yes for Aspect 1 BUT No for Aspect 2

    iii) 3 = Cannot answer or No opinion

    iv) 2 = No for Aspect 1 BUT Yes for Aspect 2

    v)  1 = No for Aspect 1 AND No for Aspect 2

    1. The researcher specifies the nature of the respondent (called panel composition), and selects the number of respondents to participate.
    2. The researcher launches the By launching is meant that the BimiLeap program either returns with a link to be sent directly to respects (called self-sourcing), works with a preferred supplier directly through a credit card, or sends the link to a specialist to recruit specific types of respondents who would otherwise be very difficult to recruit (e.g., physicians for medical studies).
    3. The respondents receive email invitations, containing a short note and the link to the The respondents participate in the study, which typically lasts 3-4 minutes on the computer. The study can be done with a smartphone, a tablet, or a personal computer. The respondent needs only to have an internet connection.
    4. The BimiLeap program analyzes the data, producing a report, which includes as its main aspect the parameters of model or equations relating the presence/absence of the elements as it affects the specific dependent

    A Worked Example – Efforts to Improve the Israel- Palestine Conflict with Efforts in Gaza

    The origin of this study emerged from a conversation with experts on the Israel-Palestine situation, and the desperate need to educate Gaza youth in technology. The precise question was ‘what type of benefits from Internet technology would be welcomed by the Palestinian population’. The question grew in its complexity from finding the benefits which would appeal to understanding whether the Palestinian respondents were like-minded in their  response.  That second soon morphed into the question of what would be the response of other people who would learn about the program in Gaza. Would respondents in other countries feel the same as respondents  in Palestine? The literature on education opportunities in Gaza is relatively sparse, and the topic of internet-based education is just emerging [8-12].

    The foregoing issue could have been solved by doing small sale studies of the same topic in Palestine, and in other countries, with the inevitable adjustments for the  country,  the  desire  to  change the language, the respondent qualifications, and so forth. From the discussions emerged the interest in whether a small scale, affordable, easily, and rapidly executable study could be done in several countries in precisely the same way, with the entire set of studies analyzed as one study. What could be learned by creating a template to do cross- national executions of the same study? Could a new approach be developed to understand the world’s response to a specific topic, creating in its wake a usable database? And, most important, could this new approach be scaled to offer an advanced in understanding the minds of people>

    The study reported here represents what may well be the first attempt to create the foregoing described database. The word is ‘attempt’ because the effort was done in a way which paralleled what might be done in those cases where funds are hard to acquire, where time to solution (viz., database) is minimal, and where the topic is totally new to the researcher, who must use methods like artificial intelligence to tackle the problem.

    Select the Topic

    The topic was ‘response to a proposal to help the Gaza economy grow by providing training in computer technology, especially technology linked closely with Internet-based efforts. It was not sufficient to teach the Palestinian youth. The effort had to focus on Internet based efforts. Section A of Table 1 presents the background given to Idea Coach.

    Create Four Questions

    Section B of Table 1 presents the first iteration to create the four questions. The Idea Coach process was run three times, each time with the same input (Section A). Each of the three iterations produced different numbers of questions, as well as different questions, although some questions repeated.

    Table 1: Input to AI and output from AI to create the four questions, and the four answers to each question

    table 1

    Create Four Answers for Each Question

    Section C presents 15 answers to question #1, as created by Idea Coach. Idea Coach was run twice for each of the four questions. From the two runs emerged the four good questions.

    Table  2 presents the four final questions, and the four answers  to each question. The questions and answers  emerged  from  the Idea Coach program, but in many cases were slightly edited by the researchers.

    Table 2: Finally array of four questions and four answers to each question

    table 2

    Step 4: Create Classification Questions

    Traditional research often focuses on how people think about topics. Although Mind Genomics is technically an experiment, as will be shown below, there is room in the protocol to ask classificaiton questions in order to learn mor about the respondent. The Mind Genomics interview builds in two ‘self-profiling’ classification questions,  on gender,  and on age respectively. In addition, however, there is room in the Mind Genomics experiment (described below) to ask an additional eight questions, each question having up to eight answers. The respondent answers these self-profiling classifications at the start of the experiment. Table 3 presents the questions and answers  to  the  questions.  Note that these questions will not be used in the analysis for this particular introductory paper, but they can be used to great advantage in studies of this type. The reason is that there would be simply too much information to deal with in the space of a short paper.

    Table 3: The two optional self-profiling questions, created by the researcher, in addition to the standard questions of gender and age

    table 3

    Step 5: Create the Orientation Paragraph and the Rating Scale

    Table 4 (top portion) shows the paragraph, which is deliberately vague. As note before, the orientation paragraph simply sets the context. It is left for the actual elements to convey the specific information. Table 4 (bottom portion) shows the rating scale. The rating scale has two dimensions, collapsed into one scale. The dimensions are ‘care’ and ‘work’.’ The five points show different combinations of caring (an emotional response) and belief that it will work (a cognitive response).

    Table 4: The respondent orientation (top) and the five point binary response scale

    table 4

    Step 6: Execute the Study on the Internet

    The BimiLeap program provides the researcher with the option of selecting either members from on-line panels world-wide, or providing one’s own respondents. In this case, the researcher opted to have BimiLeap provide respondents, specifically 20 respondents from each of 14 countries. To make the ‘fielding’ of the study possible, the researcher duplicated the study, to create 14 identical studies, all in English, differing only in the name of the study, which was the country.

    An on-line panel aggregator, Luc.id, a strategic partner, recruited and invited respondents from each country to participate in the study for that country. The objective was to provide exactly 20 respondents from each country. In some countries, there were a few more than 20 respondents who ended up participating. Once the respondent in a country numbered 20, the remaining respondent data were eliminated.

    It is important to note that Step 6 is almost automated, providing a series of identical studies, to be given to different groups in the same general population. In this study the general population is respondents in different countries. It is also important to keep in mind that the respondents in each country will end up being considered part of one big set. Thus, across the 280 respondents, there would be 280 different permutations tested, these being permutations of the same basic design. To summarize, the large study with all 280 respondents can be considered to be one big study, with 14 country subgroups.

    As a matter of record, it took less than one hour for each study to complete. Luc.id sends out ‘waves’ of invitations, with a few minutes or more between waves. The study does not close until it has obtained the requisite data from the specified group of 20 respondents, whoever they may be. The field execution could take as short of 10 minutes to acquire all the data. Sometimes, in the case of a shortfall, the Luc.id system waits 30+ minutes and send out a new invitation.

    Step 7: Combining the Data into One Large Data Set

    For subsequent analyses, the data  were  combined.  Each country contributed 480 rows of data, each row corresponding to a respondent and a vignette. Each row, in turn, comprised the country, the respondent identification number, rating on the self-profiling classification (including age and gender, but also the answers to the two additional self-profiling questions shown in Table 4). The remainder of the row comprises 16 columns, one column for each element, as well as two final columns for the dependent variables, the rating assigned, and the response time. The coding for the 16 element columns was ‘1’ when the element was present in the vignette, and ‘0’ was absent from the vignette. The rating was the 1-5 scale, and the response time was recorded to the first decimal place, tenths of seconds. Step 7 prepares the data for analysis.

    Step 8: Transform the Data

    Researchers usually feel comfortable with Likert scales, like a 1-5 or 1-9 scale, etc. With respondents the Likert scale if often accompanied by anchor points, so that the respondent ‘knows’ what the scale points mean. In contrast, users of research do not feel as comfortable with these Likert Scales, often asking ‘how do interpret a 3.7?’ or some such question. A common practice over the past century has been and remains to ‘transform’ the rating scale to something which makes the user of the data feel comfortable. This transformation usually becomes something of the order like ‘ratings of 1-3 are transformed to 0 to denote lack of …, whereas ratings of 4-5 are transformed to 100 to denote presence of…’. The exact numerical criteria are left to the researcher. However, the end goal is to divide the scale into two halves, based upon a meaningful criterion, and then assign one end the value ‘0’ to denote ‘lack of ’ and to assign the other end the value ‘100’ to denote presence of.

    In this study, there were two transformation. The first was ‘Feel’ with ratings of 5 and 4 transformed to 100, versus ratings of 3,2,1 transformed to 0. The second was ‘Work’ with ratings of 5 and 2 transformed to 100, versus ratings of 4,3,1 transformed to 0. These transformations accord with the language of the scale, picking up the two sides of the scale (feel, work).

    Step 9: Create an Equation for the Total Panel, Based Only on the Ratings

    The step uses the standard statistical method of OLS (ordinary least-squares regression). The equation relates the presence/absence of the 16 elements to the binary transformed variable. The equation is written as:

    formula

    DV is the dependent variable. The dependent variable, DV, may be R54, the transformed rating which takes on the value 100 when the rating is 5 or 4. Or the dependent variable may be R52, which takes on the value 100 when the rating is 5 or 2.

    K0 is the additive constant, an estimate of value of DV when all of the elements (A1-D4) take on the value ‘0’, viz, when all of the elements are absent from the vignette. Thus the additive constant can be considered a baseline. For instance the additive constant is the likelihood that the respondent will select the rating 5 or 4 (for DV = R54), in the absence of elements. The reality is that the underlying experimental design ensures that all vignettes comprise 2-4 elements. Thus, the additive constant can be considered to be a baseline.

    The coefficients k1-k16 show the additive (positive coefficients) or subtract effect (negative coefficients) when the element is inserted into the vignette. For the study here, we focus only on the positive coefficients. The negative coefficients are ambiguous. They can refer to the loss of positive responses because the respondent actually felt negative (viz., for R54, ‘Care’ ratings of 1 and 2), or the rating 3 (viz., cannot decide). We focus here on the element which ‘drives’ the [positive rating. It is in those elements where the story is to be found.

    Step 10: Results from the Total Panel for Care (Table 5) and for Work (Table 6)

    Table 5 (first data column labelled Total) shows the additive constant and the 16 elements for rating R54, ‘Care’) Similarly, Table 6 (first data column labeled Total) shows the additive constant and the coefficients for the 16 elements for rating R54 (‘Work’).

    Table 5: Models relating elements to ‘Care’ (dependent variable = 5 and 4)

    table 5

    Table 6: Models relating elements to ‘Work’ (dependent variable = 5 and 2)

    table 6

    The first thing we notice is that the additive constant is higher for ‘care for it’, and lower for ‘will work’ (65 vs. 52). This means that although people like what they hear (emotional response), when they think about this strategy actually working, they are substantially less positive.

    The second thing we see for the total panel is that very few elements have positive coefficients of 2 or higher, and none have strong positive coefficients of 8 or higher. This finding may be disappointing, the reality is that the ‘flatness’ of the result is probably due to different groups of people, with different points of view, competing with each other. A visual analogy might be a still pool, but with water rushing into that still pool from different directions. The water streams cancel each other out, even though we don’t yet realize that.

    Step 10: Identify Mind-sets by Clustering, and then Create a Separate Equation for Each Mind-Set

    The creation of questions for the total panel, whether for R54 (care for it) or from R52 (will work) revealed that only a few elements generated positive coefficients, and no element performed ‘strongly’, defined as a coefficient of +8 or higher.

    If the poor performance is due to different ‘groups’ or mind-set in the population who have different ways of thinking about what is presented, then how does the researcher operationally disentangle these groups, these mind-sets. The question is even more relevant when the topic is entirely new, or when the researcher wants to explore a well-explored topic, but in a new way. The problem becomes a conundrum when these different ways of considering a problem are thought of as opposite groups, who data cancel each other. There is no ingoing idea of the number of such mind-sets for data, nor the nature of each mind-set, nor even how big the mind-set may be. Each data set is different, with its own granular set of elements, its own set of respondents and so forth. How can the learning from the data be extended to mind-sets in an automatic manner, independent of any a priori knowledge?

    The answer to the question about discovering underlying mind-sets emerges from statistical methods known as clustering  [13]. Clustering refers to a class of statistical techniques, purely mathematical in nature, which seeks patterns in data so that the individuals in a dataset can be allocated to different, usually mutually exclusive, and exhaustive groups. These groups are called ‘segments’. In the language of Mind Genomics these groups are called ‘mind-sets. The mind-sets are obtained mathematically, and then interpreted in a post-hoc way by the researcher, based on commonalities among the members in each mind-set.

    For this specific type of study, so-called 4×4 (four questions, four answers for each question), Mind Genomics clusters the respondent by the pattern of their individual set of 16 coefficients, independent of any other information about the respondent. Recall that the underlying experimental design prescribed a specific set of 24 combinations, in which each of the 16 elements appears five times in the 24 vignettes and is absent 19 times. Furthermore, the experimental design ensures that the 16 elements are statistically independent of each other, and that a vignette can contain at most one element or answer from a question, never two or more answers. This design ensures that the data generated by each individual respondent can be analyzed by ordinary least-squares (OLS) regression, in the same way that the data from the total panel are analyzed. OLS regression returns with an additive constant, and 16 coefficients for the respondent.

    The embedded k-means clustering program computes the Pearson correlation, R, between each pair of respondents, based on the 16 coefficients for each respondent. The Pearson correlation measures the strength of the linear relation between two sets of observations, varying from a +1 for perfect linear co-variation, to -1 to perfect inverse linear co-variation. The k-means clustering program defines the ‘distance’ or ‘dissimilarity’ between two respondents as the quantity (1- Pearson R). With this measure of ‘distance’ the underlying algorithm assigns each of the 280 respondents first into two mutually exclusive and exhaustive groups (two segments, or two mind-sets), and then, starting from the beginning, into three mutually exclusive and exhaustive groups. The criterion for the mathematical solution is to minimize the distance between respondents within a group, and at the same time maximize the distance between the 16 centroids for two groups, or maximize the distance among the 16 centroids for three groups.

    Clustering methods are heuristic, with results only approximate. They give a qualitative sense of the possibly different mind-sets among people. The researcher using the clustering should make every effort to minimize the number of mind-sets (parsimony), while at the same time selecting an array of mind-sets which tells a meaningful story from each mind-set (interpretability). Both requirements are subjective, not fixed in stone, and rely upon the judgment of the analyst.

    The clustering was done twice, first on the basis of the 16 coefficients estimated for each respondent, with the dependent variable being R54 (the coefficients for ‘care’ for this idea; generating MS3A, MS3B, MS3), and then again on the basis of the different set of 16 coefficients estimated when the dependent variable was R52 (the coefficients for ‘will work’; generating MS3D, MS3E, MS3F). The clustering thus considered the two variables as different from each other, even though the two variables

    It is with clustering based on the coefficients that the ‘stories’ begin to emerge. Rather than being stuck with data with a great number of blanks, that we observe for the total panel, the stories are clear when the clustering is done. Furthermore, clustering based on the coefficients tend to be more meaningful, more interpretable than clustering based on the more conventional variables answered directly by respondents, such as geo-demographics (WHO), what a person says about what they believe (THINK), or what a person does (BEHAVIOR).

    When we cluster on the basis of emotion (Care, DV = R54) we find these three mind-sets, based upon the strong performing elements in cluster or mind-set.

    Table 5: Clustering based on ‘care’

    MS3A = Focus on ‘working together’ to create positive change MS3B = Focus on education and development of skills

    MS3B = Focus on improved economic outlook. Table 6: Clustering base d on ‘work’

    Only one mind-set shows strong responses,MS3D

    MS3D = The Internet will help the young Gazans develop skills, and connect with like-minded people. This mind-set strongly believes in the efficacy of the four elements.

    MS3E = The Internet will be a positive force for change. MS3E does not strongly believe in this, however, but these ended up as the strongest performing elements.

    MS3F = The internet will give opportunities for improvement, education, and investment. MS3F does not, however, believe strongly in these elements, although it begin with the highest additive constant (58), viz., the highest level of starting belief that the Internet will be a positive force.

    Step 11: Incorporating Self-profiling as Moderating Variables for More Insights

    What happens, when we want to augment our predictor set, moving beyond the 16 elements. Suppose we wish to look at the model for the Total Panel, or the model for mind-set, but while looking at the model, measure the additional ‘effect’ of country, gender, age, or even order of testing vignette (viz., effect attributable to the vignette being in positions 1-12 versus effect attribute to the vignette being in positions 13-24).

    This question moves in a different direction than has been the custom for analyzing Mind Genomics data. The traditional way has been to run separate models for each subgroup, such as what has been done for the two sets of mind-sets Tables 5 and 6 show the totally separate analyses, first for the respondents, and then only for the respondent in the different mind-sets.

    We could repeat the analysis, running a separate model by each country, a separate model by each gender, a separate model by each age group, and indeed, a separate model for each subgroup defined by the open ended question. This effort could be done but might end up being very confusing.

    The approach introduced here introduces new ‘dummy’ models, 14 for country, two for gender, five for age, and two for test order. Each vignette is defined by the respondent’s membership in country (1 for yes, 0 for no), by membership in gender, by membership in age group, and by order of appearance in the 24 vignettes (first group v second group). The OLS regression treats this information as new variables, moderating variables estimated in the same equation.

    When we do the additional we know that the respondent has to have a country, gender, age, and that the vignette has to have been presented in positions 1-12 or positions 13-24, respectively. In order for the OLS (ordinary least squares) regression to run without error, the independent variables must all be  statistically  independent.  That statistical independent for the 16 elements is ensured by the underlying experimental design, and furthermore ensured at the  level of the individual respondent. This NOT the case when we come to the classification variables. For every vignette there must be one country, one age, one gender, and one test order. Furthermore when we know the condition of any 13 countries we automatically know the condition of the 14th country. The same knowledge occurs when we know one gender. We automatically know the status of the other gender, and so forth.

    The answer to making the self-profiling classifications independent is to deliberately leave one of the classification options out of the predictor occasion. Thus one of the answers must be held out for  test order (select order 1,) country (select UAE), one gender (select Female), one for age (select age 16-21). It does not matter which of the classification answers is held out, because the coefficients will be all relative to the one held out. The regression returns with the additive constant, the 16 coefficients for the 16 elements, respectively, 13 coefficients for country with the coefficient for UAE set automatically to 0, the coefficient for male set to 0, the coefficient for age 16-21 set to 0, and the coefficient for order = 1 (first 12 vignettes) set to 0. The coefficients for these four variables are relative.

    Now, consider the results in Table 7, the ‘enhanced models’ for the dependent variable ‘care’ (R54). The UAE is held at 0. Take Mexico for example. When that is done, Mexico generates a coefficient of +8 meaning that an addition 8% of the respondents would be expected to rate the vignette 5 or 4. Now consider the opposite. Let Mexico be held out, and thus assigned the weight of 0. Then we would expect the coefficient for the UAE still to be 8 points lower, and so the coefficient for the UAE would be -8. The differences among the coefficients for the same variable (e.g., country) remain the same, but they change  in magnitude depending upon which classification variables selected to be the ‘references’, viz., not appear as predictors in the regression equation, and their coefficients set to 0.

    Table 7: Augmented models, for R54 (care), showing parameter for modes run for Total, and for the three mind-sets

    table 7

    Table 7 shows us the enhanced models for R54 (appeals to me). Table 9 shows the enhanced models for R52 (work). Again only positive coefficients are shown. Furthermore, the entire equation is re- estimated with these new sets of 13 country predictors (UAE held out as the reference), one for gender predictor (female held out), and four age predictors (age 16-21 held out) and one order predictor (order 1, vignettes 1-12(,

    The key insight comes from the Total Panel. Chile, Hungary, and Mexico care strongly for the idea. Ghana and Serbia think the effort will work. Gender makes no difference. Age makes a difference, not so much for R54 (CARE), but for R52 (will work) (Table 8).

    Table 8: Augmented models, for R54 (work), showing parameter for models run for Total, and for the three mind-sets

    table 8

    In general, the insights emerging from the augmented model are suggestive of effects, but do not pinpoint the effects as the models directly created for each country, for each age, for both orders, and for both genders. By giving up the specific, however, the augmented sense of predictors provides a general, simply summarized effect of country, gender, age, and order.

    Step 12: Looking for Insights without Knowing What Elements Mean

    Up to now we have been looking at the data with full knowledge of what the elements ‘mean.’ That is, the test stimuli, the vignettes, comprise elements which have meaning. We don’t infer what is happening from trying to guess the nature of the stimuli to which the respondents react. We KNOW what the stimuli mean. Let us turn the analysis around 180 degree. Without knowing what the elements actually mean, let us attempt to understand the nature of differences across country, gender, age, and order of testing.

    Table 9 shows what we would be left with were the elements in the study had no ‘cognitive richness’, viz., no meaning. Were we interested, we could do many different analyses, although the learning would be relatively superficial, requiring us to infer what might be happening. The only information we have available to us is the pattern of the responses themselves. There are clearly group differences, with the largest differences emerging for country. In contrast, by working both with cognitively meaningful elements and with meaningful differences among respondents, we can more deeply understand what might be happening, either by using the countries (and other predictors) as co- variates when we create models, or actually creating models for each country, each gender, or each age, respectively.

    Table 9: Patterns of ratings by country, gender, age. Numbers in the body of the table show the frequency of the rating(s) by key subgroup

    table 9

    Discussion and Conclusions

    The development of Mind Genomics in the early 1990’s recognized that experimental design applied to ideas could provide a powerful way to create databases of the mind for a variety of topics [2]. These early studies were done before the Internet became popular, and were analyzed by a systematized approach to reveal how people make decisions. One of the first studies, on coffee, was done in different countries around the world, in collaboration with early adopters of Mind Genomics, members of ESOMAR (World Society of Market Research). The study revealed four mind-sets across the participating countries, with these mind-sets emerging after the data were analyzed independent of country, to obtain the basic mind-sets. Only after the trans-national study was done and the global mind-sets extracted were the country of origin of the respondents determined [14].

    That pioneering study suggested that with the proper technology to set up, execute, and analyze experiments, it would someday become possible to run identical transnational studies on virtually any topic that involved human decision making. The early study on coffee took about three months to design, execute, and analyze, not so much because the data required the time, but because the logistic required — individual thinking about the elements, cooperation in the execution of the study, and then the careful analysis of new-to-the-work type of data, and out-of-the-box thinking about mind-set segmentation.

    The more than 25 years since the presentation of that pioneering study at the ESOMAR Congress in Turkey, 1996, has seen this early trans-national approach evolve from an effortful study to one that can be done in the space of a few hours, for a little more than $1,000 or so. The effort to think of ideas has been shifted to artificial intelligence, whether better or worse. The study implementation has been enhanced by the creation of an automatic system, www.BimiLeap.com, and the easy, fast, and inexpensive execution on the web.

    The result of the foregoing, as shown in this study about the Internet in Gaza, can be presented the next day. More importantly, however, this transnational study can be iterated half a dozen times in less than a week, often in a few days, allowing the interested party to explore different aspects of the Internet, different aspects of Gaza, or different aspects of the combination as perceived by the world. And finally, most important, in the spirit of what has been shown here, virtually any topic can be chosen, deeply explored, populated with issues and answers, and iterated several times resulting in a unique, timely, relevant data base about the mind of people where judgment is relevant.

    Acknowledgements

    The authors would like to thank their many colleagues and friends for the opportunity to develop these ideas through patient discussion.

    References

    1. Prasad V, Jena AB (2013) Prespecified falsification end points: can they validate true observational associations? JAMA 309: 241-242. [crossref]
    2. Moskowitz HR, Gofman A (2007) Selling Blue Elephants: How to Make Great Products That People Want Before They Even Know They Want Pearson Education.
    3. Moskowitz HR, Gofman A, Beckley J, Ashman H (2006) Founding a new science: Mind Journal of Sensory Studies 21: 266-307.
    4. Moskowitz HR, Gofman A, Itty B, Katz R, Manchaiah M, et al. (2001) Rapid, inexpensive, actionable concept generation and optimization: the use and promise of self-authoring conjoint analysis for the food service Food Service Technology 1: 149-167.
    5. Gallouj F, Zanfei A (2013) Innovation in public services: Filling a gap in the Structural Change and Economic Dynamics 27: 89-97.
    6. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint Journal of Sensory Studies 25: 127-145.
    7. Huang FL (2018) Multilevel modeling and ordinary least squares regression: how comparable are they? The Journal of Experimental Education 86: 265-281.
    8. Alarabeed W (2021) Youth in post-conflict reconstruction: The case of the Gaza Strip. In Youth Civic Engagement and Local Peacebuilding in the Middle East and North Africa 97-108.
    9. Al-Najar H, Khalil H, Rahayu YS (2019) High unemployment records of graduated students in the development of urban agriculture in the Gaza Strip. Indonesian Journal of Science and Technology 4: 196-203.
    10. Fares F, Taha DS, Sayad ZTE (2018) Achieving public participation in inaccessible areas using virtual reality a case study of Beit Hanoun–Gaza–Palestine. Alexandria Engineering Journal 57: 1821-1828.
    11. Roy S (1994) Separation or integration: closure and the economic future of the Gaza Strip Middle East Journal 48: 11-30.
    12. Shehab A, Alnajar TM, Hamdia MH (2020) A study of the effectiveness of E-learning in Gaza Strip during COVID-19 pandemic: The Islamic University of Gaza “case study”. In Proceedings of the 3rd Scientia Academia International Conference (SAICon-2020), Kuala Lumpur, Malaysia 26-27.
    13. Likas A, Vlassis N, Verbeek JJ (2003) The global k-means clustering Pattern Recognition 36: 451-461.
    14. Moskowitz HR, Bernstein R (2000) Variability in hedonics: Indications of world- wide sensory and cognitive preference Journal of Sensory Studies 15: 263-284.

Effects of Aqueous Extract of Spirulina platensis on Some Reproductive Performances in Rabbit Does (Oryctolagus cuniculus)

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DOI: 10.31038/IJVB.2022621

Abstract

The present study was conducted to assess the effects of Spirulina platensis extract on some reproductive performances. Twenty-four nulliparous sexually mature female rabbits weighing between 2100 g and 2200 g were used. These rabbits were divided into 4 groups of 6 animals each. Each group was randomly attributed orally the following Spirulina extract doses: 0 (control group), 5, 10 and 20 mg respectively of Spirulina per kg body weight (bw) for 60 days. After 30 days of treatment, blood was collected (for analyses) and the females were mated. The treatment continued during pregnancy. Then, receptivity, fertility, weight, viability, litter size, and pups sex-ratio were determined. Spirulina extract had no significant P>0.05) effect on the rate of receptivity, fertility, viability, body weight, serum concentration of FSH, estradiol and protein. However, administration of 10 mg per kg bw produced the best results. The serum LH concentration, litter size, time limit of male acceptance, pups weight and Sex-ratio were significantly higher (P<0.05) in the group of does which received 10mg/kg of Spirulina extract. Aqueous extract of Spirulina platensis can be used to improve female reproductive performances

Keywords

Aqueous extract, Spirulina, Does, Reproduction

Introduction

For the past decades, some plants have been playing important role in disease curing along with artificial medications commonly called medicinal plants. The growing demand for natural or Bio products reanimates the rate of interest of researchers to study plants and their extracts [1]. A larger number of these plants and their extracts have shown beneficial therapeutic effects including fertility enhancing and contraceptive compounds, anti-oxidant, anti-inflammatory, anti-cancer, anti-microbial, hépatoprotective, immunological and aphrodisiac [2,3]. These properties are used in animal production [4]. Spirulina (Spirulina platensis) is a microalgae belonging to the phylum cyanophyceae and growing in alkaline, salty and warm water. Studies of Spirulina and their extract have shown they contain anti-inflammatory, anti-cancer, anti-microbial, hepato-protective and antioxidant activities [5-7]. Many studies have been conducted in animal production on the effects of aqueous extract on growth performance; but very little information exist regarding their effect on reproductive performances especially concerning spirulina aqueous extract [8,9]. Experimental studies have shown that in rats treated with Spirulina platensis at the doses 2 and 8 mg/Kg per body weight, there was an increase in the body weight, libido and rate of reproductive hormones [8-10]. Although these studies showed some positive effects of spirulina, results on the effects of its aqueous extract on the reproductive performances especially in females are rare. Thus this study was carried out to investigate the effect of the aqueous extract of spirulina on some reproductive performances in female rabbit.

Materials and Methods

Obtainment and Preparation of Spirulina platensis Aqueous Extract

The harvested spirulina were dried in the shade and then ground into fine powder. In the Laboratory of Animal Physiology of the Faculty of Agronomy and Agricultural Sciences, 250 grams of the powder were dissolved in 1.5 liters of distilled water for 48h at room temperature and filtered through Whatman number 3 paper. The filtrate obtained was transferred to an evaporator (drying-cupboard) at 45°C until a solid blackish paste was obtained. The powder was used for extraction respecting the protocol described by Bougandan [11]. The extraction yield (Y) was 26.25% determined by the following formula:

Y (%)=weight after extraction/weight before extraction x 100

Photochemistry of Spirulina platensis Aqueous Extract

Chemical screening of the AESP has been done following standard methods (Harbone, 1973) and the components revealed are presented in Table 1.

Table 1: Chemical components of aqueous extract of Spirulina platensis

Components

Types of réactions

Aqueous extract of Spirulina platensis
Alkaloïds MAYER

+
Steroïds  

Liberman Buchar

++
Triterpèns

+
FlavonoÏds Schinoda

+
Phénols Chlorure ferrique/MeoH

+
Tanins H2O/Chlorure ferrique

++
Saponins

++

Solutions of the aqueous Spirulina platensis Aqueous Extract were prepared at different experimental doses by dissolution in distilled water, as indicated in Table 2.

Table 2: Preparation of the aqueous extract of Spirulina platensis Extract leaves

Dose (mg/kg bw)

Quantity of extract (mg)

VDW (ml)

FVS (bw ml/kg)

CS (mg/bw ml/kg)

0

0

1000

1000

0

5

5

955

1000

5

10

10

950

1000

10

20

20

980

1000

20
CS: Concentration of the Solution; VDW: Volume of Distilled Water; FVS: Volume of the Final Solution.

Twenty-four nulliparous sexually mature female rabbits weighing 2100-2200 g and aged 6 months, mated with untreated sexually mature male during the treatments, in the sex ratio 1:3 were used. The animals were randomly divided into 4 groups of 6 rabbits does each comparable. In terms of body weight (bw). Each group was randomly administered orally for 60 days (30 days before gestation and 30 days of gestation), the following Spirulina extract doses: 0 (control group), 5, 10 and 20 mg of Spirulina per kg body weight, done daily between 6:30 and 8:30 am. Throughout the experimental period, feed and water were provided ad libitum to animals.

After 30 days of treatment, animals were anaesthetized using blood samples were collected into tubes free of anti-coagulant for dosing biochemistry characterisics. Serum was isolated and stored at -20°C prior to analysis. Samples were centrifuged at 3000 r/min for 10 min to obtain plasma. The females were mated and reproductive performances collected.

Receptivity and Fertility

The rate of receptivity was determined using the following formula:

Rate of receptivity=(number of female which accepted male/number of female presented to male) x 100

The time limit of male acceptance was evaluated by considering the number of days taken by females to accept the male.

The rate of fertility was determined using the following formula:

Rate of fertility=(number of mated female/Total number of females) ×100

Pups Body Weight, Viability and Sex-ratio

The body weight of pups was evaluated at birth and every week during three weeks. Viability and sex-ratio were determined using following formula:

Rate of viability=(Number of life pups/total-pups) x 100

Sex-ratio of pups=(Number of male pups/Number of female pups)

Biochemical Analysis

Total protein contents in serum were determined using the methods of biuret [12]. FSH, LH and estradiol were determined using a commercial kit ELISA Pathozyme® (Omega Diagnostics Inc).

Statistical Analysis

The data collected were submitted to one way analysis of variance (ANOVA) to test the effects of different treatments of aqueous extracts (0, 5, 10 and 20 mg/kg bw) on studied characteristics. The Duncan test was performed to separate means when a significant difference existed (Vilain, 1999). The limit of significance was fixed at 5% and the software SPSS 20.0 was used for the analysis. Results were expressed as mean standard deviation.

Results

Body Weight

As shown in the Table 3, Spirulina aqueous extract had no significant effect (P>0.05) on the body weight of the animals. However, body weight increased more with the dose of 10 mg/kg bw of extract than the other groups.

Table 3: Centesimal composition and bromatological characteristics of the ration

Ingredients

Amount (kg/100 kg)
Corn

25.00
Bran wheat

10.00
Palm kernel cake

15.5
Cotton seal meal

5.00
Soybean meal

10.00
Fishmeal

4.00
bone meal

1.00
Premix 5%

5
Salt

0.5
Palm oil

4.00
Pennisetum purpurum

20.00
Total

100.00
Chemical Characteristics
Metabolized energy (Kcal/kg)

2600.00
Crude protein (%)

19.00
Crude fiber (%)

14.18
Calcuim (%)

1.05
Phosphorus (%)

0.68
Sodium (%)

0.27
Lysin (%)

1.01
Methionin (%)

0.4

Receptivity, Fertility, Pups Body Weight, Viability and Sex-ratio

Administration of spirulina aqueous extract to females significantly increased (P<0.05) the litter size, pups body weight and sex-ratio dose-dependently compared to control group. The time of male acceptance decreased significantly with the dose of 10mg/kg body weight of aqueous extract of spirulina. Except for the dose 20 mg/kg bw, the rate of receptivity was 100% whatever the group (Table 5).

Table 4: Effects of aqueous extract of Spirulina on the body weight of female does

Characteristics

Doses of Spirulina aqueous extract (mg/kg b w)

0 (n= 6)

5 (n=6)

10 (n=6)

20 (n=6)

p
Initial body weight

2120,17 ± 439,21a

2033,83 ± 165,86a

2094,80 ± 294,80a

2045,14 ± 244,55a

0.73
Body weight after 30 days of treatment

2408,33 ± 430,70

2240,17 ± 222.89

2516,00 ± 209,33

2352,85 ± 182,73

0.51
Final Body weight at parturition

2869,66 ± 410,07a

2692,83 ± 175.89a

2953,60 ± 184,40a

2841,17 ± 285,03a

0.61

Table 5: Effect of spirulina aqueous extract on reproductive performances of female does

Characteristics

 Doses of spirulina aqueous extract ( mg/kg bw)

0 (n=6)

5 (n=6)

10 (n=6)

20 (n=6)

p
Rte of receptivity (%)

100 ± 0.00

100 ± 0.00

100 ± 0.00

95.71 ± 7.8

0.15
Time of male acceptance

1.71 ± 1.11ab

2.33 ± 1.37a

1.00 ± 0.00b

1.83 ± 0.00ab

0.03
Fertility (%)

100 ± 0.00 a

66.67 ± 51.54 b

100 ± 0.00 a

100 ± 0.00 a

0.01
Litter size

5.85 ± 1.14b

6.25 ± 0.96ab

7.8 ± 1.70a

5.60 ± 0.89b

0.03
Pups body weight at birth (g)

50.98 ± 7.12

52.8 ± 9.55

55.58 ± 3.48

55.66 ± 4.63

0.60
Pups body weight at 3 weeks (g)

266 ± 56.51 b

292 ± 36.62ab

311.5 ± 37.25 a

290.66 ± 48.013ab

0.05
Pups viability at birth (%)

90.00 ± 22.36 ab

100 ± 0.00 a

67.5 ± 46.43 b

97.55 ± 5.49 a

0.01
Pups viability at 3 weeks (%)

30.47 ± 24.57

37.77 ± 42.71

40 ± 41.82

33.71 ± 35.82

0.73
Sex-ratio

0.50 ± 0.70b

1.53 ± 0.58ab

2.33 ± 1.53a

1.33 ± 0.58ab

0.00

Biochemical Characteristics

It appears that the serum LH increased significantly (P>0.05) with spirulina extract dose compared to the control group. The value obtained from the group that received 10mg/kg bw was higher than that of the other groups. The administration of spirulina aqueous extract did not significantly affect the serum FSH and estradiol. However the latter increased dose-dependently with higher values for the group of rabbits which received 10 mg/kg b w of extract (Figures 1-4).

FIG 1

Figure 1: Effects of spirulina aqueous extract on serum total proteins

FIG 2

Figure 2: Effects of spirulina aqueous extract on FSH concentration

FIG 3

Figure 3: Effects of spirulina aqueous extract on LH concentration

FIG 4

Figure 4: Effects of spirulina aqueous extract on estradiol concentration

Discussion

The results of this study indicated that Spirulina platensis had a significant increase on the litter size and pups body weight. These results are comparable to those found by Lienou et al. [13] in female rats treated with aqueous extract of Senecio biafrae at the dose of 32 and 64 mg/kg bw and Ainehchi and Zahedi, [14] in female rats treated with 200 and 400 mg/kg bw of hydroalcoolic extract of Artemisia lanata. This may be due to the induction of follicular growth or folliculogenesis. In fact, the process of follicular growth is under the control of FSH and LH. This extract may have biological compounds or analogous of a general excitatory neurotransmitter of the central nervous system which induce the pulsatile releases of GnRH. The latter leads to the pulsatile release of pituitary hormones which enhance the proliferation of the follicles and therefore increase litter size. The increase of pups body weight can be attributed to essential amino acids [15] present in the spirulina. This work also revealed a significant increase of pups sex-ratio in treated groups. This result could be explained by the synthesis and the action of androgens secretes by fetal testicle during sexual differentiation. In fact, spirulina antioxidant activity and its antioxydant power may protect against disturbing androgens. These disturbing androgens cause gonads feminization.

The aqueous extract of Spirulina platensis also resulted in a significant decrease of the time of male acceptance. These results corroborated the finding of Lienou et al. [13] in female rats treated with aqueous extract of Senecio biafrae at the dose of 8 and 32 mg/kg. Estrogens and estrogen –like (phytoestrogens) are well known regulators of receptivity in rabbits [16]. They exert their biological effect following their fixation to the receptors in their main target organs (ovary, uterus, hypothalamus…) thus leading to a chain of reactions, culmulating in the biosynthesis of biomacromolecules and the increase of sexual appetite. As concerning the test on biochemical parameters, a non-significant increase in serum protein in rabbits which received extract of spirulina was obtained. These results are comparable to those found by Kameni, [17]. In rats treated with aqueous extract of Nymphaea lotus at the dose of 75 mg/kg bw, and Kamtchouing et al. [18] in rats treated for 8 days with Pentadiplandra brazzeana. This may be due to the high digestibility of protein contained in the spirulina. The Spirulina platensis aqueous extract treatment also resulted in a significant increase of LH. These results corroborated the finding of Adaay et Mattar [19] in female rats treated with a mixture of aqueous and ethanolic extract of Tribulus terrestris, Phoenix dactylifera and Nasturtium officinale at the doses of 75, 150 and 300mg/kg/days et contradict the finding by Woode et al. [20] in male rats treated with éthanolic extract of Xylopia aethiopica fruits at the doses of 30, 100 et 300 mg/kg bw. This elevation may explain the increase in the litter size mentioned before and the increase of estradiol also. It is known that LH induces the pulsatile release of estrogen by stimulating ovary.

Conclusion

From the study on the effects of aqueous extracts of Spirulina platensis on the reproductive characteristics of rabbit does, the main conclusions were as follows: the Spirulina platensis aqueous extract had beneficial effects on reproduction by stimulating the production of LH estradiol and serum protein concentration and improves the litter size, time limit of male acceptance, pups weight and Sex-ratio. The reproductive characteristics were put to evidence by the significantly greater concentrations of LH with the maintenance of fertility. Therefore it can be advised for use by female to improve the reproductive performance. In case of its utilization, the dose 10 mg/kg bw is recommended, since protective effects were more pronounced at this dose.

Conflict of Interest Statement

We declare that we have no conflict of interest.

Funding

This research received no external funding.

Author Contributions

Conceptualization was done by DEUTCHEU NIENGA Sorelle, VEMO Bertin Narcisse and Ngoula Ferdinand.; Methodology, data collection and writing was done by DEUTCHEU NIENGA Sorelle, VEMO Bertin Narcisse and CHONGSI Margaret Mary Momo.

Data Availability

The data sets used during the current study are available from the corresponding author upon reasonable request.

References

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  9. Kim CJ, Yoon SK, Kim HI, Park YH, Oh HM (2006) Effect of Spirulina platensis and probiotics as feed additives on growth of shrimp Fenneropenaeus chinensis. Journal of Microbiology and Biotechnology 16: 1248-1254.
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Knowledge of Risks of Preeclampsia and Its Contributing Variables in Imo State

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DOI: 10.31038/EDMJ.2022623

Abstract

A major hazard to world health is the global pandemic of preeclampsia (PE risk. It is acknowledged as a chronic, incapacitating illness with major complications. This finally leads to the untimely death of both the mother and the fetus. It also drastically reduces life expectancy, can result in multi-system morbidities, and raises healthcare expenses. Regardless of knowledge, all forms of preeclampsia result in unacceptably high stress for Imo State in terms of people and society. Therefore, this study focused on Imo State in Southeast Nigeria to examine the knowledge impact of the hazards related to pre-eclampsia during pregnancy. In this investigation, both descriptive and analytical study designs were used. Target, stratified, and random sampling were all used as data collection methods. The sample size included 3690 individuals from different parts of the state. Data collection for the study was done using questionnaires. With the generated data, tables and charts were made. In terms of statistics, Chi-square analysis was used to determine the difference between patient and individual knowledge of risk factors. Out of 2700 persons that responded to the question on whether they know about risks of preeclampsia, 68% of them representing 1761said “Yes”, while 32% representing 829 said “No”; a chi-square contingency analysis on the respondents’ knowledge of risks of preeclampsia yielded a value of 70.6764   (p<0.05). On whether they know if they are living with risks of preeclampsia, 829 out of 2700 respondents which represent (11.33%)of the responses said “Yes”, while 2340 which accounted for (88.67%) of the responses said “No”. This puts the prevalence rate at 11.33%, but blood pressure screening results puts the prevalence rate at 39.00%. When asked if they know their blood pressure, 31% of the respondents which accounted for 811±7.8 out 2700 responses said “Yes”, while 61.00% representing 1494±2.1490 out 2700 said “No”; a chi-square contingency analysis gave a value of 152.7232 with a p-value of <0.001 indicating very high significant difference. Also, great percentage of the respondents has idea of hereditary as risk factors that associated with risks of preeclampsia. Pregnant women in Imo state are not well informed about PE. Higher education is a key element that promotes adequate knowledge of physical education.

Keywords

Impacts, Imo State, Pre-eclampsia, Risks, Knowledge

Introduction

Preeclampsia (PE) is a multisystem illness associated with pregnancy that lacks a known cause. PE’s underlying cause is currently being researched. It is believed to happen in two stages, though. The first stage includes the impairment of local placental hypoxia and fetal trophoblastic invasion of the decidua. The second stage involves abnormal production of pro-inflammatory, antiangiogenic, and angiogenic factors as well as the release of placental blood-related substances into the maternal circulation [1].

Elevated blood pressure and proteinuria are the typical symptoms of Preeclampsia, and the clinical manifestation often starts around the 20th week of pregnancy or later in the pregnancy, regressing after delivery. Early-onset PE (occurring before 34 weeks of gestation) and late-onset PE (occurring beyond 34 weeks of gestation) are the two primary kinds. Early-onset PE is linked to higher odds of problems than late-onset PE, including preterm birth, fetal growth restriction, and maternal morbidity and death [2]. This is true even if the presenting characteristics of early- and late-onset PE may overlap. Women living with Preeclampsia also exhibit a variety of indications and symptoms that are related to various organ systems. The multi-organ system dysfunction in Preeclampsia frequently results in headaches, visual abnormalities, abnormal renal function, severe hypertension, chest pain, pulmonary oedema and low oxygen saturation, nausea, and abnormal liver function, among other symptoms. First pregnancy, age (pregnancy after 18 or at an advanced age), family history of Pre-eclampsia, personal history of Pre-eclampsia, obesity, gestational diabetes, multiple pregnancy, and preexisting illnesses such chronic hypertension are all risk factors for Pre-eclampsia [3].

According to reports, Pre-eclampsia complicates 2-8% of pregnancies globally and up to 10% in underdeveloped nations, making it one of the top causes of maternal mortality and morbidity. Very high percentage of Imo people are thought to have Pre-eclampsia. It is one among the top five killers of pregnant women and newborns. PE can develop into eclampsia, which can result in adverse fetal outcomes like preterm birth, small-for-gestational-age babies, placental abruption, and perinatal death. It can also raise the risk of cardiovascular and cerebrovascular diseases, as well as venous thromboembolism in later life .Additionally, women with Pre-eclampsia are more likely to experience postpartum depression and other mental health problems such shame, remorse, failure-related feelings, a sense of loss of control, and post-traumatic stress disorder [4].

Adequate understanding of a disorder aids in its management, control, and prevention. According to reports, people who are knowledgeable about their disease are more likely to adhere to therapy and experience fewer difficulties. The slow reporting of women to healthcare facilities after experiencing a sign or symptom in Imo State Nigeria is a significant barrier in the fight against Preeclampsia. Preeclampsia is a disease with visible signs and symptoms that needs to be treated right away. With the right information, women experiencing Preeclampsia would notify the hospital sooner, receive treatment sooner, and experience fewer negative effects. This highlights how important it is for women to understand the disease fully [5,6].

In order to accomplish this, it is necessary to evaluate the pre-existing knowledge about Preeclampsia, particularly among high-risk groups like pregnant women. Previous research from the Nigeria  and a few African nations  suggests that women generally have little awareness of PE [7]. However, there isn’t a study available right now that assesses Imo State’ level of Preeclampsia knowledge.

Due to a lack of reliable statistical information, it is difficult to establish full understanding on Risks Associated with Preeclampsia during Pregnancy in Imo State. The goal of the current study is to contrast the risks associated with preeclampsia during pregnancy in Imo State, Nigeria. The results of this analysis should help Imo State, Nigeria, establish efficient preeclampsia management and general prevention efforts.

Materials and Methods

Study Area

The study was carried out in Nigeria’s Imo State. One of Nigeria’s 36 States, Imo State is situated in the Southeast geopolitical zone. Imo State has an area of roughly 5,100 sq km and is located between latitudes 4°45’N and 7°15’N, as well as longitudes 6°50’E and 7°25’E. It is bordered on the east by Abia State, on the west by Delta State and the River Niger, on the north by Anambra State, and on the south by Rivers State. Isu, Okigwe, Oguta, Orlu, Mbaise, Mbano, Mbaitoli, Mbieri, Orodo, Nkwere, and Orsu are among Imo State’s important cities in addition to Owerri [8].

Study Design

This study used both descriptive and analytical study designs [9]. This included the knowledge of risks connected to pregnancy-related pre-enclampsia. Analytical design was utilized to analyze the distribution’s determinants, whereas descriptive design was employed to evaluate the risks associated with pre-enclampsia during pregnancy.

Survey Methods and Sampling Technique

The survey methods used in this study were random, target, and stratified sampling [10]. Random sampling was used to gather data from the LGAs, target was used to gather data from the hospitals, and stratified was used to gather data for the entire state, in which case each LGA was used as a stratum.

Sample Size

With survey software’s sample size calculator, the confidence interval and level were set at 5% and 90%, respectively. The distribution of Imo State’s population by gender, age, profession, and other factors is not known with any recent accuracy. The official 2006 census served as the foundation for this study’s population estimations. It is reported that Imo State had 3,927,563 people living there as per the official census from 2006. According to projections, the population will increase by 3.3% from 2006 to reach 5,408,800. Males made up 1,976,471 (or 50.3%) of the population in 2006, while females made up 1,951,092 (or 49.7%). There is no discernible difference in the proportion of men and women.

One can extrapolate from the aforementioned facts since there was no official information available regarding the number of women of childbearing age. Groups of people aged 0 to 14 (1,415,929) and 65 and older (170,069) were not included because they were either too young or too old. The group of people aged 15 to 64 (2,341,565) has now left. 49.7% of the population was female overall in 2006. From the entire 15- to 64-year age range, the female population was estimated as 0.497 × 2,341, 565=1,163,75.

Questionnaire 1: 2700 (no of questionnaires administered to each LGA depended on the population of the LGA) respondents for the general populace.

Questionnaire 2: 540 (20 from each LGA) respondents for the category of Risks Associated with Pre-enclampsia during pregnancy.

Method of Data Collection

Research instrument for data collection was questionnaires and materials such as blood pressure measuring kits, measuring tape and weighing balance was used for physical examination.

Questionnaires

Well-structured questionnaires were used to obtain data from respondents; the questionnaires were arranged in the following order:

Questionnaire 1

This was used to indicate information from the general populace. It was organized into knowledge impact of Risks Associated with Preeclampsia during pregnancy

Ethical Consideration

Before administering surveys to respondents, letters of approval or authorization were submitted for the management of health institutions’ approval. Additionally, before giving out questionnaires, those who had Risks Associated with Preeclampsia during Pregnancy were asked for their permission. Before administering the questionnaires to the broader public, a similar consent was requested.

Data Presentation and Statistical Analysis

The association between the risks of preeclampsia during pregnancy and age was measured using correlation and regression analysis, in which case r (correlation coefficient) and r2 (coefficient of simple determinant) were obtained using SPSS statistical software version 17.0.

Tables and charts with the generated data were created. Data that were produced in accordance with various parameters that were taken into consideration in this study were measured for correlation using descriptive statistics, including mean, relative standard error, and standard deviation. Version 17.0 of the statistical program SPSS was used for this [11]. Patients’ perceptions of risk factors for preeclampsia and complications were evaluated using chi-square.

Utilizing computer-aided software, GenStat Statistical Software, the coefficient of variation (% CV), which measures variability, was calculated for the data collected from the various LGAs.

Results

This research work on knowledge impacts of Risks Associated with Pre-eclampsia during pregnancy in Imo State. The data and results that were obtained from this research study were presented in Tables (Figures 1 and 2).

fig 1

Figure 1: Responses to knowledge risk of preeclampsia.
Knowledge of risk of preeclamsia (1) The results showed that 1761 (68%) respondents answered positively to knowing about risk of preeclamsia while 829 (32.00%) responded negatively to knowing about preeclamsia. A chi-square statistical test yielded a value 70.6764 (p< 0.0526) which was very significant at p< 0.05.
The result on whether the respondents knew whether they were living with risk of preeclamsia showed that 299 (11.33%) knew they were living with risk of preeclamsia while 2340 (88.67%) did not know if they were living with risk of preeclamsia. A 27 x 2 contingency chi-square test of significance gave a value of 13964.021 (p<0.0000) which was significant at p<0.001.
Greater percentage of the respondents which represented 1883 (72.62%) answered negatively to having a relative with risk of preeclamsia while 710 (27.38%) responded positively to having relatives with risk of preeclamsia. A chi-square test gave a value of 58.4932 (p=0.2808) which was not significant at p>0.05.
The results showed that 1056 (40.51%) of the respondents have never been screened for risk of preeclamsia while 1551 (59.49%) respondents have been screened for risk of preeclamsia before. A chi-square test of significance gave a value of 93.493 (p=0.0005) which was very highly significant at p<0.05.

fig 2

Figure 2: Responses to Knowledge risk of Preeclampsia 2.
Knowledge of risk of preeclampsia (2) The second section on the knowledge of risk of preeclampsia (2) is shown in Table 2 below. 850 (33.44%) respondents answered ‘Yes’ to knowing their aging contribute to Risk of preeclampsia while 1692 (66.56%) respondents answered ‘No’ to knowing their aging contribute to Risk of preeclampsia. A chi-square test of significance having degree of freedom of 26 yielded a value of 115.7206 (p<0.001) which was very highly significant at p<0.05.
955 (39.00%)respondents answered ‘Yes’ to knowing their blood pressure level while 1494 (61.00%) respondents answered ‘No’ to knowing their blood pressure level. A chi-square test of significance yielded a value of 152.7232 (p<0.001) which was very highly significant at p<0.001.The results equally showed that majority of the respondents did not know their blood pressure level.
On whether the respondents knew being obese contribute to risk of preeclampsia, 257 (11.24%) respondents answered ‘Yes’ to knowing that being obese contribute to Risk of preeclampsia while 2030 (88.76%) respondents answered ‘No’ to knowing that being obese contribute to Risk of preeclampsia. A chi-square test of significance having degree of freedom of 26 yielded a value of 71.2682 (p=0.047775) which was very highly significant at p<0.05.

Discussion

Preeclampsia Risks in Imo State: The Impact of Knowledge

Preeclampsia risks have been shown to have a negative impact on Imo State people. Other studies have measured knowledge status using a number of characteristics, including career, education, income, or regional deprivation. Numerous facets of knowledge state may be represented by these markers [12].

One of the reasons for poor performance at work has been linked to preeclampsia risk. Preeclampsia knowledge increases the likelihood that a woman will be at low risk. Obesity and blood pressure are associated with higher preeclampsia risks and also have worse knowledge levels [13]. The fact that most participants were aware of PE, primarily due to awareness of chronic hypertension, can be linked to the population’s lack of knowledge of PE. However, only a small percentage of people were well informed on the signs, causes, and complications of PE.

Preeclampsia is now well acknowledged as a potential problem. It is immediately identified as “high blood pressure in early pregnancy” due to its alarming nature. Almost everyone who was tested or interviewed in this study referred to the illness that was being studied as a “sickness that hurt the embryo [14].

This suggests that most people in Imo State were already aware of the disease. Preeclampsia is a risk that many people in the state acknowledged, although a sizable portion of them did not know about other preeclampsia risks. Contrary to the fact that they were aware of the sickness, many did not know what their blood pressure was. This shows that many people, whether they have preeclampsia or not, have not been diagnosed with the risks associated with the condition or do not care to know what their blood pressure is [15].

Pre-eclampsia often begins after 20 weeks of pregnancy in women whose blood pressure was previously normal. The mother and the kid could both encounter serious, perhaps fatal, issues.

There might be no symptoms. High blood pressure and protein in the urine are important indicators. However, it could be difficult to distinguish between this and an usual pregnancy [16].

Pre-eclampsia is commonly managed with oral or intravenous medication until the infant is old enough to be delivered. In many cases, this entails weighing the risks of an early birth against those of chronic pre-eclampsia symptoms. Pre-eclampsia is responsible for 9% of maternal mortality in Africa and Asia and problems in 2-8% of pregnancies worldwide [17]. Globally, the majority of deaths attributed to pregnancy-associated hypertension diseases occur in underdeveloped countries. According to the World Health Organization, pre-eclampsia is projected to occur seven times more commonly in less developed countries (2.8% of live births) than in more developed ones (0.4%) [18,19]. Imo State, Nigeria, has a higher and nearly twice as high prevalence rate when compared to the rest of the world and the continent of Africa. It’s possible that Imo State in Nigeria’s rising crises is to blame for this high incidence. The genesis of preeclampsia may be influenced by maternal, paternal, and fetal genetic factors, according to early family-based research. According to the WHO, with a 2.8 prevalence rate, there are about three new cases every 40 seconds, or close to 10 million cases per year [20]. In Imo State, four new cases would consequently occur every 40 seconds, with a prevalence rate of 11.33%. According to observation, the largest rises are anticipated to take place in regions with a majority of developing economies. Imo State is located in Nigeria, where emerging economies are the majority. This makes Imo State’s situation worse.

Without concerted efforts to halt it in its tracks, the prevalence rate of 11.33% in Imo State would likely rise to greater levels in the upcoming years, which is quite concerning. Throughout the course of the study, more residents of Imo State were discovered to be ignorant about their preeclampsia risks. After being admitted to the hospital or when their health has gotten worse, they only realize they are at risk for preeclampsia [21,22].

Preeclampsia concerns have also resulted in restrictions on movement in preeclampsia patients due to increased blood pressure. As a result, it makes social interaction between people take longer. However, given factors that affected awareness of PE were not static or general demographic factors, the low knowledge of PE found in this study might be improved. Evidently, after controlling for confounders that could have confounded the association, the high educational level was the only significant factor that was independently associated with adequate knowledge of PE. This study suggests that efforts to reduce PE-related fatalities in Imo State might be greatly aided by the employment of an efficient method of teaching women, possibly at prenatal appointments and through media channels. Indeed, it has been demonstrated that increasing patient understanding of PE encourages earlier reporting of signs and symptoms, which can result in prompt treatment and better health outcomes for both the mother and the infant.

Conclusion

Residents of Imo State are increasingly at risk for preeclampsia, as many sufferers are unaware of their illness. Preeclampsia chances varied across the state based on factors like knowledge.

Indeed, few pregnant women are aware of preeclampsia. A higher degree of education is a key element that promotes adequate knowledge of physical education. This emphasizes the necessity of stepping up efforts to increase women’s knowledge about PE in order to enhance pregnancy outcomes. Education may be provided through national education programs, media platforms, or contextual health education at Antenal care.

References

  1. Morton CH, Seacrist MJ, VanOtterloo LR, Main EK. (2019) Quality improvement opportunities identified through case review of pregnancy-related deaths from preeclampsia/eclampsia. J Obstet Gynecol Neonatal Nurs 48(3): 275-287. [crossref]
  2. Das S, Das R, Bajracharya R, Baral G, Jabegu B, Odland JØ (2019) Incidence and risk factors of pre-eclampsia in the paropakar maternity and women’s hospital, Nepal: A retrospective study. Int J Environ Res Public Health 16(19): 1-8. [crossref]
  3. com.ng (2022). Imo State History, Local Government Area, and Senatrial Zones/Districts. [crossref]
  4. Ebrahimi A, Sayad B, Rahimi Z. (2020) COVID-19 and psoriasis: biologic treatment and challenges.J Dermatolog Treat. J Dermatolog Treat 1-5. [crossref]
  5. Belay AS, Wudad T. (2019) Prevalence and associated factors of pre-eclampsia among pregnant women attending antenatal care at Mettu Karl referral hospital, Ethiopia: cross-sectional study. Journal of Clinical Practice 25(1): 14. [crossref]
  6. World Health Organisation’ (2011). WHO recommendations for prevention and treatment of preeclampsia and eclampsia. [crossref]
  7. Wandabwa J, Doyle P, Kiondo P, Campbell O, Maconichie N, Welishe G. (2010) Risk factors for severe pre-eclampsia and eclampsia in Mulago Hospital, Kampala, Uganda. East African Medical Journal 87(10): 415-424. [crossref]
  8. Stevens W, Shih T, Incerti D, Ton TGN, Lee HC, Peneva D. (2017) Short-term costs of preeclampsia to the United States health care system. Am J Obstet Gynecol 217(3): 237-248.e16. [crossref]
  9. Nnodim J, Emmanuel N, Hope O, Nwadike C, Ukamaka E, Christian O. (2017) Membrane potential, serum calcium and serum selenium decrease in preeclampsia subjects in Owerri. Universa Medicina 36(2): 88-93.
  10. Siddiqui A, Deneux-Tharaux C, Luton D, Schmitz T, Mandelbrot L, Estellat C (2020) Maternal obesity and severe pre-eclampsia among immigrant women: a mediation analysis. Sci Rep 10(1): 1-9. [crossref]
  11. Ajah LO, Ozonu NC, Ezeonu PO, Lawani LO, Obuna JA, Onwe EO. (2016) The Feto-Maternal Outcome of Preeclampsia with Severe Features and Eclampsia in Abakaliki, South-East Nigeria. Journal of Clinical Diagnostics and Research 10(9): QC18-QC21. [crossref]
  12. Amaral LM, Wallace K, Owens M, LaMarca B (2017) Pathophysiology and Current Clinical Management of Preeclampsia. Curr Hypertens Rep 19(8): 616. [crossref]
  13. Vidaeff A, Pettker CM, Simhan H (2019) Gestational Hypertension and Preeclampsia ACOG PRACTICE BULLETIN. Clinical Management Guidelines for Obstetrician-Gynecologists. Am Coll. Obstet Gynecol 133(1): 1–25. [crossref]
  14. Williams PJ and Broughton Pipkin F (2011) The genetics of pre-eclampsia and other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 25: 405-417. [crossref]
  15. Cerdeira AS, O’Sullivan J, Ohuma EO. (2019) Randomized interventional study on prediction of preeclampsia/eclampsia in women with suspected preeclampsia: INSPIRE. Hypertension 74: 983-990. [crossref]
  16. Churchill D, Duley L, Thornton JG, Moussa M, Ali HS, Walker KF. (2018) Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks’ gestation. Cochrane Database Syst Rev 10: CD003106. [crossref]
  17. Chappell LC, Brocklehurst P, Green ME (2019) Planned early delivery or expectant management for late preterm preeclampsia (PHOENIX): a randomised controlled trial. Lancet 394: 1181-1190. [crossref]
  18. Bellamy, L, Casas, J, Hingorani, AD, Williams, DJ. (2007) Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. British Medical Journal 335: 974-985. [crossref]
  19. Birhanu MY, Temesgen H, Demeke G, Assemie MA, Alamneh AA, Desta M, et al. (1995) Importance of matrix metalloproteinases in human trophoblast invasion. Early Pregnancy 1(4): 263-269. [crossref]
  20. Gray KJ, Kovacheva VP, Mirzakhani H, Bjonnes AC, Almoguera B, Wilson ML, et al (2018) Gene-Centric Analysis of Preeclampsia Identifies Maternal Association at PLEKHG1. Hypertension 72(2): 408-416. [crossref]
  21. Duhig KE, Myers J, Seed PT (2019) Placental growth factor testing to assess women with suspected pre-eclampsia: a multicentre, pragmatic, stepped-wedge cluster-randomised controlled trial. Lancet 393: 1807-1818. [crossref]
  22. Hayes-Ryan D, Khashan AS, Hemming K (2021) Placental growth factor in assessment of women with suspected preeclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland). BMJ 374: n1857. [crossref]

A Clinical Audit of Documentation of Inpatient Medical Record (Admission Note)- Medicine Department in Sea Ports Corporation Hospital – Port Sudan – Red Sea State – Sudan on May 2022

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DOI: 10.31038/JCRM.2022563

Abstract

Objective:

  • Assessment and evaluation of medical records (admission sheets).
  • Emphasizing the importance of proper documentation in medical records.
  • Step towards professional practice.

Methodology:

  • The standards of proper medical records were identified using different references and literature reviews, then Standardized questionnaire was generated
  • Consisting of 18 questions related to proper admission sheets documentation.
  • The data were collected retrospectively from inpatients medical records (admission sheets) in Sea Ports Corporation Hospital- medicine department in May 2022.
  • A total number of 101 admission sheets were inspected
  • The data were collected manually within 1 week.
  • Then data were analyzed use SPSS 22.

Conclusion:

  • There is clearly large discrepancy between the standards and local hospital medical records.
  • The Medical records must provide an overall accurate description of each patient care and the way of communication between care providers.
  • The medical records are vital, legally and for future hospital planning so must be a point of concern.
  • Regular check of medical records should be performed by a senior consultant and quality improvement team. Periodic audit in different departments must be done and re auditing is very important for quality improvement.

Keywords

Documentation is the a vital part of professional practice, It is the main predictor of patient care and outcome but it wasn’t given its importance by medical staff who was only depending on verbal communication

This study is mainly to reflect the importance of accurate and complete medical record and the reason behind poor documentation, So it is to attract the attention towards good medical practice which can be achieved through staff training and document sheath modification. This study is considered as Step towards evidence based practice and quality improvement.

Introduction

Clinical audit is quality improvement process that seeks to improve patient care and outcomes through systemic review against explicit standard criteria  and implementation of change in practice if need [1]. Medical audit is the way towards evidence based practice and not an opportunity to name, shame or blame. A qualified Medical record should enable health care professionals to plan and evaluate patient’s treatment and continuity of care among multiple care providers [2]. It is the Vital part of professional Practice. The purpose of documentation [3]

  • Documentation is the way of Communication & continuity of care among physicians & other health care Professionals involved in the patient care.
  • It provides Peer review and continuity of education through audit and research.
  • Proper document reflects high Quality of care, professionalism & competency.
  • Documentation guarantees Legal protection for medical staff.
  • The confidentiality of medical records should be fully maintained and should be consistent with the requirements of medical ethics and law.

Types of data in medical record: [2-5]

There are two types of data in medical records

The objective data: this is the facts, it is measurable, Nonjudgmental and it is what you see, hear, smell or palpate e.g.: examination findings, Lab reports

The subjective data: this is the information that received from patient or Co- patients. e.g.: Chief complains HPI, PMH, FH, SH etc.

Aims and Objective

  • Assessment and evaluation of medical records (admission sheets).
  • Emphasizing the importance of proper documentation in medical records.
  • To make Step towards professional practices.

Methodology

  • the standards of proper medical records were identified using different references and literature reviews, then Standardized questionnaire was generated consisting of 18 questions related to proper admission sheets documentation.
  • The data were collected retrospectively from inpatients medical records (admission sheets ) in Sea Ports Corporation Hospital- medicine department in May 2022.
  • A total number of 101 admission sheets were inspected.
  • The data were collected manually within 1 week.
  • Then data were analyzed use SPSS 22.

Results

The data were assessed and valued as (satisfactory, borderline, unsatisfactory) according to explicit criteria and standards of admission sheets. Personal data are 75 % borderline, that means there is no complete personal data, specifically. No concentration on residence area, marital status, tribe, occupation and telephone number of the patient and no one can deny the legal value of complete and satisfactory personal data. Chief complain fortunately satisfied 60% and it is the area that took doctors concentration. History of presenting illness, this must contain analysis of the main complaint and systems involved but in this study it is found that it hasn’t been done properly and satisfied only 20%. Systemic review was satisfactory by 5% and this big and important questioning area. Past medical and surgical history are vital parts of patient history specifically in medicine where most of the illnesses are complications of past diseases and operations, so doctors must take their time in taking detailed past history, in our research it is satisfactory by only 15%. Good physician must have solid therapeutic package and Drug history must take its value, in our research drug history is 47% unsatisfactory. The Family history is satisfactory by only 4% and this rises many questions as why doctors didn’t take family history although most of the diseases run in families.

The Social history is 82% unsatisfactory, this rises the question of is there awareness to take patient as human being and not just a disease, and also social background has a correlation with diseases. When we come to physical examination, the Vital signs recorded in80%of the cases. General examination 20% which is borderline. Specific system examination is recorded in 60 %of cases which is borderline. Investigation is documented and 55% satisfactory but there is no specific area in the sheet to write them down so they are impeded within the history and follow up sheath. Fortunately the ER sheet is adherent to the admission file so that the Initial plan documented in ER sheet by 94% satisfaction. Working diagnosis is 14% satisfactory to highlight that is our guidance in patient care and daily patient follow up so must have clearly problem list from the start till have provisional diagnosis which in our audit 33% satisfactory. Doctor name and signature must be Cleary written as it has a legal value in this study It is 90 % unsatisfactory. Unfortunately We have not found a registrar or senior review space in the file so mostly not written in the record.

Conclusion

  • There is clearly large discrepancy between the standards and local hospital medical records.
  • The Medical record must provide an overall accurate description of each patient care and the way of contact among hospital staff.
  • The medical records are vital legally and for future hospital planning so must be point of concern.
  • Regular check of medical record should be performed by a senior consultant and quality improvement team. Periodic audit in different departments must be done and re auditing is very important for quality improvement.

Recommendation

  • Reformulation of medical record sheets to generate local hospital standards.
  • Encouraging the hospital staff to give a lot of importance to good medical records keeping.
  • Training of hospital staff in the professional way of documentation.
  • Increase the number of admitting doctors to minimize the work load.
  • Proper documentation need MDT cooperation.

References

  1. Kediegile G, Madzimbamuto F (2014) Obstacles faced when conducting a clinical audit in Botswana. Southern African Journal of Anaesthesia and Analgesia [ONE-STAR rated by Journal Publishing Practices and Standards (JPPS) https://wwwjournalqualityinfo/jpps-criteria/one-star (assessed: 2019-03-01)] 2014; Southern African Journal of Anaesthesia and Analgesia [ONE-STAR rated by Journal Publishing Practices and Standards (JPPS) https://www.journalquality.info/jpps-criteria/one-star (assessed: 2019-03-01)].
  2. Patnaik S, Singh M, Sridhar B (2017) Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in India. International Journal of Research Foundation of Hospital and Healthcare Administration 5: 77-83.
  3. com. 2022. https://www.google.com/url?esrc=s&q=&rct=j&sa=U&url=https://www.scp-health.com/blog/think-with-your-ink-4-reasons-why-proper-medical-record-documentation-is-vital/&ved=2ahUKEwilgcnvhIr5AhVVQ0EAHW-0B8sQFnoECAIQAg&usg=AOvVaw3s6AosxNxBHwKNPZhralqm (accessed 21 Jul 2022).
  4. Innes J, Dover A, Fairhurst K (2018) Macleod’s Clinical Examination E-Book. Philadelphia: Elsevier 2018.
  5. Longmore J, Wilkinson I, Baldwin A et al. Oxford handbook of clinical medicine. 10th ed.

Traffic in Bogota, Colombia: Empowering the Public to Think about Reducing Societal Problems by Coupling Mind Genomics with Artificial Intelligence

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DOI: 10.31038/MGSPE.2022223

Abstract

The paper presents a novel way of solving societal problems, combining experimental design of ideas (Mind Genomics), artificial intelligence, and consumer research. The objective is to identify social problems, and then create a mechanism to suggest solutions to these problems, doing so in a way which poses questions, obtains answers, doing so quickly, easily, and inexpensively. The long term objective of the approach is to empower the average citizen to participate in the solution of problems, doing so as an integral part of the effort, and not just a source of complaints, such complaints being processed in unknown fashion, by unknown professionals, too often disappear without really being publicly addressed.

Introduction

A voyage across the literature of public problems, whether this literature is conventional popular literature or academic literature, will continue to reveal study after study detailing the nature of the problem. The material to which the public is exposed varies from virtual ‘hand wringing about how things are’ onto less passionate, more academically focused papers which deal with the problem in a disciplined way. One can be sure, however, that there is rarely a lack of published materials about the problem being reported. One can also be sure, however, that the majority of the writing is given over to descriptions of the problem for the sake of description, and precious little if anything is given over to specific solutions.

The topic of this paper is a small-scale demonstration of what might happen when a group of young people is allowed to select a ‘tough societal problem’, and then use artificial intelligence to help them solve the problem, along with the help of real but a minimal number of human judges (respondents) who evaluate the problem and the solution in a disciplined fashion presented below. The motivation for the actual experiment (or better, the actual ‘experience’) was the desire to implement the steps, and assess the potential for a new way to solicit answers to social problems. The process was to be very rapid (hours), very low cost, knowledge-building, and when possible ‘actionable’, pointing to actions, not just feelings.

Three converging ‘realities’ prompted this paper. The first is the evolution of the new science of Mind Genomics, a tool coming from a synthesis of consumer research method, statistical experimental design, and the ability to work with small and affordable groups of consumers to obtain stable, and often insight-delivering data. The second is the incorporation of artificial intelligence in the Mind Genomics tool, making the creation of intellectually advanced experiments easy and quick to do, often taking 15-30 minutes to set up a study which previously would have taken several hours or even longer. The third is the evolving recognition that in the world of everyday, the effort by scientist to be right creates the situation recognized by Voltaire that ‘the perfect is the enemy of the good’ [1]. It the world of everyday, the better strategy is to ‘satisfice’, not to optimize [2]. We might have better solutions if we improve things in modest, but continuing ways, rather than search around with high-paid consulting talent for the perfect solution, a search which generates wonderful reports, but often hinders progress because the process is inherently filled with barriers. It is much like the heralded ‘stage-gate’ process, which prevents failure at the cost of reducing success because it is a complex, clerically oriented process, designed to minimize risk, rather than maximize opportunity [3].

As will be shown below, the process presented here might be called ‘fast and easy’, or ‘best guesses with a little help from friend and artificial intelligence.’ The goal is to avoid perfection, or even the effort to be ‘right’, but rather get out into the world , get a sense of what is happening, what might work, and what seems to be absolutely ‘off target.’

The Available Tools

The actual study (traffic in Bogota, Colombia) was made possible by two tools, the Mind Genomics suite of tools (www.BimiLeap.com), and the incorporation of artificial intelligence provided by OpenAI LP (2022). Together, these tools made it possible for a group of students in Bogota, at a weekend class, without any experience, to design a study on solving the traffic problem in Bogota, launch the study, and in a few hours receive fully analyzed results. This paper presents their work, more deeply explicated, showing the societal opportunities emerging from the combination of two worlds. The first is world is, Artificial Intelligence, which provides a rich vein of information relevant to the problem, augmenting human thinking by ‘coaching. The second is Mind Genomics to incorporate and measure human judgment in powerful way which, in turn, actually augments Artificial Intelligence.

Mind Genomics

Mind Genomics is the systematic evaluation of how we make decisions about the issues of the everyday. Mind Genomics posits that one can learn a great deal about decision making by presenting respondents (test subjects) with combinations of ideas, these combinations having been set up so that there is an underlying structure. The respondent evaluates combinations of ideas, rather than single ideas alone. The database generated by the Mind Genomics experiment is analyzed by ‘regression modeling’ (curve fitting). The outcome is a measure of the strength of each idea (or element) as a driver of the rating. When presented with this approach, most people wonder why respondents rate combinations, rather than rate each idea or element separately. The answer is that when a respondent rates combinations, it is impossible to guess what is the appropriate or right answer. Furthermore, with a set of combinations the respondent ends up keeping a consistent rating scale. In contrast, when the researcher presents the set of ideas ‘one idea at a time’, it is possible to guess the ‘right answer’. Furthermore when the specific ideas change in their nature (e.g., problems phrases, solution phrases), that rating scale has to change, but the researcher does not recognize that issue of ‘criterion change’, and ends up using the same scale. The strategy of having respondents rate mixtures avoid both ‘guessing the right answer’ and ‘maintains a consistent rating scale across stimuli [4].

Artificial Intelligence Made Possible by Advances in Computation, and Public Availability

By itself, artificial intelligence is a vast ocean of material, whose contents can be accessed, albeit with appropriate tools. We use artificial intelligence within the framework of Mind Genomics to create questions relevant to a topic, and create answers relevant to those questions. Artificial intelligence does not stop there, however, but rather works within a tightly constrained system. It is artificial intelligence which creates information about problems and solutions, that information is then put into the Mind Genomics framework. Artificial intelligence becomes ‘augmented intelligence.’ Rather than allow people to think about problems and solutions by themselves, with whatever knowledge and insights they may bring to a situation, the artificial or augmented intelligence provides additional material for them to use, or acts as coach, providing the material, and helping the thinking [5].

Demonstration – Putting Together Mind Genomics and Artificial Intelligence to Address a Problem

As Mind Genomics evolved it became increasingly obvious that the best way to teach it was by doing it. In the world of medicine this is known colloquially is ‘learn it, see it, do it’ (Cooper, personal communication to HRM, 2022). With Mind Genomics studies, actually setting up and executing a study with as few as 5-10 respondents, taking the better part of 45 minutes to one hour, ends up being the best teacher. Furthermore, the data is ‘rich’, leading to insight, scientific learning, and publishable data which increases knowledge, and may lead to follow on actions. This paper proceeds in that spirit, showing with the steps to set up the study, acquire the data, and then interpret the results. Furthermore, the ‘research effort’ was done with people who had never done this type of work before, whose native language was Spanish, who were confronted with the requirement to identify a problem, and who were given 45 minutes to set up and launch the study. Finally, the effort involved 20 respondents, small enough to be affordable in a school exercise, but large enough to generate quite interesting results, as reported here.

Step 1: Define the Problem

The students who participated in the study had never experienced Mind Genomics. They were challenged by the senior author to think of a very hard societal problem in Bogota, Colombia, indeed a very hard and seemingly unsolved problem. The objective here was to put the new ‘researchers’ into the frame of mind that this exercise would be real, and not simply a marketing research exercise. The topic had to be relevant. The group decided to deal with the problem of traffic in Bogota, Colombia, and how to solve the problem.

Step 2: Create Four Questions Which Tell a Story, and for Each Question Create Four Answers

The questions themselves will never be part of the material shown to the respondent. The purpose of the four questions is to prompt a set of answers to each question. It will be the combinations of these answers that will comprise the test stimuli.

Continuing observation from more than a decade of research with Mind Genomics suggests that it is at Step 2 when the natural discomfort with the process begins to emerge. Although the instructions sound easy, viz., ‘select four questions which tell a story,’ the reactions to the instructions both amuse and concern. Many people appear visibly uncomfortable when asked to ‘fill in the empty space’ of questions. It is simply too different from that to which they are accustomed. People answer questions, not design sets of questions. People may ask one or two questions during the course of a conversation, but the reality of our daily experience is that questions emerge at the spur of the moment, to flesh out a topic, not to create a dialogue or stream of information. It is for the above reason, the resistance to or fear of creating questions, that Idea Coach was developed. Idea Coach utilizes APIs from OpenAI LP.

After the questions are created, the answers often flow freely. A great deal of the effort appears to be the structured thinking needed to solve the problem. It appears that creating the structure is difficult, filling the structure with answers is a great deal easier.

The important thing to keep in mind is that the phrasing of the questions and the phrasing of the answers come from artificial intelligence, with the group of researchers slightly polishing and enhancing the phrases that emerged. If the researcher is unable to provide four questions, the researcher presses the Idea Coach box. A second screen opens up, instructing the researcher to write a short description of the topic. The underlying artificial intelligence provided by OpenAI LP then processes the information, and returns with 10-30 relevant questions, from which the researcher can select up to four questions, insert them automatically, and even edit the selected elements. In addition, the research can, of course, select fewer, providing the researcher’s own questions. In those cases when the researcher fails to find the relevant questions, the researcher can return with the same paragraph submitted to Idea Coach, this time with a different paragraph, re-run Idea Coach, and receive another selection of 10-30 questions. The goal for Idea Coach is to provide the 30 questions each time.

The same capability for AI to provide the necessary text information occurs for the creation of four answers to a question This time, however, the question has already been selected. The researcher does not have the ability to rephrase the question. Rather, the researcher who cannot provide four answers simply invokes Idea Coach, which has been programmed to provide 15 answers. Once again, if the researcher fails to find the appropriate answer, the researcher can invoke Idea Coach again to have another pass through the AI engine. Figure 1 shows the schematic screens requesting questions, and offering the use of Idea Coach. The right panel shows the request to fill in the box with a description of the topic. The artificial intelligence returns with up to 30 questions.

FIG 1

Figure 1: Schematic screen to get questions, and the Idea Coach screen to elicit the help of AI. The researchers must describe the topic and the objective in a short paragraph.

Figure 2 shows the use of artificial intelligence to suggest answers. The left panel shows the request for the answers to a question. The right panel shows the automatic use of Idea Coach to provide 15 answers to the same question. Once again, generating a set of separate answers to each of the four question is simply a matter of pressing two buttons, one on the left to ‘start’ Idea Coach, and one on the right to obtain the 15 answers to the already selected/created question (here the first question of the four).

FIG 2

Figure 2: One of four screens, set up to elicit answers, and the Idea Coach to invoke the help of AI. The AI works automatically, based upon the text of the question that has already been selected and inserted into the system in the previous stage, viz., selecting the four questions.

Step 3: Introduction, Rating Question, and Additional Background Information

Moving beyond the creation of the raw materials (questions and answers), the Mind Genomics process proceeds to an orientation paragraph to tell respondents what they will be evaluating, as well as the scale that they will use. Finally, the Mind Genomics process allows the researcher to request additional background information about what the respondent does and thinks about a topic (self-profiling classification; open ended question), and finally the researcher’s own documentation about why the study is being run. Table 1 provides this information, which is recorded in the report provided to the researcher at the end of the study.

Table 1: The information page

Study Title

Traffic Jam in Bogota
Identification Number of the study: 11052022.Traffi
Date when the study was run: (11/05/2022-11/05/2022)
Number of respondents: 20
Purpose of the study (for the researcher, not the respondent): Traffic in Colombia, Mexico and Brazil is bad in rush hours, reducing productivity and quality of life of people living in this countries. Is key to find a solution for this problem.
Keywords: Traffic, traffic jam
Study info: Tell us about how you feel about traffic jams in cities
Self-profiling question: What is your interest in traffic?
Possible answers: 1=Never think about it 2=Bother about it but there’s no solution 3=Bother about and I’m looking for a solution 4=I talk with my friends all the time because it bothers me
Self-profiling question: What are the main ways of transportation used
Possible answers: 1=Bicycle 2=Walking 3=Bus 4=Train 5=Private transportation
Rating question: In a 5 points scale please choose the phrase below that expresses your feelings.
Ratings 1=Can’t be solved and doesn’t describe my situation
2=Can’t be solved but it does describe my situation
3=I don’t have a point of view
4=Can be solved but does not describe my situation
5=Can be solved and describes my situation

Step 4 – Artificial Intelligence Returns with up to 30 Questions

Within approximately 30-45 seconds, the embedded link to the artificial intelligence system returns with up to 30 questions. Up to four can be selected, dropped into the questions, and even edited afterwards. In the frequent case that the Idea Coach does not generate the ‘best questions’, the researcher can use the same paragraph in Table 1 and try again, or change the paragraph and try again. Within a minute or two the questions are created, usually to the approval of the researcher, who learns more from the exercise than would have been imagined. Table 2 shows the final set of questions, selected by the students, without any guidance.

Table 2: The four questions and the four answers to each question. Most of the text can be traced to Idea Coach, with some text slightly edited as per the preferences of the researcher.

Question A: What are some of the potential solutions to reduce traffic congestion in Bogotá?
A1 Improve public transportation options
A2 Improve traffic flow through infrastructure improvements
A3 Implement intelligent transportation systems
A4 Stagger work hours
Question B: What is the role of the private sector in reducing traffic congestion in Bogotá?
B1 The private sector can help reduce traffic congestion in Bogotá by providing incentives for employees to use alternative modes of transportation, such as carpooling or telecommuting.
B2 The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.
B3 The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.
B4 The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.
Question C: What is the role of the citizens in reducing traffic congestion in Bogotá?
C1 Carpooling
C2 Consolidating trips
C3 Biking or walking instead of driving
C4 Avoiding travel during peak hours
Question D: How can public transportation be improved to reduce traffic congestion in Bogotá?
D1 Increase the capacity of public transportation.
D2 Increase the use of public transportation.
D3 Improve the infrastructure for public transportation.
D4 Improve the marketing of public transportation.

Step 5: Invoke the Underlying Experimental Design to Create Different Sets of 24 Vignettes

As noted above, the Mind Genomics process works by presenting combinations of answers (now called elements). The basic experimental design for the study comprises 24 vignettes, each vignette containing 2-4 elements. To many people looking at the design in simple format (e.g., an Excel file with 24 rows, one per vignette), everything looks random. Indeed, to respondents participating in the study, who evaluate the 24 vignettes, one after another, the experience feels like the baby’s perception of the world, in the words of Harvard psychologist William James, ‘a blooming, buzzing confusion’ [6]. Nothing could be further from the truth as the next paragraphs will show. The goal of the experimental design is to ensure that the ‘correct’ combinations of elements be shown to the respondent. The term ‘correct’ is used here to mean ‘statistically appropriate for analysis by OLS (ordinary least=squares) regression, or simply standard regression analysis [7].

There are two specifications for the experimental design. These are explained in the next two paragraphs.

The first specification is that the design comprise a moderate number of vignettes or combinations of messages, allowing a single respondent to evaluate all of the combinations, which in turn would allow the data from a single individual to be analyzed by OLS regression. This is called a within-subjects design [8]. The actual system is descended from the very popular group of methods called ‘conjoint measurement’ or ‘conjoint analysis’ [9,10]. The popularity of conjoint has extended into traffic planning, anticipating this study [11,12].

For the Mind Genomics efforts, a total of 16 elements combined into 24 combinations has been found to be easiest both for the researcher who has to come up with the questions and answers, and for the respondent, who only has to evaluate 24 combinations, a 3-4 minute task. As an aside, but well worth noting, many researchers want custom experimental designs with unequal sized groups of attributes and level (viz., unequal numbers of answers, with some questions generating many answers, and other questions generating few answers). The objective is Mind Genomics is to present an easy-to-use system, giving solid, robust results, in a way which satisfies many needs. Experience has shown that many of these custom-developed experimental designs really could be turned into a Mind Genomics design with little loss of truly relevant information.

The second specification is that each of the respondents should test different sets of 24 vignettes rather than having all the respondents test the same set of 24 vignettes. The analogy to this is the creation of an underlying picture of human tissue afforded by the MRI (magnetic resonance imaging approach). The MRI takes pictures of the same tissue from different angles. After the fact, the computer program integrates all the picture into a three-dimensional representation. In the same way, the Mind Genomics system covers different combinations, giving a view of the underlying design space. Rather than spending the effort to measure the response to one set of combinations, doing so with many respondents to reduce ‘sampling error,’ Mind Genomics figuratively ‘throws a blanket over the design’, and gets a sense of the strong performing elements (answers), and the weak performing elements. In the end, this approach, permuting the combinations [13] enables the discovery of important versus unimportant elements, as well as the discovery of underlying mind-sets, groups of individuals with different patterns of results, suggesting different ways of thinking about the topic.

Table 3 shows an example of the experimental design for two respondents. The mathematical structure is the same for each respondent, but the two designs are permuted. Each row correspond to one of the 24 vignettes evaluated by a respondent. The matrix comprises 16 columns, one column for each element. When an element or answer is present in the vignette, the cell is coded as ‘1’. When an element or answer s absent from the vignette, the cell is coded as ‘0’.

Step 6: Invite Respondents to Participate and Acquire the Ratings

As noted several times earlier in this paper, the objective of Mind Genomics is to create a system which produces knowledge at an industrial scale, with speed, volume, and price all optimized. One of the continuing issues in consumer research is the ongoing decline of participation in studies, along with fraudulent data, such as data produced by ‘bots’ which scour the network to discover opportunities to get paid for participation.

The Mind Genomics process attempts to reduce some of the friction and fraud in the acquisition of respondent data. The first way is to work with a panel supplier with known credibility, which in the case of Mind Genomics is Luc.id Inc., in the United States. Luc.id is not a panel provider but rather an aggregator of panel providers world-wide, a group that has been vetted and accepted by the consumer research community. Thus, the source is credible. The respondents can be specified in terms of number of characteristics, such as age and gender. The panel can be further specified in terms of country, which here was Colombia.

The second way to ensure quality is by measuring the time between the appearance of a vignette and the rating of that vignette. A ‘bot’ would not be able to simulate the necessary response times. Figure 3 shows a histogram of the median response time for each of the 20 respondents across the 24 vignettes. A ‘bot’ would not have produced longer response times, especially response times of a second or more, unless specifically programmed to do so.

FIG 3

Figure 3: Distribution of median response times to 24 vignettes from each of 20 respondents

Step 7 – Transform the Ratings to a Binary Scale

Although researchers are accustomed to the believed precision of scales, such as the category or Likert Scale, with each category labelled, once the researcher averages the scale the manager has a difficult time understanding the meaning of the average in terms of practical next steps. As easy as it is to calculate the average, the interpretation of the averages is quite confusing. For example, what does it mean for two test averages to different by 0.58 scale points (e.g., 3.58 vs. 3). The typical manager does not know, and in reality except for the statistics involved, the researcher does not know either. It makes no real sense to say that the averages are statistically different from each other. The underlying statistics may be valid, but the interpretation is difficult.

Consumer researchers have recognized the seductiveness of scales, as ways to measure feelings, but the reality is that most researchers feel more comfortable with percentages, such as ‘70% of the respondents rated Test Product ‘A’ 4 or 5, whereas only 40% rated Test Product B 4 or 5. There is still the discomfort of ‘what does it really mean’, but much of the discomfort goes away after the data are transformed. The transformation is simple; ratings of 4 and 5 are transformed to 100 vs. ratings 1,2, and 3 are transformed to 0. This is called a ‘top down’ transformation. We can also do the opposite, transforming ratings of 1 and 2 to 100, and ratings 3,4, and 5 transformed to 0. This is called a ‘bottom up’ transformation. The transformation from 5-point Likert Scale (1-5) to a binary scale will help us interpret the result.

The five point scale in Table 1 really comprises two scales, allowing us to create the following four binary transformations:

Solvable – Ratings 5 and 4 transformed to 100, ratings 1,2,3 transformed to 0.

Not Solvable – Ratings 1 and 2 transformed to 100, ratings 3,4, and 5 transformed to 0.

Affects Me – Ratings of 5 and 2 transformed to 100, ratings of 1,3, and 4 transformed to 0

Does Not Affect Me – Ratings of 1 and 4 transformed to 100, ratings 2,3 and 5 transformed to 0.

After the transformation to our binary scale, a vanishingly small random number (<10-4) was added to the transformed variable. This prophylactic measure was done ensure that there would be some variation in the dependent variable, so that the ensuing OLS (ordinary least-squares) regression would not ‘crash.’ OLS regression crashes (viz., stops automatically) when the dependent variable (the transformed binary variable) has no variation. There is generally no problem with group data, but when the models or equations are created for individual respondents there are many situations when the respondent ends up assigning all 24 vignettes numbers which either transform to 0 or transform to 100. The prophylactic action of adding the random number ensures that this unhappy event never ends up affecting the OLS regression.

Step 8 – Run a Separate OLS Regression for the Four Transformed Variables, Using Total Panel (All Data)

We want to discover how each of the 16 elements, our ‘answers’ or ‘messages’, drives the binary transformed rating. To discover the driving power of the elements, we subject the data matrix to OLS regression. Regression, often known colloquially as ‘curve fitting’, creates an equation of the form: Dependent Variable = k0 + k1(A1) + k2(A2)…k16(D4) + (Test Order).

The regression equation summarizes how the 16 elements contribute to the dependent variable. The dependent variable in turn, becomes R54 (solvable), R12 (not solvable), R52 (affects me), and R14 (does not affect me). A separate regression equation is estimated for response time versus the variables A1 – D4, and Test Order. The only difference is that the regression equation for response time does not have an additive constant, k0.

We introduce Test Order as a new independent variable. Our focus here is on the possible change of the rating as the respondent proceeds through 24 vignettes, independent of what the composition of the vignettes happens to be.

Step 9 – Present the Results from the Total Panel in an Easy-to-Read Form

Mind Genomics studies return a great deal of data, once the large matrix of raw data is processed by OLS regression. For every key dependent variable, and selected subgroup, the regression analysis will return 16 coefficients, the 17th number, the additive constant (except for response time). It is critical to eliminate the coefficients which do not tell a story. Consider the data for Total Panel in Table 4.

The additive constant (also called the intercept) in the regression model tells us the conditional probability of the respondent assigning a rating of 5 or a rating of 4 (both denoting ‘solvable’) in the absence of any elements. Of course, the experimental design ensured that each of the 24 vignettes comprised a minimum of two elements or messages, and a maximum of four. Nonetheless, the OLS regression can estimate what would have been the expected value of dependent R54 had there been no elements. Such an estimate emerges from the pattern of the ratings and can be treated as a ‘baseline’. With this in mind, we look at the four additive constants, to get a sense of the baseline:

R54 – Additive constant of 45 suggests that slightly fewer than half of the responses would be positive (solvable)

R12 – Additive constant of 39 means slightly fewer, but a large proportion of responses would be negative (not solvable)

R25 – Additive constant of 21 means that only about of fifth of the responses would be that the situation describes the person

R14 – Additive constant of 63 means that a majority of 63% of the responses suggest that the situation does not describe the person.

Moving now to the coefficients (A1-D4) in Table 4, we see that the table has only positive numbers, many empty cells, and that some cells are shaded. The underlying reason for this is that we learn nothing from negative coefficients. Negative coefficients can either mean the ‘opposite’ of the rating scale or a rating of 3 (I don’t know). The negative and zero coefficients are ambiguous, often misleading because of the rating of ‘3’, and thus can be discarded from the presentation. They are still relevant for the statistics, but need not be interpreted.

Table 4: Parameters of the models for Total Panel. Only positive coefficients are shown for the four binary transformed rating scale. Strong performing elements (10 or higher) are presented in shaded form.

 

Total Panel

R54

R12

R25

R14

RT
  Solvable

Y

N

      
  Describes Me    

Y

N

  
  Additive constant

45

39

21

63

NA 
D4 Improve the marketing of public transportation.

10

15

1.6
D1 Increase the capacity of public transportation.

8

10

1.1
C4 Avoiding travel during peak hours

7

8

1.7
D2 Increase the use of public transportation.

7

4

1.0
B2 The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

3

1.6
C1 Carpooling

4

7

1.6
A3 Implement intelligent transportation systems

3

7

0.9
A1 Improve public transportation options

3

1.4
B4 The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.

13

2.1
C2 Consolidating trips

11

1.4
D3 Improve the infrastructure for public transportation.

11

1.6
B3 The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

9

1.8
C3 Biking or walking instead of driving

5

1.8
A4 Stagger work hours

4

1.4
B1

 

 

 The private sector can help reduce traffic congestion in Bogotá by providing incentives for employees to use alternative modes of transportation, such as carpooling or telecommuting.

4

1.3
A2 Improve traffic flow through infrastructure improvements

1.8
Test order

0.5

-0.5

-0.1

0.1

-0.1

The coefficient itself is the ‘additive conditional probability’ that the dependent variable will be selected when the element is inserted into the vignette. Recall that the coefficient emerges from the full pattern of ratings assigned to the 480 vignettes. An easier way to think about the additive constant is that it represent the ‘incremental percent of responses which select the dependent variable when the element is present’.

Here are the patterns emerging from the total panel:

Dependent Variable = R54 (Solvable)

Begin with the additive constant of 45, meaning that in the absence of elements, 45% of the responses will be 4/5.

Now look at the coefficients, which have been sorted by the value of coefficient for R54. The coefficients which appear are those respondents feel drive increased solvability of the problem From Table 4 we see the following strong performing elements for the dependent variable, R54 (solvable). Only one of the elements, D4, is a very strong performer, operationally defined as a coefficient of + 10 or higher.

D4          Improve the marketing of public transportation.                                                          10

D1          Increase the capacity of public transportation.                                                            8

C4          Avoiding travel during peak hours                                                                                  7

D2          Increase the use of public transportation.                                                                      7

B2           The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.                   3

Dependent Variable = 52 (Applies to Me)

Begin with the additive constant of 21, meaning that in the absence of elements 21% of the responses will be 5 or 2 (viz., applies to me, whether solvable or not.)

D4     Improve the marketing of public transportation.                                                               15

B4     The private sector can help reduce traffic congestion in Bogotá by

           sponsoring car-free days or other events that encourage people

           to use alternative modes of transportation.                                                                       13

C2     Consolidating trips                                                                                                                  11

D3     Improve the infrastructure for public transportation.                                                      11

D1           Increase the capacity of public transportation.                                                          10

Dependent Variable R12 (Cannot be Solved)

This variable has a moderate additive constant (39), a s similar baseline to variable R54 (solvable, additive constant 45). There are no strongly performing elements, however.

Dependent Variable R14 (Does Not Apply to Me)

This variable has a high additive constant (63), suggesting a high baseline, viz., not applicable. There are no strong elements either.

Response Time (RT)

The Mind Genomics program, Bimileap, measures the time elapsed between the presentation of the vignette on the screen and the response to the vignette, no matter which of the five scale points is selected. The regression analysis does not, however, contain additive constant, because the assumption is that the response time would be ‘0’ in the absence of elements.

The deconstruction of the elements into response times is shown at final column, at the far right. The table shows the coefficient for response time for all 16 elements. The coefficients for response time tend to be higher than many coefficient for different topics emerging from studies whose native language is English (viz., respondents living in the USA, Canada, etc.). Given the fact that the respondents live in Colombia, there is the reasonable supposition that the response times might be higher simply because a respondent might require a longer time to read and process the information. Thus, the criterion for an ‘engaging’ message was set at 1.7 seconds.

B4     The private sector can help reduce traffic congestion

          in Bogotá by sponsoring car-free days or other events that encourage

           people to use alternative modes of transportation.                                                                          2.1

B3     The private sector can help reduce traffic congestion in Bogotá by

           developing apps or other technology solutions that help people avoid

           traffic jams or plan their routes more efficiently.                                                                              1.8

C3     Biking or walking instead of driving                                                                                                    1.8

A2     Improve traffic flow through infrastructure improvements                                                              1.8

C4           Avoiding travel during peak hours                                                                                                 1.7

Test Order

The issue has often been raised about Mind Genomics that the data are not stable over time. There are no particular observations to support the contention of instability. On the other hand, one may be able to discover an ‘order’ effect by using order of presentation as an independent variable, along with the presence/absence of the elements in a vignette. Operationally the incorporation of response time into the independent predictors means simply that each of the 480 vignette has a new variable, Test Order, which takes on a value between 1 and 24, dependent upon the order of appearance.

When the analysis was run, an order effect emerged for the dependent variable of for solvability (R54, R12), and for the dependent variable of response time (RT). Over 24 vignettes, from 1 to 24, we expected to see as 12 point increase in the binary rating of R54 (solvability), and a 12 decrease in the binary rating of R12 (not solvable). Over the same range of 24 vignettes, we expected to see a decrease in response time of 2.4 seconds (24 x -0.1 = -2.4). The decrease in response time is not unexpected, and makes intuitive sense. With increasing number of vignettes, the respondent ‘learns’ to graze information quickly, becoming much faster. In contrast, with dependent variables which depend upon judgment, such as ‘solvability’ (R54) there is no priori expectation other than perhaps sensitization to the problem leading to a change in criterion underlying the rating. Order effects approached in this way through Mind Genomics may eventually teach a lot more about the change in judgment criteria for different types of messages.

Step 9 – Uncover ‘Minds’ at the ‘Granular’ Level of the Specific Topic

A hallmark of Mind Genomics is the ability to uncover different ‘mind-sets’ in the population. The term ‘mind-set’ refers to a group of respondents who show the same pattern of coefficients for a specific topic. Thus, Mind Genomics enjoys the distinct benefit of generating specific, testable, viz, actionable data. Individuals who fall into the mind-set may differ radically from one another in the common ways that people are described, namely by who they ARE, what they Do, what they say they BELIEVE, and so forth. By definition, mind-sets emerge from the granular world of everyday experience, making them far more actionable that comparable ways of dividing people using general phrases, not specific phrases.

The division of respondents into these aforementioned ‘mind-sets’ is accomplished in a straightforward manner, a manner which does not require any deep knowledge about the topic. Creating mind-sets is a purely statistical endeavor. Only after mind-sets are created does judgment come into play, for two specific aspects. The first aspect is parsimony. Fewer mind-sets are better than many mind-sets. The second aspect is interpretability. The mind-sets must make intuitive sense, and allow for interpretation, even though the mind-sets are create by methods which are purely statistical In nature. Nonetheless, the mind-set must ‘tell a story’, no matter what their origins.

The clustering follows a standard statistical procedure [14]. The first stage computes the additive constant and the 16 coefficient for each respondent. This ability to create an additive model for the individual is made possible by the up-front creation of 24 vignettes for an individual following the experimental design (Table 3). Each individual respondent has a separate set of 24 vignettes, specified according to the underlying experimental design [15].

Table 3: The experimental design for two respondents. The design prescribes the composition of vignettes for each respondent. The columns correspond to the respondent number, the number of elements in the vignette, the order of appearance, and then the specific elements appearing (coded by ‘1’) versus absent (coded by ‘0’).

Resp

# EL

Order

A1

A2

A3

A4

B1

B2

B3

B4

C1

C2

C3

C4

D1

D2

D3

D4
1 3 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0
1 3 2 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0
1 3 3 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0
1 3 4 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0
1 4 5 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 1
1 4 6 0 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0
1 4 7 0 0 0 1 0 0 1 0 0 0 0 1 0 0 1 0
1 3 8 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1
1 4 9 0 1 0 0 1 0 0 0 0 0 1 0 0 0 1 0
1 4 10 0 0 1 0 0 0 1 0 1 0 0 0 0 0 1 0
1 3 11 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0
1 3 12 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0
1 3 13 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1
1 3 14 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1
1 3 15 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 0
1 4 16 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 0
1 4 17 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0
1 4 18 1 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1
1 2 19 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 4 20 0 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0
1 4 21 0 1 0 0 0 1 0 0 0 0 0 1 1 0 0 0
1 2 22 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0
1 3 23 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0
1 3 24 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0
2 4 1 0 0 0 1 0 0 1 0 0 1 0 0 0 1 0 0
2 4 0 0 1 0 0 0 1 0 0 0 0 0 1 0 1 0 0
2 4 3 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0
2 3 4 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1
2 3 5 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0
2 4 6 1 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0
2 3 7 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0
2 3 8 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1
2 4 9 0 0 1 0 1 0 0 0 0 1 0 0 0 0 1 0
2 4 10 0 0 0 1 0 1 0 0 1 0 0 0 0 0 1 0
2 3 11 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0
2 3 12 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0
2 3 13 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0
2 4 14 0 1 0 0 0 0 1 0 0 0 1 0 1 0 0 0
2 3 15 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1
2 3 16 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0
2 3 17 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0
2 2 18 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0
2 4 19 0 0 1 0 0 1 0 0 0 0 1 0 0 1 0 0
2 4 20 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 1
2 3 21 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1
2 3 22 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0
2 2 23 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0
2 2 24 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0

Each respondent’s data, viz., the 24 vignettes and their ratings, are subject to an individual-level OLS regression. This action creates 20 rows of “data”, which will be the input to the clustering program., the first column being the additive constant, the second to the 17th column being the coefficient, with each row corresponding to a respondent. The clustering program computes the ‘distance’ between each pair of respondents, using the value (1-Pearson R). The Person R or correlation coefficient measures the strength of the linear relation between two variables. The ‘distance’ between people based on the Pearson R is defined as quantity (1-R). When two respondents show a highly positive pattern pair of 16 comparable coefficient, then the correlation is close to 1.0, and the distance is 1-1 or 0. When the two respondents show no correlation, viz. no discernible pattern of coefficients when coefficients are plotted again each other in a scattergram, then the correlation is 0, and the distance is (1-0) or 1.0. When the coefficients show opposite patterns when plotted against each, the correlation is -1, and the distance (1-R) is 2 (viz, 1- -1 = 2).

The clustering algorithm puts the respondents into two groups, so that the distance is minimal between the respondents in group, while at the same time the distance between the ‘average person’ in the two groups is as large as possible. The clustering algorithm then repeats the process, this time with three groups, using the same thinking about minimal person to person ‘distances’ within the group, but maximal distance among the three ‘average people’, these three average people computed from the values in the three groups or clusters, respectively. The process of clustering, the aforementioned method of assigning people to non-overlapping groups, is not ‘fixed in stone’, but rather a heuristic. It is a statistically valid manner to uncover patterns in a noisy set of data. The clustering program does not ‘know’ the meaning of the groups, which will be called ‘mind-sets’. It is the job of the researcher to discover the meaning (viz., the criterion of interpretability).

With this introduction, turn now to the two groups created by the k-means clustering program. Once the clustering has assigned the respondents to the two groups, we re-run the equations, using only the data from the respondents in a single group. Table 5 shows the results for cluster 1, or mind-set A, Table 6 shows the results for cluster 2, viz., mind-set B. It is now the researcher’s task to find the patterns, by looking at the elements which score highest in each mind-set, viz., each cluster.

Table 5: Key results for Mind-Set A – Focus on changing one’s own behavior within the system

  Mind-Set A – Focus on changing one’s own behavior within the system

R54

R12

R25

R14

RT
  Solvable

Y

N

      
  Describes Me    

Y

N

  
  Additive constant

61

36

39

58

  
C4 Avoiding travel during peak hours

13

5

1.5
D2 Increase the use of public transportation.

12

1

0.7
D4 Improve the marketing of public transportation.

3

11

1.4
C2 Consolidating trips

3

5

1.1
C3 Biking or walking instead of driving

3

3

1.5
D3 Improve the infrastructure for public transportation.

6

10

1.2
A1 Improve public transportation options

5

9

1.5
D1 Increase the capacity of public transportation.

9

0.9
A3 Implement intelligent transportation systems

3

7

0.7
B4 The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.

8

4

2.6
B3 The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

3

3

1.8
A2 Improve traffic flow through infrastructure improvements

2.1
A4 Stagger work hours

1.2
B1 The private sector can help reduce traffic congestion in Bogotá by providing incentives for employees to use alternative modes of transportation, such as carpooling or telecommuting.

1.4
B2 The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

15

4

2.3
C1 Carpooling

1.7
Test order

0.7

-0.9

-0.5

0.3

-0.1

Table 6: Key results for Mind-Set B

Mind-Set B: Create system solutions

R54

R12

R25

R14

RT
Solvable

Y

N

      
Describes Me    

Y

N

  
Additive constant

14

51

-5

70

  
D1 Increase the capacity of public transportation.

26

14

1.4
B2 The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

21

2

0.6
D4 Improve the marketing of public transportation.

21

27

1.9
D3 Improve the infrastructure for public transportation.

18

18

2.1
A2 Improve traffic flow through infrastructure improvements

12

7

14

5

1.3
B3 The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

11

18

2.0
B4 The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.

9

28

1.4
A1 Improve public transportation options

7

16

1.4
A4 Stagger work hours

3

8

1.8
B1 The private sector can help reduce traffic congestion in Bogotá by providing incentives for employees to use alternative modes of transportation, such as carpooling or telecommuting.

3

5

1.0
C2 Consolidating trips

20

1.8
C1 Carpooling

7

17

1.4
D2 Increase the use of public transportation.

9

1.2
C3 Biking or walking instead of driving

6

2.1
A3 Implement intelligent transportation systems

4

5

1.3
C4 Avoiding travel during peak hours

11

1.9
Test order

0.4

0.0

0.5

0.0

-0.1

Results for Mind-Set A

Mind-Set A – (base size 8 of 20 respondent) (Table 5). A possible name for this mind-set is Focus on Changing One’s Own Behavior within the System. The reasons for this choice of names are:

Dependent variable R54 (solvable) – additive constant = 61, very high. Strong solvability elements are

C4 (avoiding travel during peak hours)

D2 (Increase the use of public transportation

Dependent variable R12 (not solvable) – additive constant 36 = los. Strong elements militating against solution is the expectation that anyone other than the individual can really solve the problem. A particular negative element, diminishing the hope for solvability, is

B2         The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

Dependent variable R25 (describes me) – additive constant = 39. The strongest performers are:

D4           Improve the marketing of public transportation

D3           Improve the infrastructure for public transportation

Response Time – The elements that generate the longest response times are those which propose actions that the government can do. That is, these respondents pay the greatest attention to elements which talk about specific actions that can be done. Of course those elements also tend to be the longest elements, and thus some of the increased response time may be due to the fact that the respondents, non-native speakers of English, are reading long sentences (except for C1, Carpooling, which is one word. Here are the five most ‘engaging’ elements, based upon the response time.

B4    The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.

B2    The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

A2    Improve traffic flow through infrastructure improvements

B3    The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

C1         Carpooling

The final row, test order, suggests that as the experiment goes on, and the respondent works her or his way through the experiment with the 24 vignettes. Mind-Set A will feel that the solutions are more solvable (coefficient 0.7 or an increase of almost 17% from start to finish in the solvable rating, R54). They will feel like the problem is less ‘theirs’, with a drop of 12 points in the value of R25 (describes me). Finally, their response time will drop about 2.4 seconds for a vignette from the first rating to the last rating.

Results for Mind-Set B

Mind-Set B (Base size of 12 of 20 respondents) (Table 6). A possible name for this mind-set is Create System Solutions.

Dependent variable R54 (solvable) – additive constant = 14, very low. It is the elements which drive solvability, not simply a change of behavior. Strong solvability elements require cooperation to change the system, perhaps a reason for the low additive constant. These elements are:

D1     Increase the capacity of public transportation.

B2     The private sector can help reduce traffic congestion in Bogotá by working with the government to create incentives for businesses to locate closer to public transportation.

D4     Improve the marketing of public transportation.

D3     Improve the infrastructure for public transportation.

A2     Improve traffic flow through infrastructure improvements

B3               The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

Dependent variable R12 (not solvable) – additive constant 51. However, there are no elements which militate against a solution.

Dependent variable R25 (describes me) – additive constant=-5. These respondents want to see specific solutions. They are not ready to agree ‘at a basic level’ with a high additive constant. Just the opposite – they seem to be ‘show me’ types, consistent with their interest in changing the system, along with changing some behaviors. The strong elements which describe them are listed below. Elements B4, D4 and C2 generate exceptionally high scoring elements, with coefficients of +20 or higher.

B4       The private sector can help reduce traffic congestion in Bogotá by sponsoring car-free days or other events that encourage people to use alternative modes of transportation.

D4       Improve the marketing of public transportation.

C2       Consolidating trips

D3       Improve the infrastructure for public transportation.

B3       The private sector can help reduce traffic congestion in Bogotá by developing apps or \\ other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

C1             Carpooling

Dependent variable 14 (Not me). As expected the additive constant is very high. Mind-Set 2 respondents are more critical. Only two elements perform strongly, however, saying ‘not me’

A1 Improve public transportation options

C4 Avoiding travel during peak hours

Response Time – The elements to engage the respondents in Mind Set B are not necessarily the long elements, but rather the simple types of solutions, of different types. One gets a sense that respondents in Mind-Set 2 are more ‘thoughtful’ about the topic. Keep in mind that Response Time was not a consideration when developing mind-sets

D3 Improve the infrastructure for public transportation.

C3 Biking or walking instead of driving

B3 The private sector can help reduce traffic congestion in Bogotá by developing apps or other technology solutions that help people avoid traffic jams or plan their routes more efficiently.

D4 Improve the marketing of public transportation.

C4 Avoiding travel during peak hours

A4 Stagger work hours

C2 Consolidating trips.

The final row, test order, suggests that as the experiment goes on, and the respondent works her or his way through the experiment with the 24 vignettes, Mind Set B will feel more positive about the solvability of the problem, and about the degree to which they agree with the solution as fitting ‘them’. Both order coefficients are positive, 0.4 for solvable (a 9.6 increase in the expected rating R54 for a vignette), and 0.5 for R25 (a 12,0 increase in the expected rating R25 for a vignette), both across the 24 vignettes. The coefficient for RT, response time, is -0.1, meaning once again a 2.4 second decrease in response time for a vignette, starting with the first vignette, and finishing with the 24th vignette. This decrease in response time is based on the coefficient for Test Order across all 24 response time.

Discussion

The study that we report was done ‘at the spur of the moment’, over a 90 minute zoom meeting, with a class of graduate students in Bogota Colombia, the lecturer for that class (author Herrera), and the senior author of this paper (author Moskowitz), who had been invited to talk about Mind Genomics. Author Rappaport introduced the notion of AI to Mind Genomics, and worked with author Deitel, the programmer.

The initial effort revealed the ease with which one could work with novices to arrive at possible solutions to common societal problems. As the data emerged from the study, so did the realization that a combination of artificial intelligence and human responses could provide a new opportunity to solve common problems. The solutions proffered here are those which emerged after 20 minutes of effort at the start of the project, and about 45 minutes in the field as the project was being completed by the 20 respondents. The respondents were invited by a link in the BimiLeap program which led immediately to the Luc.id system, and in turn secured the respondents in what was designed to be a ‘turn-key system’ for the user.

If we were to look at this study from the point of view of traditional science, we would immediately receive comments that the base size is too small, viz., that there are too few respondents participating to use as a database to decide or to plan. This criticism is often levelled at small-scale studies, primarily because researcher in the world of science are searching for replicable, meaningful result, a noble cause, but one which end up forcing the studies to be long, expensive, and overly focused. One consequence is the effort to be right, to achieve statistical significance, to ensure replicability, subtly forcing the research into the world of ‘confirmation,’ rather than the world of exploration.

This paper stands in contrast to the world of the more thought out studies, the careful delineation of that which is being explored, and the search for what can be defended rather than what can ‘teach’. This paper stands for early stage, simple, low cost exploratory research, research of a type which reveals potentially interesting patterns in nature, patterns which may excite more stringent, focused, larger-sale researcher. Yet, in terms of scientific potential, this paper argues for the value of early stage, but disciplined exploration of a topic, explorations. These studies can form the foundation of a science once the small-scale explorations move to more acceptable studies, viz., simply studies with a much higher base size. In other words, the approach presented here explores nature in the way that early scientists did, to find out ‘what’s going on’ in people’s minds, when people are confronted with realistic situations in society worth addressing, and problems worth solving.

Acknowledgments

The authors are grateful to the students who put together this study on a five-minute notice, and completed the set-up of the study with very little help. This exercise was done in the Consumer Knowledge Management class of CESA’s Master of Marketing Management in November 2022, with the MDM22 group.

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Prevalence of Tuberculosis in Patients Visiting Massawa Hospital: Cross-Sectional Study, 2021

1 Reply

DOI: 10.31038/EDMJ.2022622

Abstract

Background: Despite the availability of efficacious drugs, tuberculosis remains a major public health problem in low- and middle-income countries. This study was aimed to determine the prevalence of tuberculosis in Massawa Hospital, Eritrea.

Methods: Laboratory and medical records of tuberculosis patients in Massawa Hospital were reviewed. All patients who did sputum exam by Xpert Gene from January 01, 2018 to May 1, 2021 in Massawa Hospital were enrolled in this study. Categorical variables were presented in percent, frequencies, Chi-square test, and odds ratio with 95% confidence interval. P value <0.05 was considered significant.

Results: Sputum examination was done on 2178 patients and the prevalence of bacteriologically positive tuberculosis was 7%. Moreover, the prevalence of rifampicin resistant tuberculosis among the total tested and bacteriologically positive patients was 0.4% and 5.9% respectively. The main reason for sputum examination was presumptive diagnosis of tuberculosis (85.5%). Tuberculosis spondylitis (15.6%) and adenitis (13.6%) were found to be the most common types of extra pulmonary tuberculosis. The prevalence of tuberculosis in HIV patients was 5.2% and all started highly active antiretroviral therapy. Patients aged 15 to 24 years were having higher prevalence of tuberculosis (8.8%, 95%CI 0.68-4.72, OR-1.79). And, those from Ghelaelo subzone were having about two times higher prevalence of tuberculosis (9.9%, 95%CI 1.39-3.06, OR-2.06). Patients who had previous history of tuberculosis were having about five times higher prevalence of tuberculosis (27.5%, 95%CI 2.65-11.17. OR-5.4, p<0.001) and Rifampicin resistant tuberculosis (9.1%, p<0.002).

Conclusion: The prevalence of tuberculosis and the multidrug resistant tuberculosis among the confirmed cases was comparatively increased than the average WHO estimates for Eritrea and similar to a study conducted in Nakfa subzone, Eritrea. The prevalence of tuberculosis in HIV patients was higher to the WHO estimates and previous studies in the country. Previous history of tuberculosis was significantly associated with the prevalence tuberculosis and multidrug resistant tuberculosis. Further prospective studies to evaluate the national prevalence of tuberculosis and rifampicin resistant tuberculosis are highly recommended.

Keywords

Tuberculosis, Prevalence, Multidrug resistance tuberculosis, Eritrea

Introduction

Tuberculosis (TB) is a life-threatening disease caused by Mycobacterium tuberculosis having an increased prevalence in developing countries [1]. It is a major global health problem and ranks alongside HIV as a leading cause of mortality worldwide [2]. Mycobacterium tuberculosis is an intracellular bacterium, causing respiratory illness, tuberculosis. The bacilli infect about one-third of the world’s population, leaving the majority with an asymptomatic state of a disease called latency [3]. While only a few proportions (10%) of those latently infected develop active TB, the majority (90%) will remain asymptomatic [4].

According to World Health Organization (WHO) 2019 tuberculosis report, there are an estimated 10 million people infected with TB and 1.2 million tuberculosis deaths among peoples living with HIV/AIDS globally [5]. Worldwide, millions of people continue to fall sick and die from TB, a preventable and curable infectious disease [6].

Treatment outcome is an important indicator to evaluate the effect of TB prevention and control program. Globally, in 2012, the treatment success rate (TSR) was 86% among all new TB cases and in the African region, it was 81% [7]. WHO recommends that at least 90% TSR for all persons diagnosed with TB and initiated on TB treatment services [8]. The latest global TB treatment outcome data for new bacteriologically confirmed pulmonary TB cases indicates a global fall in TSR from 86% in 2014 to 83% in 2017 [9].

According to the recent WHO estimate report, a total of 3100 new TB cases were present in 2018 in Eritrea which correspond to 89 cases per 100,000 populations [10]. Of these cases 140 were patients with TB and HIV co-infection and 66 of the cases had multidrug resistant TB. Nationally, 550 patients died from tuberculosis and related complications and 47 of them had HIV [10]. The 2018 conducted survey also revealed that the incidence rate of estimated proportion of TB cases with MDR-TB was 2% and 4.1% of them were from previously treated cases [10].

Study conducted in Nakfa subzone, one of the 58 subzones of Eritrea; showed prevalence of smear positive pulmonary TB cases was 7.8%, relatively increased prevalence of smear positive pulmonary tuberculosis than the average WHO estimate for the country [11]. This study also showed that females (8.2%), the adult age group of 41- 60 years (11%) and during the year 2014 (16.8%) had the highest rate of pulmonary TB infection [11].

From observational point of view and work experience, the prevalence of pulmonary, extra pulmonary and multi-drug resistant tuberculosis seems higher in Massawa Hospital starting in 2020.  This study was aimed to determine the prevalence of tuberculosis in Massawa Hospital, Eritrea.

Materials and Methods

Study Design and Population

This was a retrospective cross-sectional type of study that medical profile and laboratory results of all TB suspected patients, who did sputum exam by Xpert Gene from January 01, 2018 to May 1, 2021 in Massawa Hospital was retrieved, reviewed and analyzed in the study.

Data Collection, Analysis and Interpretation

Sputum results of patients were retrieved from the Xpert Gene machine register by experienced laboratory technicians from May 2-20, 2021. The socio-demographic characteristics and treatment outcomes were collected from the medical profile of patient’s treatment cards using a pre designed checklist.

Data was entered in CSPro 7.3 and analyzed by SPSS software. Categorical variables were presented in proportions, frequencies and Chi-squared test were implemented to assess association between  the dependent and independent variables. Besides, odds ratio with 95% confidence interval was also presented and P value <0.05 was considered significant.

Ethical Clearance

Ethical approval was obtained from the Ministry of Health Ethical Review and Clearance Committee on 03/05/2021. Patient’s data confidentiality was kept secured and personal identifiers were not collected. A unique number was assigned to each patient in the data set and it was coded and interpreted in aggregates. Further permission was requested from the Zonal and Hospital Medical Directors.

Results

Socio Demographic Characteristics of the Patients

A sputum exam of 2178 patients was retrieved and about forty percent of them were requested by medical doctors. Majority of the patients who did sputum exam were in the age group of 35-54 years (36.1%) and the main reason was presumptive diagnosis of tuberculosis (85.5%). The prevalence of bacteriologically positive tuberculosis was 7%. The prevalence of Rifampicin resistant tuberculosis from all those who did sputum exam and the confirmed cases was 0.4% and 5.9% respectively (Table 1).

Table 1: Socio demographic characteristics of patients

Variables

Categories

Frequency (N)

Percent (%)
 

 

 

Diagnosis year

 2018

404

18.5
2019

562

25.8
2020

878

40.3
May 2021

334

15.3
 

 

 

Age of respondent (years)

 < 15

98

4.5
15-34

701

32.2
35-54

785

36.1
55 and above

594

27.2
 

Sex of respondent

 Female

1086

49.9
Male

1092

50.1
 

 

 

Subzone of respondent

 Massawa

1087

49.9
Ghelaelo

535

24.6
Foro

336

15.4
Others

220

10.1
 

 

 

Reason for sputum exam

 Presumptive

1796

82.5
Previous TB

40

1.8
contact trace

121

5.6
Others

221

10.2
 

 

Requested by

 Doctor

961

44.1
Nurse degree

572

26.3
Nurse 645 29.6
 

Sputum result by Xpert Gene

 MTB detected 152 7.0
MTB not detected 2026 93.0
 

 

Rifampicin Resistance

 Resistant 9 0.4
Indeterminate 12 0.6
Sensitive 131 6.0
Total 2178 100.0

Association of Background of Patients with Prevalence of Tuberculosis

The prevalence of bacteriologically confirmed tuberculosis cases was higher on patients aged 15 to 24 years (8.8%, 95%CI 0.68-4.72, OR-1.79). Patients from Ghelaelo subzone were having about two times higher prevalence of tuberculosis compared to patients from Massawa subzone (9.9%, 95%CI 1.39-3.06, OR-2.06). Patients who had previous history of tuberculosis were having about five times higher prevalence of tuberculosis compared to the other groups (27.5%, 95%CI 2.65-11.17, OR-5.4, p<0.001). Other background of patients did not show significant association with the prevalence of tuberculosis (Table 2).

Table 2: Association of background characteristics with prevalence of Tuberculosis

Variables Sputum result N (%) P value Odds Ratio 95%CI
Negative Positive
Diagnosis year
2018 373 (92.3) 31 (7.7)  

 

0.802

 1
2019 527 (93.8) 35 (6.2) 0.80 (0.48-1.32)
2020 814 (92.7) 64 (7.3) 0.95 (0.61-1.48)
May, 2021 312 (93.4) 22 (6.6) 0.08 (0.48-1.50)
Age of respondents (years)
< 15 93 (94.9) 5 (5.1)  

 

 

 

 

0.828

 1
15-24 333 (91.2) 32 (8.8) 1.79 (0.68-4.72)
25-34 314 (93.5) 22 (6.5) 1.30 (0.48-3.54)
35-44 345 (92.7) 27 (7.3) 1.46 (0.55-3.88)
45-54 385 (93.2) 28 (6.8) 1.35 (0.51-3.60)
55-64 288 (93.8) 19 (6.2) 1.23 (0.45-3.38)
65 and above 268 (93.4) 19 (6.6) 1.31 (0.48-3.63)
Sex
Female 1008 (92.8) 78 (7.2)  

0.710

 1
Male 1018 (93.2) 74 (6.8) 0.94 (0.68-1.31)
Subzone
Massawa 1032 (94.9) 55 (5.1)  

 

 

0.018

 1
Ghelaelo 482 (90.1) 53 (9.9) 2.06 (1.39-3.06)
Foro 310 (92.3) 26 (7.7) 1.57 (0.97-2.55)
Others* 202 (91.2) 18 (8.2) 1.67 (0.96-2.91)
Reason for sputum exam
Presumptive 1679 (93.5) 117 (6.5)  

 

 

0.001

 1
Previous TB 29 (72.5) 11 (27.5) 5.4 2.65-11.17
contact trace 119 (98.35) 2 (1.65) 0.24 0.06-0.98
Others* 199 (90.0) 22 (10.0) 1.59 0.98-2.56
Requested by
Nurse degree 531 (92.8) 41 (7.2)  

0.238

 1
Doctor 903 (94.0) 58 (6.0) 0.83 (0.55-1.26)
Nurse 592 (91.8) 53 (8.2) 1.16 (0.76-1.77)
Total 2026 (93.0) 152 (7.0) 2178 (100.0)
*Dahlak, Gindae, Afabet, Nakfa, Shieb

**Follow up, HIV patient, unresponsive Smear negative

Association of Background of Patients with MDR Tuberculosis

The highest prevalence of Rifampicin resistant (MDR) tuberculosis was detected in 2020 (9.4%) and was higher on patients aged 55 years an above (10.5%). The prevalence of MDR tuberculosis was higher on males (9.5%) and, residents of Foro and Ghelaelo subzones showed higher MDR prevalence compared to the other subzones. Patients who had history of tuberculosis were having higher prevalence of MDR tuberculosis (p<0.002). Background of patients did not show significant association to the MDR-TB prevalence. Patients’ with indeterminate Rifampicin resistance results were put on follow up and sputum exam was repeated after an interval of several days in which all of them were negative for rifampicin resistant tuberculosis (Table 3).

Table 3: Association of background characteristics with MDR Tuberculosis

Variables Rifampicin resistance N (%) P value
Indeterminate Sensitive Resistant
Diagnosis year
2018 0 (0.0) 30 (96.8) 1 (3.2)  

 

0.085
2019 1 (2.9) 32 (91.4) 2 (5.7)
2020 7 (10.9) 51 (79.7) 6 (9.4)
2021 4 (18.2) 18 (81.8) 0 (0.0)
Age of respondents (years)
Under 15 1 (20.0) 4 (80.0) 0 (0.0)  

 

 

0.335
15-34 3 (6.8) 39 (88.6) 2 (4.6)
35-54 5 (9.1) 47 (85.5) 3 (5.5)
55 and above 3 (7.9) 31 (81.6) 4 (10.5)
Sex
Female 4 (5.1) 72 (92.3) 2 (2.6)  

0.071
Male 8 (10.8) 59 (79.7) 7 (9.5)
Subzone
Ghelaelo 5 (9.4) 44 (83.0) 4 (7.5)  

 

0.927
Massawa 3 (5.5) 49 (89.1) 3 (5.5)
Foro 1 (3.8) 23 (88.5) 2 (7.7)
Others 3 (16.7) 15 (83.3) 0 (0.0)
Reason for sputum exam
Presumptive 10 (7.8) 110 (86.0) 8 (6.2)  

 

0.002
Previous TB 0 (0.0) 10 (90.9) 1 (9.1)
Others 2 (15.4) 11 (84.6) 0 (0.0)
Requested by
Nurse degree 1 (2.4) 37 (90.2) 3 (7.3)  

 

0.205
Doctor 4 (6.9) 49 (84.5) 5 (8.6)
Nurse 7 (13.2) 45 (84.9) 1 (1.9)
Total 12 (7.9) 131 (86.2) 9 (5.9) 152 (100.0)

Treatment Success of Tuberculosis

A total of 154 patients had started treatment for tuberculosis in the hospital in the study time and about nineteen percent were below 15.  Two third (66.2%) of patients had pulmonary tuberculosis, and tuberculosis spondylitis (15.6%) and adenitis (13.6%) were the most common causes of extra pulmonary tuberculosis. The prevalence of tuberculosis in HIV patients was 5.2% and all patients these tested  positive  for  HIV  had  started  anti-retroviral  treatment  and co-trimoxazole preventive therapy. The prevalence of Rifampicin resistant tuberculosis from these started treatments was 5.8% and all were referred to Merhano National MDR-TB treatment hospital for management. The treatment success of tuberculosis was 81.2% with a death rate of 7.1% (Table 4).

Table 4: Treatment successes of tuberculosis patients

Variables Categories Frequency (N) Percent (%)
 

Address

 Massawa 131 85.1
Foro 19 12.3
Others 4 2.5
 

 

Age of respondent (years)

 < 15 29 18.8
15-34 39 25.3
35-54 51 33.1
55 and above 16 22.7
 

Sex of respondent

 Female 81 52.6
Male 73 47.4
 

Treatment started year

 2018 52 33.8
2019 40 26.0
2020 62 40.3
 

Site of infection

 Extra pulmonary 52 33.8
Pulmonary 102 66.2
 

If Extra pulmonary; Specify

 Bone TB 24 15.6
Skin TB 6 3.9
TB adenitis 21 13.6
 

Type of patient

 New 147 95.5
Relapse 7 4.5
 

HIV status

 Negative 146 94.8
Positive 8 5.2
Ante-retroviral therapy started No 146 94.8
Yes 8 5.2
Co-trimoxazole preventive therapy No 146 94.8
Yes 8 5.2
 

Rifampicin resistant

 No 118 94.2
Yes 9 5.8
 

 

 

Treatment outcome

 Cured + Completed 125 81.2
Died 11 7.1
Failure 1 0.6
Not evaluated 8 5.2
Referred 9 5.8
Total 154 100.0

Discussion

Determining the prevalence of tuberculosis is very crucial for  the management of the disease. This study was aimed to evaluate this challenge in Massawa Hospital. The prevalence of bacteriologically confirmed tuberculosis was 7%, (152 cases per 2178). This was almost similar to a study conducted in Nakfa subzone, Eritrea; which showed that the overall prevalence of 7.8% [11]. According to the recent WHO estimate report, the prevalence of tuberculosis in 2018 in Eritrea corresponds to 89 cases per 100,000 populations [10]. Estimated tuberculosis incidence in the Horn of Africa ranges from 65 cases per 100,000 people per year in Eritrea [12]. This higher prevalence could be attributed to the higher detection rate of tuberculosis after the introduction of diagnostic modalities like Xpert Gene and increasing community awareness about the disease and early health seeking behavior. The contributions of the community tuberculosis agents are also remarkable [13].

The prevalence of Rifampicin resistant tuberculosis in the bacteriologically confirmed new cases and previously treated was 5.9% and 9.1% respectively. This was higher to the national average based on the WHO estimates for Eritrea; the prevalence of MDR-TB among new cases and previously treated cases was 2.6% and 18% respectively [14]. It was also higher to a preliminary survey done in Eritrea that Rifampicin resistance among new cases and previously treated cases was 2% and 7.5% [14]. The introduction of the new diagnostic modalities could have a value on the higher incidence of MDR cases.

This study revealed that the prevalence of extra-pulmonary cases was 33.8% and tuberculosis spondylitis and adenitis were the most common cause. This was similar to the national average that the proportion of extra pulmonary notified in 2016 was 34% but higher to 16% for Africa [14]. This result showed that the disease is not contained in the lung which seeds it to different extra pulmonary sites that leads to different complications.

The prevalence of tuberculosis in HIV patients was 5.2%, which was slightly lower to the national average (6%) in 2017 [14] and higher to other study (3.7%) [13]. This shows that the impact of the previously introduced strategy by the Ministry of Health to screen all TB patients for HIV had increased to detect the co-infection and burden of these diseases.

This study showed that 85.7% of patients that were on treatment were new TB cases and 4.5% were with relapse. This was lower to other study that 92.6% of the patients were new TB cases, but there were 1.9% relapses cases [13]. Furthermore, this research reported that, 76.6% of the patients were bacteriologically positive before starting treatment. This was higher to the national average that of these notified 58% were bacteriologically positive compared to 64% in Africa in 2015 [14]. This was also higher to other study that 73% [15] and 45.1% [13] of the patients were bacteriologically positive pulmonary TB. This result explained that, some cases of the extra pulmonary cases, mostly the TB adenitis and skin TB were bacteriologically positive for mycobacterium tuberculosis.

This study revealed that the treatment success rate was 81.2%. Even though this was lower to the national average in 2016, 90% [14], it was similar to the 2012 treatment success rate in the African region, which was 81% [7]. When compared to other countries, this was similar to studies in South Africa 80% [16], Ethiopia 79.4% [17] and 81.8% [18]. But, it was lower to studies in South Africa 82.2% [19] and Ethiopia 90.1% [20], 86.8% [21]. It was higher to studies in Uganda 39% [22], Zimbabwe 70% [23], Nigeria 57.7% [24], and Russia 77% [25]. Since some patients (5.8%) were referred for MDR treatment and some were not evaluated (5.2%) as they didn’t yet complete their treatment, this could significantly decreased the success rate from the national average.

This study reported that majority of tuberculosis cases were in the age group of 15-54 years (58.4%) and children less than 15 years contribute 18.8%. This was similar to the national average in Eritrea in 2017 that the age of 15-54 years and children < 15 years was 61.5% and 17.1% respectively [14]. A study in Nakfa, Eritrea; showed that the adult age group of 41-60 years had the highest rate of pulmonary TB infection [11]. The higher prevalence in the pediatric and geriatric population could be due to their poor containment of the latent infection that leads to pulmonary or extra-pulmonary tuberculosis.

The mortality rate of tuberculosis in the hospital was 7.1%. This was higher to other studies, 5% [25] and 3.7% [13]. This higher rate of mortality could be due to other comorbid diseases, delayed health seeking behaviors and treatment complications.

Patient with previous history of tuberculosis showed significant association with the prevalence of tuberculosis and MDR tuberculosis. This could be mainly due to the presence of other smear positive cases in the family which didn’t get treated and spread the infection. Besides, treatment defaulters could be another cause for the higher prevalence of MDR cases in the previously treated patients.

Conclusion

The prevalence of tuberculosis was higher to the national average and the WHO estimates for the African region. Majority of the bacteriologically positive tuberculosis patients were new cases. The prevalence of extra pulmonary and tuberculosis in HIV patients was slightly lower to the national average but higher to other studies and WHO estimates for Eritrea. The treatment success rate was lower to the national average and patients with previous history of tuberculosis had showed significant association to the prevalence of tuberculosis and MDR tuberculosis.

Recommendations

To estimate the current prevalence of tuberculosis and MDR– tuberculosis, a national survey is highly recommended. Awareness of the community about adherence, disease and treatment complications are essential. Further prospective studies to evaluate the difference of tuberculosis prevalence by subzone and the impact of nutritional status are indispensable. Routine contact tracing for  MDR-tuberculosis and the directly observed treatment strategy should be advocated to decrease the relapse and MDR-tuberculosis.

Declarations

Ethics Approval and Consent to Participate

Ethical approval was obtained from the Ministry of Health Ethical Review and Clearance Committee on 03/05/2021 and that informed consent was obtained from all subjects and/or their legal guardian (s). All methods were carried out in accordance with relevant guidelines and regulations.

Acknowledgment

Authors acknowledges for the patients for using their data.

Author’s Contribution

The proposal was drafted by BT, FK and further edition was done by all the authors. Data was analyzed by FK and all authors have participated on data interpretation. The draft of the manuscript was written by BT and the final form was shaped by BT, HG and FK. All authors have contributed by interpretation, analysis, critical discussion and approved for publication.

Abbreviations

TB: Tuberculosis, MDR: Multi Drug Resistant, TSR: Treatment Success Rate, HIV: Human Immunodeficiency Virus, ART: Antiretroviral Therapy, WHO: World Health Organization, MTB: Mycobacterium Tuberculosis, CSPro: Census and Survey Processing System, SPSS: Statistical Package for the Social Sciences.

References

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Use of Cytosorb in Pediatric Septic Shock due to Untreated Systemic Lupus Erythematotus since the Childhood Onset

1 Reply

DOI: 10.31038/PSC.2022222

Abstract

Systemic Lupus Erythematosus (SLE) is an autoimmune disease characterized by unpredictable multiorgan involvement and a broad range of age of onset and unspecific manifestations. The identification of the onset of the SLE is very complex. The incidence is higher in young women with a peak between 15 and 40 years and a female to male ratio of 6-10:1. In childhood, the incidence is lower by a factor of ten with a female/male ratio=2:1. The variable prevalence is higher in Afro-Caribbean and Asians (207 and 50/100,000 cases, respectively), lower in Caucasians with an incidence of 20/100,000. The disease results from complex and multifactorial interaction of genetic, epigenetic and environmental factors that led to immune dysregulation and loss of tolerance to self antigens. An exaggerated defense response of the body to a noxious stressor as quiescent Epstein Barr Virus infection involves the release of acute-phase reactants, by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm and can cause a massive inflammatory cascade leading to end-organ dysfunction (kidney and liver more frequently) and even death due to a self-mantaining process. We present a case of Septic shock and MOF on childhood untrated SLE.

Keywords

Lupus Eritematosus sistemico, Immunology, Etiopatology, Clinical manifestation, Voluntary avoided therapeutic treatment, Cytosorb, Rescue therapy

Introduction

A 16-year-old female was transferred to our hospital (tertiary care hospital with the only pediatric intensive care of country) on 17 February with a diagnosis of deep respiratory and cardiovascular insufficiency and anuria (Tables 1 and 2).

Table 1: Clinical features of SLE

Mucocutaneous Manifestations. (face and shoulder)
Musculoskeletal Manifestations
Hematologic and reticuloendothelial manifestations
Neuropsychiatric and Gastrointestinal Manifestations
Renal and Liver Manifestations (late onset and life-threatening)
Cardiovascular and Pulmonary Manifestations (late onset and life-threatening)
Exitus due to MODs.

Table 2: Epidemiology of SLE

Male Age > 40 y 10.1 on 1000000
Female  15< age <40 y  6 on 1000000
Pediatric Ages  Age <16 y  M/F=2:1
Carribean 207 on 1000000
Caucasians 50 on 100000
 Asian 20 on 100000

Past Medical History

Previous diagnosis at 10 years age of “Bullous systemic lupus erythematosus” (BSLE) an uncommon cutaneous presentation that occurs even less frequently in the pediatric population. Unfortunately the patient received inadequate therapeutic treatment with consequent rapid evolution in a severe form of SLE, and in the last two years there wa a rapid worsening of desease expressions in the whole body function leading till the observed rapid evolution in MOF. On admission the patient presented agonic clinical conditions, respiratory failure, bilateral pleural effusion and pulmonary consolidation throughout the area, state of coma (GCS 6-7), hyporesponsiveness to painful stimulation, discrasic oedema of the face and of the lower and upper limbs. A blood gas analysis showed values incompatible with the correct functioning of the metabolic-respiratory systems: PaO2< 50, PCo2 >89; PH 6.86: HCo3-12, BE: -20, Lactacidemia >25.

We proceeded to emergency intubation, mechanical ventilation in PCV and positioning of central vascular accesses to initiate inotropic support in the need to recover the respiratory and metabolic function. Brain protection was performed with morphine, dexdemetomidine and propofol. Fenoldopam infusion, 1 mg/kg/h was started On careful physical examination resulted the presence of muscle-tendon retractions of the major joints due to prolonged immobility and untreated lupus skin lesions. She also presented with an ulcerated bullous lesion, deepened to the tibial bone, suppurating and bleeding in the left lower leg. There were: cold cyanotic skin (rectal temperature 33°C) and the presence of unidentifiable patches spread throughout the body that showed generalized rigidity, a so called “rigor mortis precox”-like state. To study the anasarca state a scan was performed at bedside that found 6,000 ml of ascites,pericardial effusion and bilateral pulmonary consolidations.

Laboratory testing revealed: hypoalbuminemia and significant dysprotidemia, creatininemia> 3 times the basal value, proteinuria>3 gr/dl, persistent anuria from> 12 h (Tables 1-3).

Table 3: Laboratory tests on admission

Laboratory tests

 T.I. Ped Admission

 WBC 14430 uL
 Neu 95.39%
 Linf 2.72%
 RBC 2.200000 uL
 HGB 5.7 gr/dl
 HCT 17.48%
 PLT 103000 u/L
Glicemia 92 mg/dl
Azotemia 262 mg/dl
Creatinina 3.59 mg/dl
Prot. Tot. 5.8 gr/dl
Albumina 17 gr/L
 AST 22 U/L
 ALT 11 U/L
 GGT 16 U/L
 LDH 285 U/L
Bil Tot. 0.27 mg/dl
Bil ind. 0.15 mg/dl
Bil dir. 0.12 mg/dl
 CPK 132 U/l
 Mioglob. 325 ng/ml
 PCR 178 mg/L
 PCT 9.44 ng/ml
troponina 17.3 ng/ml
PT-INR 1.16
PTT-Ratio 1.54
Fibrinog. 218 mg/dl
 ATIII 62%
D-dimero 34072 mg/L
Pro-BNP 72906 pg/ml
Presep. 2748 pg/ml

CT scan was performed looking for hemorrhagic-ischemic cerebral lesions, with negative result but confirming the massive ascitic effusions in the pelvic cacities and between the viscera as well as in the Epiplon retrocavity, with no other acute organ lesions, except for renal congestion and bilateral alteration of the cortical density of the kidneys. Invasive ventilation and cardiovascular support were modulated. Management included continuous administration of packed Red Blood Cell, repeated administration of Fresh Frozen Plasma, Albumin 19% at 2 ml/h in continuous infusion, heparin infusion 50 IU/Kg/day, provertinum, AT III, Fibrinogen, diuretics and Glucose in adequate percentage (Table 4).

Table 4: Fluids, hematologic therapeutics, cardiovascular support intake after admission

Concentrated Blood Red Cells

 250 mls

250 ml after three/hours
Fresh Frozen Plasma 200 mls plus 200 mls 200 ml bidaily for 1 week
Albumine 19% %0 ml at 2 ml/hts IV continuos infusio The same regimen for 10 days
Provertinum 250 mg and 250 mg after 5 hrs As per needed 150 mg IV
AT III 400 IU and 250 IU after 5 hrs As per needed on lab test referral
Fibrinogen 259 mg and 250 after 5 hrs As per needed on lab tests
Diuretics 60 ml bolus followed by 10 mg Hr IV infusion Untilldismission from ICU
Glucose 33% 10 ml/hr for 6 hrs IV continuous infusion Only as per parenteral nutrition at 50% of total caloric daily requiring
Fenoldopam 1 mg/kh/day 1 week (Titrate)
Noradrenaline 0,1 mcg/kg/min 1 week (Titrate)
Adrenaline 0,1 mcg/kg/min 8 days (Titrate)
Milrinone 0,5 mcg/kg/min 25 days (Titrate)

Blood samples were taken, skin wound swab for PCR’s bacteria detection was negative as weel as throat swab for PCR for viruses and bacteria. Bronchoculture was positive for enterococcus faecium, subsequently, even for Aspergillus Niger treated with Voriconazole. Blood culture and urine culture positive for Candida Albicans treated with Fluconazole. A further examination of the biological parameters showed: leukopenia=2730, lymphopenia and thrombocytopenia 47000 uL, CRP=100 mg/dl, PCT> 1.5 pgr/ml, D-Dimers: 10000 UI/ml, PT INR 2.5 and PTT ratio: 2.7, Fibrinogen=500 mg/dl, LDH> 400 mg/dl, creatinine> 3 mg/l, reduced transaminase values such as chronic liver failure, altered values of ferritin and triglycerides compatible with the initial macrophage-histocytic activation process, albuminemia 12 mg/dl, total protein 2.0 Mg/dl, proteinuria> 3 g/l. Broad-spectrum antibiotic therapy was started and then targeted on antibiogram and culture outcomes, with Teicoplanin, fosfomycin and fluconazole, in rotation during the same hospitalization with Meropemen, Vancomycin, Voriconazole and Sulfamethoxazole trimetropin.

Due to worsening anasarca following the capillary leak and deteriorating renal function Treatment with CVVHD-F was initiated. Under this therapeutic management at the maximum support, in the following hours there wasn’t any improvement, especially persisting the state of severe acidosis mixed with Ph value never above 7.10. In order to control the multiorgan dysfunction caused by septic shock and the state of total functional anergy and dysregulation, presumably triggered by auto cannibalism process, we proposed to the parents the option to aply as rescue therapy the “Cytosorb Adsorber” to try to block the “Cytokine Storm” (that we where convinced was the principal cause of the functional dysfunctions), in an desperate attempt to restore an acceptable energy and metabolic production capable of supporting the life-saving needs of the patient [1-24].

Materials and Methods

Since 2016, in our Unit, a therapeutic project started, initially experimental, later well-defined and applied, for the Adsorber Cytosorb (Cytosorb Corporation-GmBH-Berlin D (E) – (USA) use in immunity dysregulations case in order to stop Cytokine Storm Progression and to initiate a “Rescue Therapy Treatment”, for compassionate purpose in patient in “Imminentia Mortis” condition. In this case, three cycles of CytoSorb Absorber were performed, mounted on Dialysis Machine Prismaflex (Baxter) in a downstream position to the filter used for CVVHD-F. Each cycle lasted 24 hours, circuit anticoagulation was maintained with low molecular weight Enoxaparin at a dose of 15-30 IU/kg/h (while continuing systemic administration of 50 U/I of heparin per day in continuous infusion). The PTT value was maintained at 70 sec and the act (200-220); the dialysis flow was established at 150 ml/min and a blood filtration flow of 200 ml. The priming of the circuit was integrated with 90 ml of concentrated RBCs for filling the Cytosorb. In the first two days about 4000 ml of ascitic fluid were removed with CVVHDF, and then another 2000 ml removed with permanent peritoneal drainage until the fourth day. After each suspension of use of Cytosorb, a cycle of albumin plasmapheresis was performed for other seven days.

Results

Right after the application of the first Cytosorb Adsorber, about eight hours later, there was a greater respiratory metabolic stability of the patient, a regression of lactates and a normalization of NaHCO3 values. The inothropic weaning began thanks to improved metabolic state and completely stopped within 36 hours. Fenoldopam, Furosemide and Milrinone continuous infusions (Triteted) were maintained longer because the renal function was never recovered. After the second application of Cytosorb the improvement of the pleural effusion was observed and sierositys resolved as well as the improvement of the pulmonary interstitial-alveolar function leading to a rapid reduction of the ventilatory support and FiO2 and successful extubation in the sixth day after the third cytokines apheresis with Cytosorb. At daily physical examination the neurological status improved after discontinuation of the neuroprotective drugs, and the patient showed attention and obeying to command, even if with limitation due to severe osteotendinous and muscle lesions. On the twelfth day the patient was transferred to Nephrology department of the same hospital with a specific pharmacological program and for dialysis treatment due to persistent anuric renal failure.

In the following 72 hours from the transfer, she developed malignant arterial hypertension and posterior reversible encephalopathy syndrome (PRES), heart failure and respiratory failure, so she needed intensive care setting for ventilatory assistance and control of blood pressure with angiotensin-converting-enzyme inhibitor and calcium channel blockers. In addition, an episode of angina occurred requiring enzymatic monitoring and therapy with nitratesTransthoracic critical care echocardiography was used to evaluate biventricular function and complications following acute coronary syndromes: hypertrophic-dilated myocardiopathy was highlighted and controlled by inotropic, lusitropic, and vasodilatory properties of milrinone and levosimendan.

Brain stem MRI was performed showing acute/subacute developmental hemorrhagic foci of posterolateral white and gray matter hemispheres, basal nuclei, brainstem (pons and midbrain) images consistent with posterior reversible encephalopathy (PRES) in addition to the presence of arteritis and narrowing of the arteries of the Polygon of Willis, compatible with the probable presence of the factor Lupus anticoagulants and the development of a picture of diffuse vasculitis and nervous and cardiac involvement during the progression of previously untreated Les. All the necessary pharmacological and depurative support therapies was resumed with a daily cycle of albumin plasmapheresis than scheduled on alternate days meanwhile continuing dialysis for anuria. Corticosteroid treatment with prednisolone was well tolerated and stabilized with a bolus of 0.5 mg/kg/day IV, followed by 50 mg/day through day 7 and progressive tapering during the 2 weeks treatment course up to a fixed dosage of 5 mg/day.

Fortunately, throughout this period of time the patient did not suffer infectious-inflammatory insults, even from the laboratory test point of view Immunosuppressive therapies currently in use was not taken into consideration given the exceptional nature of the case and. The poor clinical state of the patient and mostly because we were not able to find any specific references in the literature treating cases like this. Finally, a single dose of Intravenous Immunoglobulins of 75 mg/kg was administered because a biological fluids (blood, plasma, derivatives of both) administration strategy was preferred in an attempt to accompany, stimulate and regain her spontaneous immunity rather than replace or inhibit it with synthetic and/or semi-synthetic substitutes ( plasma, apheresis ). This therapeutic strategy is very frequent in our group during treatment with MOF sepsi related treated with Cytosorb apply. And it seems to us a well-founded opinion if related to our clinical results already well presented in letterature. Table 5 presents the lab test evolution before and after each single Cytosorb application, 48 hrs after application suspension and at 6 days from the end of Cytosorb application.

Table 5: Cytosorb application lab data timing

table 5

The progression of the systemic SLE was completely stopped in ten weeks. We witnessed complete regression of imaging (except for acute evolution of PRES signs) and laboratory parameters, as well as restoration of cardiovascular function with optimal pressure control, complete recovery of neurological status and total functional reactivity, even if paresis of the left upper limb hesitated. At 3 months there was no recovery of renal function consisting in the lupus nephritis picture. The patient, discharged from Intensive Care Unit on March 17th to Nephrology Ward, was then transferred to another hospital for physical rehabilitation on May 31st.

Discussion

The “Rescue Therapy” with compassionate purposes, in a patient in “Imminentia Mortis”, with CytoSorb and cycles of plasmapheresis for uncontrolled macrophage-histocyte activation syndrome (MAS), secondary to infectious trigger evolved in septic state with organ damage, is a consolidated reality. As such, however, the scientific community unconditionally accepts it only in 50% of cases. The majority of patients with pediatric sepsis has favorable outcomes except when sepsis leads to multiple organ dysfunction syndrome (MODS) and the risk death increases in proportion to the number of organs affected. Immune dysregulation is a hallmark of pediatric severe sepsis and MODS, triggered by the uncontrolled and amplified activation of the cytokine cascade leading to prolonged hospitalization and increased late mortality.

Organ dysfunction can be identified as a 2-point variation of the Pediatric Sequential Organ Failure Assessment Score (p-SOFA) assuming that the score is zero in the previously healthy patient, in the absence of comorbidities. A pSOFA score of 2 corresponds to a 10% increased mortality risk in the hospital population with suspected infection associated with organ dysfunction. p-SOFA is computed every day, providing a dynamic assessment of the progression of the disease. It is clear that the further aggravation of organ damage conditions, in the presence of pre-existing dysfunctions, amplifies the severity of state needing the institution of prompt and appropriate treatment.

The initial trigger response of the host is activated by the recognition of a Pathogen Associated Molecular Patterns (PAMPS) or by tissue damage caused by cellular apoptosis and the release of Damage Associated Molecular Patterns (DAMPS). These in turn activate receptors such as the Toll-like receptor and C-type Lectin receptor which, through the activation of Th1 and Th2, activate the cytokine cascade with the release of IL1, IL6 and TNFα. The release of cytokines is trigger for the further activation of numerous pathways of innate and acquired immunity, which results in the migration and activation of macrophages and other cells of the innate immune system, in the release of many others cytokines, chemokines, proteases and reactive oxygen species and amplification of cell damage. The activation of the coagulation system amplified by the notable release of cellular tissue factor and by the imbalance of the anticoagulation system due to protein C deficiency leads, in turn, through the protease activated receptor (PAR’s), resulting in the amplified production and thrombin deposition, to the interruption of the integrity of the endothelial barrier and the Leak Syndrome with tissue edema, dysproteinemia and hypoalbuminemia (and loss of the redox power of the latter). the renin-angiotensin system with increased incidence of renal insufficiency, hyperlactacidemia, cardiovascular instability, respiratory distress.

This condition of SLE has evolved into severe sepsis, favored by a high underlying pathological activity due to the high title of autoantibodies responsible for the exacerbation of organ damage (demonstrated by the high level of ANA and Anti dsDNA and by the low immunoglobulin title of specific immunity and the decrease of C3 and C4, Proteinuria> 3 gr/dl in the urine of 24 h). The meeting point in this state of dysregulation is the initial and final path of the altered innate and acquired immunity during the SLE. In the past, MAS was considered an exclusive complication of rheumatic disease. The progression of SLE in MODS due to the MAS is supported and initiated by a genetic, epigenetic and environmental basis (infections or severe septic state, vitamin D deficiency) which leads to self-persistence of autoantigens and cell damage in the presence of humoral dysregulation with increased cytokines TH1 (IL2), TH2 and TH17 (IL5, IL6, IL21) amplified by the innate immune response and by the self-maintenance of the T cell response and by the production of autoantibodies. The latter is amplified by the increase of INFϒ concentration supported by TNF-dependent factors, through the toll-receptors. The stimulation of B lymphocytes and the uncontrolled macrophage activation with cyclic amplification of the increasing organ damage, is worsened by a break-down of immunological regulation due to TGF-β production and deficit or dysregulation of the TREG/TH17 system.

With an innate substrate of severe immunological dysregulation pathognomonic of SLE, the overlap, as in our case, of the septic trigger with uncontrolled and amplified cytokine cascade aggravating the organ damage and increasing the activity of the disease, was the cause of an abnormal and unstoppable secondary lymphohistocyte-macrophage activation (MAS) which resulted in a serious risk of life for the patient. Rescue therapy with cytokine apheresis through CytoSorb absorber, established early at the onset of organ dysfunction, allowed its reduction with restoration of consciousness, reduction of support and rapid respiratory weaning within 48 hours of treatment with CytoSorb and the reduction until the suspension of the inotropic support at 24 h. There has never been recovery of renal function but only stabilization of renal organ damage with AKI KIDNO SCORE 2 which has attested to dependence on CRRT. The initial calculated pSOFAscore was 13 with an increased risk of mortality of 95% and an APACHE II score of 27 with an estimated non-operative mortality of 55%. Thanks to the Cytosorb treatments, a net reduction in the risk of death was observed: final SOFA calculated equal to 1 with expected mortality lower than 33.3% and an APACHE II calculated equal to 2 with estimated non-operative mortality <4%. The subsequent exacerbation of organ damage at the second admission was controlled with boluses steroid therapy of 500-750 mg/ml for 3 days and subsequent administration of 0.5-1 mg/kg/day subsequently reduced in 2 weeks to 5 mg/day of maintenance in addition to twice a week plasmapheresis. Heavier immunosuppressive therapy with cyclophosphamide or methotrexate and/or azathioprine was contraindicated. Biological immunological therapy with Rituxumab was also evaluated but was not administered due to the worst patient conditions.

Rescue therapy with CytoSorb has been shown to be safe and effective, reducing both the risk of morbidity from 95% to 33% in untreated SLE linked to sepsis and MODS and mortality. Early diagnosis and improved management of SLE significantly increased the probability of survival over the last decade from 5% vs. 95% at 5 years and from 0% vs. 92% at 10 years, from 1995 to 2003. Mortality is essentially linked to disease activity and organ damage as well as bacterial infections that occur in immunosuppressed or immunodeficient patients, as in the case of our patient, subjected to a high dose of glucocorticoids. Immunoapheresis with CytoSorb, in our case, interrupted the self-maintained course of the inflammatory cascade, amplified and mitigated the effects of immunological dysregulation and the imbalance of immune regulation at the basis of SLE, avoiding the progression towards massive lymphohistiocytosis (LHS) and the activation of macrophages (MAS). We await the results of the assay of the cytokines IL6, IL10 and TNFα, before and after each cycle of immunoapheresis performed in another German laboratory, for desirable and precise confirmation of these data.

Conclusion

Immunoapheresis with cytokines has proved effective, in our case, in the treatment of sepsis with organ damage and even more it has been shown to reduce the mortality associated with it, even in the presence of acute and amplified dysregulation of innate immunity. and insufficient and acquired immunological regulation of systemic inflammation as in SLE. It has been shown, as in previous clinical cases, to control uncontrolled lymphohistocytic and macrophage hyperactivation secondary to infectious triggers (MAS). However, further randomized controlled trials in pediatric patients are needed to better frame and define the role of apheresis with CytoSorb as a targeted therapy of amplified systemic inflammation and in the reduction of related organ damage, even more in the context of potent immunological dysregulation. of the acquired and innate immunity, amplified by the septic state.

Author’s Note

The case report of this paper represents a clinical rarity, I would say an exceptionality, since nowadays it has not been found, by us, in the available literature any description of patient like this, suffering from a pathology such as well recognized SLE, has come to medical observation so defied and in so severe clinical state as to require intensive treatment (described in this paper).

References

  1. Gliwińska A, et al. (2020) A rare complication of systemic lupus erythematosus in a 9-year-old girl: Questions. Pediatr Nephrol. [crossref]
  2. Leonardo Milella, Maria Teresa Ficarella, Gerolmina Calabresel, Michele Sisto, sorption in Rito Launa Grieco, et al. (2019) Application of Hemoadsorption in Neonatal and Pediatric Hyperinflammatory States:A case Series. American Journal of Pediatrics 5(2): 34.
  3. Milella Leonardo, Raimondo Pasquale, Ficarella MariaTeresa, Calabrese Gerolmina, Sisto Michele, et al. (2021) Application of combined hemadsorption with eculizumab as rescue treatment of a pediatric patient with multiple organ failure related to severe hemolytic uremic syndrome. J Clin Rev Case Rep 6(8): 718.
  4. Zhang L, et al. (2022) Continuous renal replacement therapy combined with double filtration plasmapheresis in the treatment of severe lupus complicated by serious bacterial infections in children: A case report. Open Life Sci. [crossref]
  5. Milella L, Ficarella MT (2017) First application of CVVHDF, Plasmapheresis and “Cytosorb Absorber” to solve Pediatric Haemophagocitic Histyocitosis case. Research in Neonatology and Pediatrics 1.
  6. LisaMaria Steurer, et al. (2019) Hemadsorption as rescue therapy for patients with multisystem organ failure in pediatric intensive care-Report of two cases reports and review of the literature. Artif Organs. [crossref]
  7. Leonardo Milella. (2019) Hemoadsorbtion to treate Neonatal and pediatric septic shock and sepsis. World Neonatology and Pediatric Care Meeting 2019.
  8. L Milella. P RaimondoESA (2020) Hemoadsorption: A promising Rescue Therapy in the Treatment of Critical ill Pediatric Patients. Oral Presentation-European society of Anesthesia.
  9. Milella Leonardo, Raimondo Pasquale, Ficarella Maria Teresa, Calabrese Gerolmina1, Sisto Michele1 et al. (2021) Hemoadsorption as Bridge to Liver Transplant in A Six-Month Old Patient with Hepatic Failure.Journal of Pediatrics and Neonatology. J Pediatr Neonatol 2(2): 1017.
  10. Milella, P. Raimondo, N. Lombardi, Maldera M. F. Cito, et al. Hemoadsorption: A Promising Rescue Therapy In The Treatment Of Critical Ill Paediatric Patients.. Conference Paper · May 2020
  11. Milella L MD, Ficarella MT, MD, Raimondo P MD, Moliterni P MD, Cito F MD, et al. (2016) “Is Cytosorb® a Rescue Therapy in neonatal and pediatric patients?
  12. Milella, P. Raimondo, N. Lombardi, F. Cito, M.L. Lasorella, MT. Et al. (2019) Hemoadsorption in the rescue treatment of a pediatric patient with MOF related to severe Hemolytic Uremic Syndrome. Bologna 5-6 december 2019
  13. Scobell, Rebecca (2020) Management of Lupus Nephritis in Children. Indian Pediatr. [crossref]
  14. Onengiya Harry, et al. (2018) Onset Systemic Lupus Erythematosus: A Review and Update. J Pediatr.[crossref]
  15. P Srivastava, et al. (2016) Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years. [crossref]
  16. L Milella (2020) Our experience with Cytosorb in Children and Newborns with Hyperinflammatory states. Ostrawa-News in Pediatric Intensive care.
  17. Milella Leonardo, Cito Fabiana, Raimondo Pasquale, Ficarella Maria Teresa, Moliterni Paola, et al. (2020) “Our Four Years Experience of Hemoadsorption, Albuminand Heparin Treatment for Paediatric Sepsis: Let’s Give a Chance in Multifactorial Pathological Conditions”. American Journal of Pediatrics 6(3): 207.
  18. Milella Leonardo1, Cito Fabiana1, Raimondo Pasquale, Ficarella Maria T eresa1, Moliterni Paola, et al. (2021) Our Four Years of Paediatric Sepsis Treatment with Hemoadsorption, Albumin and Heparin: Let’s Give it a Chance in Multifactorial Pathological Conditions. Highlights on Medicine and medical Research 14.
  19. Vahid Ziaee, et al. (2013) Peripheral gangrene: A rare presentation of systemic lupus erythematosus in a child. Am J Case Rep. [crossref]
  20. Raimondo P, Ficarella M, Moliterni P, Sisto M, Cito F, Calabrese G, Milella L (2019) Rapid treatment of unexpected septic shock: a single pediatric case recovery for Septic Shock due to Streptococcal Arthritis using early extracorporeal cytokine adsorber treatment. PurificationTherapies-Le idee per la ricerca clinica”-Milano.
  21. Anadi Mahajan, et al. (2020) Systemic lupus erythematosus, lupus nephritis and end-stage renal disease: a pragmatic review mapping disease severity and progression. Lupus. [crossref]
  22. Leonardo Milella (2018) Use of CytoSorb in a pediatric case of acute hemorrhagic encephalitis and multiple organ failure. Cytosorb Library. Case of the week.
  23. Pasquale Raimondo, Maria Teresa Ficarella, Paola Moliterni, Michele Sisto, Fabiana Cito, et al. (2019) Use of CytoSorb in a pediatric patient with septic shock due to streptococcal arthritis. Purification Therapies Workshop – The ideas for clinical research. Milan, Italy March 15-16 2019.
  24. Milella L (2021) Webinar.“Pediatric use of “Cytosorb”Marijana Matejc –“Cytosorbent”–USA-Stefania magnani,“Aferetica”, Italy.

Prevention of Sepsis in the Elderly with Diabetic Foot Ulcers: Letter to the Editor

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DOI: 10.31038/ASMHS.2022665

What is Sepsis?

It is a dangerous disease that is caused by an overreaction of the body’s immune system to infection and gradually covers the whole body. This disease occurs due to a strong reaction to the infection; to deal with the threat, the body sends a large volume of chemicals into the bloodstream. This causes severe inflammation that over time slows blood supply and damages organs.

Diabetes in Old Age

One of the common chronic diseases of old age is diabetes, which has many effects on the quality of life of the elderly and sometimes causes death in the elderly due to its many complications.

Diabetic Foot Ulcer

One of the serious complications of diabetes is the diabetic foot ulcer, which increases the possibility of amputation if not treated and controlled. And it has irreparable effects on the life of the elderly and their families. Elderly people who do not have enough self-care or are neglected by their family are more likely to suffer from diabetic foot ulcers [1].

Sepsis and Diabetic Foot Ulcer

Failure to properly treat small leg wounds in the early stages and negligence provides the basis for the wound to spread to higher parts of the body. And on the other hand, the contamination of the hospital environment, non-observance of sterile technique in wound treatment and weakness of the immune system provide the basis for local wound infections and finally in an acute form of sepsis, which increases the risk of death due to the special physiological conditions of the elderly [2]. The question is, how can we prevent sepsis caused by diabetic foot ulcers in the elderly? Below are some strategies that can help.

  1. Accurate control of blood sugar at the appointed time and adherence to the insulin protocol.
  2. Sterile dressing by the wound nurse and use of new dressings instead of traditional ones.
  3. Adhering to a high-protein and vitamin-rich diet, according to the patient’s body conditions.
  4. Regular use of antibiotics and other medicines for the patient at the right time.
  5. Cultivation from the wound site in case of suspicion of infectious symptoms.
  6. Periodically and regularly check the condition of the nerves and blood vessels of the body.
  7. Encouraging the patient to move and move to establish organ perfusion.
  8. Prevention of secondary infections (urinary, respiratory, digestive catheters, non-sterile procedures, etc.)
  9. Antibiotics should be prescribed based on the results of the anti-bio-gram culture.
  10. According to the kidney condition of the patient, adequate hydration should be done.
  11. Reporting symptoms such as fever and chills, tachycardia, shortness of breath, decreased urination, dizziness, weakness, sweating, and low blood pressure.
  12. In case of distal limb necrosis, the patient’s consent for amputation should be obtained as soon as possible, in order to prevent further limb necrosis.
  13. Conducting psychiatric consultations for patients who do not consent to amputation.
  14. Correction of secondary problems of patients (kidney failure, electrolyte disorders, cardiovascular problems Arterial and venous insufficiency).
  15. Extensive cooperation of the treatment team with patients to improve the treatment process.

Conclusion

If any hospital follows the above simple platform at the beginning of admitting diabetic elderly, it will greatly help the process of treatment and timely discharge of patients.

References

  1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, et al. (2013) Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock (2012) Critical Care Medicine 41: 580-637.
  2. Phillips A, Mehl AA (2015) Diabetes mellitus and the increased risk of foot injuries. J Wound Care 24: 4-7. [crossref]

Immediate Effects of Task-Oriented Training on Walking and Balance in Patients with Stroke: A Preliminary Study

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DOI: 10.31038/ASMHS.2022664

Abstract

Objective: The purpose of this study was to evaluate the immediate effects of task-oriented training on walking and balancing in-patient clients with chronic stroke.

Design: A randomized trial with pre-training and post-training evaluations.

Subjects: Ten participants were randomly assigned to an experimental group (N=6) or a control group (N=4).

Methods: The GAITRite (GAITRITE)? The system was used to assess the spatial and temporal walking parameters and the “Timed Up & Go” Test (TUG) was used to assess functional mobility. The Berg Balance Scale (BBS) was used to assess balance. Both groups received a single session of exercise training. Patients in the experimental group received task-oriented training that involved task-specific activities and functional tasks. Patients in the control group received conventional physical therapy training focused on facilitation and normalization of movement.

Results: Analysis of the data indicates that the experimental group performed significantly better than the control group with respect to walking speed (p<0.001) and stride length (p<0.001). Following intervention, the task-oriented training group exhibited a statistically significant (p<0.04) decrease in TUG scores compared with the control group. There was no significant difference in BBS scores between the two groups after intervention.

Conclusions: Task-oriented training can improve walking and functional mobility in patients with stroke. The findings of this study provide preliminary evidence supporting the short-term benefits of task-oriented training for patients with chronic stroke.

Keywords

Stroke, Hemiplegia, Exercise, Rehabilitation

Introduction

It is estimated that each year about 1.2 million people experience a new or recurrent stroke in Europe and 700,000 in the United States [1,2], making it by far the most common cause of long-term disability [3,4]. About one-third of stroke survivors are functionally dependent at one year post stroke and are unable to walk without assistance; and of those who are independent ambulators, 60% of them experience limitations in community ambulation [5,6].

Walking and balance disorders have been reported to be common impairments in people with stroke [5,7,8], and are frequently the common cause of long-term disability and handicap, which contributes to overall increased risk of falls [7]. Improving walking and balance has been the primary goal in the rehabilitation of patients with stroke [4]. Many of the traditional neurofacilitation approaches have been designed to target walking and balance, with many of these approaches focused on managing impairments [9]. Since improvements in impairments may not be generalized to function, the effectiveness of these approaches in improving walking and balance is limited [9].

Current evidence suggests that rehabilitation training is most effective when the related task is specific to the intended outcome [9], and the training allows patients to perform activities in real-time situations [10]. Numerous recent studies have demonstrated that task-oriented training is a critical rehabilitation strategy to improve the functional status of individuals with stroke [11-16]. A published systematic review [17] analyzed 151 trials on the effects of physical therapy on functional outcomes in patients with stroke and found that there is strong evidence that patients with stroke benefit from task-oriented training intervention in which functional asks are directly trained [17].

Relatively, very few studies have explored the effects of task-oriented training on walking and balance in individuals with chronic stroke. A Cochrane review conducted by Pollack et al. [18] reported that there is a need for high quality randomized trials to determine the efficacy of task-oriented training. Although improvements in walking and balance in people with stroke have been reported as the results of participation in a task-oriented program over a period of time, evidence regarding the immediate effect of a task-oriented training on walking and balance has not been reported in the literature. Therefore, the purpose of this study was to examine the immediate effects of task-oriented training on walking and balance in people with chronic strokes.

Methods

Study Design

A randomized controlled trial with pre-training and post-training evaluations was used. All participants completed the pre-training evaluation and then were randomly assigned to the experimental (n=6) or control (n=4) group. The randomization process was carried out by a person independent of the study. The investigator who collected the data is a physical therapist who is a Neurology Certified Clinical Specialist with 12 years of clinical experience working with patients with neurological disorders.

Participants

The participants included ten community-dwelling individuals with a first-time stroke who were recruited from outpatient physical therapy clinic in a university setting. The volunteer convenience sample was selected based on the following criteria: (1) a stroke experienced more than 6 months prior to study enrollment; (2) age between 35 and 80 years; (3) able to walk 10 meters independently with or without walking aids or orthotics; and (4) able to follow verbal commands. Exclusion criteria included: (1) debilitating illness before or during the study; (2) surgical procedure up to six months prior to the study; (3) inability to follow commands; or (4) a medical condition that precluded exercising. All subjects were blinded to their group assignment. All the assessment and intervention procedures were carried in the same treatment area. After having been informed about the study procedures, each participant signed an informed consent before enrolling in the study. The study was reviewed and approved by the Institutional Review Board of …………BLINDED…………………. University.

Examination

Subjects were evaluated twice, immediately before (pre-test) and immediately after (post-test) the intervention. The outcome measures included a self-paced walk over the GAITRite system, the “Timed Up & Go” Test (TUG), and the Berg Balance Scale (BBS).

GAITRite System

Temporal and spatial parameters of walking were measured using the GAITRite system (CIR Systems, Havertown, PA). The GAITRite system is a computerized system developed to measure and record temporal and spatial walking parameters. The GAITRite system uses an electronic walkway approximately four meters long with grids of embedded pressure sensors that detect footfalls as the subject walks the length of the walkway. It is a valid and reliable clinical measure for spatial and temporal walking parameters [19]. Each subject was instructed and then asked to practice one walking trial before the actual data were collected. Each subject was instructed to walk over the walkway at a comfortable walking speed. Subjects started walking at a point one meter in front of the walkway and stopped at a point one meter behind the walkway to eliminate the effects of acceleration and deceleration. Subjects who were using walking aids were allowed to use their preferred walking aid. Temporal and spatial parameters of walking including walking speed and stride length were recorded.

The “Timed Up & Go” Test

The TUG is a performance-based test designed to assess functional mobility. The TUG test is a useful tool to monitor the progress of mobility function in ambulant patients with chronic stroke. This test demonstrated good (ICC=.99) and interrater (ICC=.99) reliability as well as validity for people after stroke [20]. The examiner first demonstrated how to perform the TUG test and then instructed the participant to rise from a standard armchair, walk to a line on the floor three meters away, cross the line, turn, walk back to the chair, and sit down again while being timed with a stopwatch. Each participant was allowed to practice one trial before the actual data were collected. Participants performed the test at their own pace, and those who were using walking aids were allowed to use their preferred walking aid.

Berg Balance Test

The BBS was identified as one of the most commonly used assessment tools to measure balance function across the continuum of stroke rehabilitation [20,21]. The BBS is a task-oriented performance-based test that has been used to assess balance function in people after stroke and evaluate response to treatment. The scale consists of 14 functional tasks frequently performed in everyday life. The BBS has strong psychometric properties and has been shown to be a valid test with excellent interrater (ICCs=0.95-0.99) and intrarater reliability (ICC=0.97) for people with stroke [20,21].

Intervention

Both groups received a single session (60 minutes in length) of physical therapy intervention designed to improve walking and balance. Subjects in the control group received conventional intervention focusing on improving walking and balance through facilitation and normalization of movement patterns. Subjects in the experimental group practiced task-oriented activities that focused on walking and balance. The task-oriented training included overground walking, standing up, sit to stand, rising from a chair then walking a short distance, performing step-ups/step-downs, stepping forward, backwards and sideways, walking through an obstacle course, walking while carrying an object, walking at maximal speed, walking backwards and sideways, tandem stance, single leg stance, and functional weight shifting exercises. In all cases, activities were set up on an individual basis and were adapted to the individual’s performance and ability. Assistance or manual guidance was provided, if required, and participants received feedback as needed. Participants were allowed to use their assistive devices as needed. Throughout the therapy session, the therapist emphasized the importance of speed, the number of repetitions was modified according to the participants’ ability. During the testing time, participants were allowed to rest as needed.

Data Analysis

Frequency distributions as well as means and standard deviations were used for descriptive purposes. At the baseline, differences in age and time since the onset of stroke between the two groups were analyzed with an independent 2-sample t-test. Differences in gender and side of hemiplegia were compared between intervention groups using chi-square. The 2-way repeated measure analysis of variance (ANOVA) for repeated measures on the time factor was used to compare the difference between groups (experimental and control) and timing (preintervention, postintervention) for each studied outcome. The alpha level of statistical significance was set at p<0.05. The SPSS statistical software package was used for the analysis.

Results

Ten subjects participated in this study. Participant demographic information, group assignment, side of stroke, and time since strokes are shown in Table 1. There were no statistically significant differences between groups at baseline with respect to demographic, characteristics, or outcome measures. Table 2 shows the group means, and standard deviations of the pre and post scores for time and distance walking parameters, the TUG scores, and the Berg Balance Scale scores. Analysis of the data indicates that the experimental group performed significantly better than the control group with respect to walking speed (p<0.001), and stride length (p<0.001) (Figure 1). Following the intervention, the task-oriented training group exhibited statistically significant (p<0.04) decrease in TUG scores compared with the control group (Figure 2). There was no significant difference in BBS between the two groups after intervention.

Table 1: Subject demographics, characteristics and group assignments

Subject

Group

Age (year)

Gender

Side of Hemiplegia

Time Since Stroke (month)
1 Experimental

72

 Male Right

22
2 Experimental

49

 Male Left

6
3 Experimental

55

 Female Left

9
4 Experimental

68

 Male Right

15
5 Experimental

62

 Female Left

18
6 Experimental

71

 Male Right

17
7 Control

65

 Male Right

11
8 Control

53

 Female Left

14
9 Control

69

 Female Right

13
10 Control

79

 Male Left

25

Table 2: Pre-test, post-test, and change scores, means, standard deviations, and mean changes by group

Variable

Score

Change scores

 

Experimental

Control

Experimental

Control

P-value

Pre

Post

Pre

Post

Post-pre

Post-pre
Walking speed (m/s)

0.43 ± 0.14

0.55 ± 0.14

0.49 ± 0.16

0.55 ± 0.15

±0.12

±0.06

< 0.001
Stride length (m)

0.59 ± 0.15

0.70 ± 0.14

0.61 ± .15

0.62 ± 0.15

±0.11

±0.01

< 0.001
TUG (s)

60.8 ± 10.6

55.67 ± 10.83

58.7 ± 14.0

56.25 ± 13.70

-5.53

-2.45

0.04
BBS

32.5 ± 4.85

35.5 ± 6.06

34.5 ± 5.32

35.75 ± 5.38

±3

±1.25

0.17

TUG: Timed “Up & Go” test; BBS: Berg Balance Scale

fig 1

Figure 1: Mean changes for walking speed and stride length for both groups

fig 2

Figure 2: Mean changes for the Timed “Up & Go” test and the Berg Balance Scale for both groups

Discussion

There is a growing body of evidence that supports task-oriented training as a beneficial intervention for patients with stroke. The purpose of this study was to examine the immediate effects of task-oriented training on walking and balance in subjects with chronic strokes. The findings of this study demonstrate that task-oriented training is associated with improvements in walking and balance in people with chronic stroke.

Spatial and temporal walking variables were significantly improved with task-oriented training. The results of the present study are in agreement with the findings of Knox et al. Salbach et al. and Dean et al. [11,15,16], who reported significant improvements in walking speed of individuals with stroke who participated in task-oriented training relative to participants in the control groups. Knox et al. [11] showed improvements in participants following participation in task-oriented circuit gait training as compared to the control group. Salbach et al. [15] showed that 6 weeks of task-oriented training induced an increase in walking speed as compared to the control group. Dean et al. [16] evaluated the effects of task-oriented training, including circuit training, on a small sample of individuals with chronic stroke and found a significant effect on walking speed after 4-week of task-oriented training.

Following the intervention, the task-oriented training group required less time to perform the TUG. Improvement in the TUG scores was statistically significant between the experimental and control groups. This result came in agreement with the finding of Knox et al. Leroux et al,. and Malik et al. [11,14,22] who examined the effect of an 8-week exercise program aimed at improving balance and mobility through various functional tasks in 10 subjects with chronic stroke. Knox et al. [11] reported improvements in TUG score in the experimental group who participated in task-oriented circuit gait training. Malik et al. [22] reported improvements in four weeks of task-oriented training. TUG scores following participation in Leroux et al. [14] concluded that task-oriented exercise program significantly improved the TUG scores in subjects with stroke. In contrast to the improvement in the TUG scores in the present study, Chan et al. Salbach et al. and Dean et al. [13,15,16] reported that task-oriented training did not have statistically significant improvement in the TUG scores. In the Dean et al. study [16], the results reflect a ceiling effect for this measurement tool for two subjects from the experimental group (N=5), these two subjects were able to obtain scores comparable with healthy subjects; in contrast, one subject from the control group (N=4) improved by 10 seconds and this may account for lack of significance in the TUG scores in the Dean et al. study [16]. Several factors may account for the improvements in the TUG scores in the task-oriented training group. Perhaps the most important aspect of task-oriented training is the specificity of training, the task-oriented training in the present study involved rising from a chair and walking this activity which was similar to testing conditions during training was specifically targeting the TUG scores, and may account for the improvement seen in this variable. In addition, previous studies [21,23] showed that there is high correlation between the TUG scores and walking speed in patients with chronic stroke. This high correlation is not surprising since TUG test incorporates walking speed. Given the association between walking speed and the TUG, improvements in walking speed were partially responsible for the improvement seen in the TUG scores in the experimental group.

Although changes in the BBS scores were not statistically significant between the study groups, there were trends toward greater gains in the balance scores in the experimental group compared with the control group. This result is similar to the findings of Salbach et al. study [15] who found no significant effects of task-oriented training on BBS. This is in contrast with the results of Knox et al. Chan et al. and Leroux et al. [11,13,14] who reported significant improvement in the balance following task-oriented training. The differences in the amount of practice and stages of recovery between the present study and Chan et al. and Leroux et al. [13,14] studies may be responsible for the lack of significance in the BBS reported in the present study. However, given the small number of subjects, lack of statistical significance between groups in regard to the BBS scores may be due to a lack of statistical power rather than a lack of effect.

Evidence has shown that task-oriented training is an effective intervention strategy to promote meaningful improvement in motor function [14,18,24] The effect of intervention involving task-oriented training is highly specific and the effectiveness of the training is related to the training parameters used with the maximum training occurs when training activities are similar to real-life tasks [18,22,25]. The intervention activities used in this study were specific and included walking and balance activities. The intervention activities used in the task-oriented group allowed the participants to practice functional tasks used in everyday activities, in real-time situation taking into consideration normal biomechanics, strength, balance, and lower limb function. The improvements in walking and balance may be related to the specificity of training used in this study.

In interpreting the results of this study, several limitations must be considered. The sample size was small in the current study. The results of this study are preliminary for this small sample size, limiting external validity. There was potential for bias since the researcher was not masked to the group assignments. In the present study we did not consider a single-session of task-oriented training to be a major study weakness, because the purpose of the present study was to determine the immediate effects of the task-oriented training, rather than the additive effects of multiple sessions.

The findings of this study demonstrated that task-oriented walking and balance intervention improved walking function in people after stroke. The application of task-specific activities may promote improvements in spatial and temporal walking parameters and functional mobility. The results of the present study suggest that people with chronic stroke may benefit from a task-oriented training program. Further research with a larger sample size is warranted to see if the results of the current study can be replicated. Further study is needed to document the efficacy of a task-oriented home program in people after stroke. Further research is necessary to document the effect of multi-sessions and different schedules of task-oriented training on walking and balance functions. The results of the present study concern the immediate effects of task-oriented training, research should be performed to examine the long-term effects after a training period on recovery of walking and balance functions after stroke.

Conclusions

The findings of this study provide preliminary evidence supporting the short-term benefits of task-oriented training for patients with chronic stroke. Although the generalization of the results of this study is limited due to the small sample size, this study provided preliminary data for a larger controlled trial to examine the effects of task-oriented training in people after stroke. The intervention activities in this study included repetitive practice of functional activities used in everyday activities and did not involve the use of any specific exercise equipment; these activities can be easily incorporated into a home exercise program. The results of the present study indicate that patients with chronic stroke would benefit from task-oriented training.

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Mini-Open Carpal Tunnel Release in Carpal Tunnel Syndrome

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DOI: 10.31038/IJOT.2022521

Abstract

Background: Carpal tunnel syndrome is considered the most common nerve compression disorder of the arm and an important cause of pain, neurologic symptoms and functional limitation of the wrist and hand. Carpal tunnel syndrome is a complex disorder associated with localized compression of the median nerve at the carpal tunnel.

Aim and objectives: To assess the functional outcome of Mini open carpal tunnel release.

Patients and methods: The present study was conducted on 25 patients in Post graduate Department of Orthopaedics, Govt. Hospital for Bone and Joint Surgery, an associated hospital of Govt. Medical College Srinagar from July 2019 to August 2021.

Results: The average symptom severity score improved from 3.5 preoperatively to 1.3 at final follow up of 6 months. The average functional status score improved from 3.3 preoperatively to 1.42 at the final follow up of 6 months. The mean DML and mean DSL decreased from 5.9 mS and 5.2 mS pre operatively to 4.7 mS and 3.9 mS respectively at the final follow up of 6 months. The mean sensory conduction velocity at 6 months post-operative was 39.6 m/s with range from 22.6 to 60.9 m/s. The mean sensory conduction velocity increased from 28.4 m/s pre operatively to 39.6 m/s at the final follow up of 6 months. 2 patients (8%) in our study experienced persistent symptoms 1 patient (4%) had superficial infection which settled with oral antibiotics.

Conclusion: Mini open carpal tunnel release is an effective procedure which gives excellent symptomatic and functional outcome with very few complications. The mini open technique gives an additional advantage of less operative time, less wound related complications, improved cosmesis and quicker return to routine activity as compared to the open release.

Keywords

Carpal tunnel syndrome, Mini-open, Median nerve, Transverse carpal ligament

Introduction

Carpal Tunnel Syndrome (CTS) is a fairly common peripheral neuropathy, caused by median nerve compression at the wrist level. The prevalence of CTS is believed to be 3.8% of general population around the world. The syndrome is more common in females than in males, with a peak age range of 40-60 years. On the basis of clinical examinations and nerve conduction studies, it had been approximated that one ·in every 5 subjects who complain of symptoms such as pain, numbness and a tingling sensation in hands could have CTS.

In recent years there has been an increase in incidence of CTS, may be due to the awareness of people about this disease, the upward disease detection rate, the work is more and more meticulous and delicate requiring using wrist continuously [1-7]. The etiology of CTS is largely structural, genetic and biological, with environmental and occupational factors. 70% of CTS cases are of unknown causes, the others are due to intrinsic and extrinsic factors. Intrinsic factors which exert pressure within the tunnel are pregnancy, hemodialysis, gout, diabetes, Rheumatoid arthritis, various other inflammatory and connective tissue disorders and systemic diseases like hypothyroidism, etc. Extrinsic factors which exert pressure outside the tunnel are lipomas, ganglion and vascular formations. Patients with CTS present with a constellation of symptoms including numbness and tingling of hand in the distribution of median nerve, nocturnal paresthesias as well as weakness and atrophy of the thenar muscles [8-11].

CTS may be managed conservatively at first with local corticosteroid injections, splints, and other techniques. However, in recent practice, treatment is selected considering various factors such as the stage of disease, the severity of symptoms or the patient preference. Splinting, local steroid injections and oral steroids have proven effective in some cases. The rationale for wrist splint is based on observations that CTS symptoms improve with rest and aggravate with activity. Subsequent research has suggested that the therapeutic effect of wrist splinting arises from minimizing carpal tunnel pressures. Corticosteroid treatment is effective in reducing inflammation and edema of synovium and tendons. It also has harmful effect on tenocyte function by reducing collagen and proteoglycan synthesis. However non operative modalities are preferred in the early stages of the disease. Advanced stages with persistent clinical features need a surgical release from the compression. Surgery offers an effective way of treating the condition. The basic principle of CTS surgery is to increase the volume of the carpal tunnel by releasing the transverse carpal ligament (TCL) thereby releasing pressure on the median nerve. A wide variety of surgical techniques have been described for CTS. However, as of yet, no strong evidence has suggested that any one approach is superior to the others [12-17].

Mini incision release is a less invasive technique with lower rate of complications, shorter operative time and more cost effectiveness. Although each technique has advantages and disadvantages, a few studies reported that mini incision release technique decreases the pathologic swelling of the median nerve and scar formation at the inlet of the carpal tunnel [18,19]. Thus in this study we aim to evaluate the safety, effectiveness and recurrence rate of mini-open carpal tunnel release technique.

Patients and Methods

This was a prospective study that was conducted from July 2019 to July 2021 which included 25 consenting patients who presented to the Post graduate Department of Orthopaedics, Govt. Hospital for Bone and Joint Surgery, an associated hospital of Govt. Medical College Srinagar and diagnosed as having carpal tunnel syndrome following approval by institutional ethical committee.

Inclusion Criteria

  • Signs, symptoms and electro-diagnostic tests characteristic of carpal tunnel syndrome
  • No response to conservative treatment for at least 6months
  • Age >18 years
  • All sexes

Exclusion criteria

  • Peripheral Neuropathy
  • Prior Carpal Tunnel release
  • Inflammatory arthropathy
  • Deformity of hand/wrist
  • Prior trauma (<2weeks)
  • Pregnancy
  • Operation for excision of neoplasm

Surgical Technique

Prophylactic Antibiotic (IV Cefuroxime 1.5 gm) was given half an hour before surgery. The surgical intervention was performed under regional Anaesthesia (Axillary / Supra clavicular block) using a tourniquet. The patient placed in the supine position with the hand, wrist and fingers stretched in slight extension position, a small support placed under the wrist. A 1.5-2 cm longitudinal incision, located on the vertical line drawn from the third inter digital space and extending proximally to the distal wrist crease, was performed. The skin subcutaneous tissue dissected, the proximal end of the transverse carpal ligament visualized, and the dorsal and ventral surfaces of the ligament were dissected. Using scissors, the transverse carpal ligament was cut in the proximal to distal direction. After achieving hemostasis, the surgical field was irrigated with a physiological saline solution and the skin closed with silk. The patients’ hands and palms dressed with ample cotton padding and elevated (Figure 1).

fig 1

Figure 1: Intra-operative pictures.
(A) On Table Skin Marking for Incision (B) Skin Incision(C) Superficial Dissection (D) Cutting of Transverse Carpal Ligament (E) Exposure of Median Nerve (F) Skin Closure (G) Bulky Antiseptic dressing.

Post-operative Rehabilitation and Follow-up

Single dose of IV antibiotic was given Post Operatively followed by oral Antibiotics for 5 days. Finger ROM exercises were started immediately after surgery. Dressing was changed to a lighter one at 3 to 4 days to start wrist motion. Patients were allowed to return daily normal activities at 3 to 4 weeks post operatively. Patients were followed up at 3 and 6 months post operatively and NCV was repeated at 6 months post operatively. Outcome was assessed by Boston Carpal Tunnel Questionnaire-1993 (Tables 1 and 2).

Table 1: Symptom severity scale according to BOSTON CARPAL TUNNEL

1 2 3 4 5
1. How severe is the hand or wrist pain that you have at knight? Normal Slight Medium Severe Very serious
2. How often did hand or wrist pain wake you up during a typical knight in the past two weeks? Normal Once 2-3 times 4-5 times More than 5 times
3. Do you typically have pain in your hand or wrist during the daytime? No pain Slight Medium Severe Very serious
4. How often do you have hand or wrist pain during the daytime? Normal 1-2 times/day 3-5 times/day More than 5 times Continued
5. How long on average does an episode of pain last during the daytime? Normal <10 minutes 10-60 continued >60 minutes Continued
6. Do you have numbness (loss of sensation) in your hand? Normal Slight Medium Severe Very serious
7. Do you have weakness in your hand or wrist? Normal Slight Medium Severe Very serious
8. Do you have tingling sensation in your hand? Normal Slight Medium Severe Very serious
9. How severe is numbness (loss of sensation) or tingling at knight? Normal Slight Medium Severe Very serious
10. How often did hand numbness or tingling wake you up during a typical knight from last two weeks? Normal Once 2-3 times 4-5 times More than 5 times
11. Do you have difficulty with the grasping and use of small objects such as keys or pens? Without difficulty Little difficulty Moderate difficulty Very difficulty Very difficulty

Table 2: Function status scale according to BOSTON CARPAL TUNNEL

No difficulty Little difficulty Moderate difficulty Intense difficulty Cannot perform the activity due to hand and wrist symptoms
Writing 1 2 3 4 5
Buttoning in cloths 1 2 3 4 5
Holding a book while reading 1 2 3 4 5
Gripping of a telephone handle 1 2 3 4 5
Opening of jars 1 2 3 4 5
Household chores 1 2 3 4 5
Carrying of grocery basket 1 2 3 4 5
Bathing and dressing 1 2 3 4 5

Results

In our study, the mean age of patients was 50.4 (range 35-60) years. The mean duration of surgery was 10.8 (range 8-15) minutes. Demographic and baseline clinical data for the patient cohort are shown in Table 3. In our study, the average symptom severity score at 3 and 6 months post-operative was 1.8 (range 1.45 to 3.18) and 1.58 (range 1.27 to 2.9) respectively. The average symptom severity score improved from 3.5 preoperatively to 1.3 at final follow up of 6 months. The average functional status score at 3 and 6 months postoperative was 1.68 (range 1.33 to 3) and 1.42 (range 1.6 to 2.5). The average functional status score improved from 3.3 preoperatively to 1.42 at the final follow up of 6 months (Table 4). The mean DML and DSL at 6 months post-operative was 4.6 mS (range 3.3 to 6.2 Ms) and 3.9 mS (range 3.1 to 6.5 mS) respectively. The mean DML and mean DSL decreased from 5.9 mS and 5.2 mS pre operatively to 4.7 mS and 3.9 mS respectively at the final follow up of 6 months. The mean sensory conduction velocity at 6 months post-operative was 39.6 m/s with range from 22.6 to 60.9 m/s. The mean sensory conduction velocity increased from 28.4 m/s pre operatively to 39.6 m/s at the final follow up of 6 months (Table 5). 2 patients (8%) in our study experienced persistent symptoms 1 patient (4%) had superficial infection which settled with oral antibiotics (Table 6). Overall, most of the patients achieved satisfactory results.

Table 3: Descriptive Statistics of the Study Population (N=25)

Variables No. of patients Percentage
Sex Male 2 8
Female 23 92
Age group <34 years 0 0
34-45 years 5 20
46-55 years 15 60
>55 years 5 20
Side Right 13 52
Left 7 28
Bilateral 5 20
Pre-operative symptom duration <6 months 0 0
6-12 months 11 44
13-24 months 11 44
25-36 months 3 12

Table 4: Symptom severity score and function status scale according to BOSTON CARPAL TUNNEL

 

 

 Average score Pre-operative 3 months post-operative 6 months post-operative
No. of patients Percentage No. of patients Percentage No. of patients Percentage
Symptom severity score 1-2 0 0 21 84 23 92
2.01-3 0 0 3 12 2 8
3.01-4 23 92 1 4 0 0
4.01-5 2 8 0 0 0 0
Mean 3.5 (range3.09-4.09) 1.8 (range 1.45-3.18) 1.58 (range 1.27-2.9)
Functional status score 1-2 0 0 24 96 24 96
2.01-3 11 44 1 4 1 4
3.01-4 14 56 0 0 0 0
4.01-5 0 0 0 0 0 0
Mean 3.15 (range 2.66-4) 1.68 (range1.33-3) 1.42 (1.16-2.25)

Table 5: Distal motor latency, Distal sensory latency and Sensory conduction velocity Pre-operatively and 6 months post-operative

  Average score Pre-operative 6 months post-operative
No. of patients Percentage No. of patients Percentage
Distal motor latency (mS) <4 0 0 7 28
4-6 16 64 16 64
6.01-8 7 28 2 8
>8 2 8 0 0
Mean 5.6 (range 4.2-8.1) 4.6 (range 3.3-6.2)
Distal sensory latency (mS) <4 4 16 13 52
4-6 16 64 11 44
6.01-8 3 12 1 4
>8 2 8 0 0
Mean 5.2 (range 3.45-8.5) 3.9 (range 3.1-6.5)
Sensory conduction velocity (m/s) <20 6 24 0 0
20-30 9 36 1 4
30.01-40 6 24 15 60
>40 4 16 9 36
Mean 28.4 (range 12.3-44) 39.6 (range 22.6-60.9)

Table 6: Superficial infection which settled with oral antibiotics

Complications No. of patients Percentage
Persistent symptoms 2 8
Superficial infection 1 4
Nil 22 88
Total 25 100

Discussion

Conventional open carpal tunnel release has been widely accepted as an effective method for treating carpal tunnel syndrome after failed conservative management. This prospective study demonstrated the benefits of mini-open carpal tunnel release under local anesthesia, in terms of clinical recovery and relief of symptoms in the short and long term (3 and 6 months respectively). These improvements were of both statistical significance and clinical relevance. These procedures have shown comparable postoperative pain, earlier recovery and return to work, improved grip strength, and reduced complication rate. These are easier to perform and safer procedures as compared to endoscopic ones and do not require any special equipment. The technique requires limited dissection and little interruption of tissue planes as compared to the open method and doesn’t divide the subcutaneous tissue or the palmar fascia as much as the open method does [20-24].

In this study we found that the mean age of development of carpal tunnel was 50.4 years, which is comparable to Thanh Ma Ngoc et al. (2017) which showed that the mean age was 50.3 years. Hamid Reza Aslani et al. (2012) noted high incidence of carpal tunnel syndrome in females, which is similar to our study. In our study the mean pre-operative symptom duration was 17.4 months with range from 6 to 36 months. In other previously done studies, the mean pre-operative duration ranged from 10.8 to 13.3 months. In our study, the average pre-operative DML was 5.6mS with range from 4.2 to 8.1. In other previously done studies this mean ranged from 5.44 to 7.3 which is comparable to our study. The mean operative time in our study was 10.8 minutes with a range from 8 to 15 minutes which is comparable Keykhosro Mardanpour et al. (2018) who noted in his study the mean operative time was 12 minutes. In our study, the average 3 months post-operative symptom severity score was 1.8 which is comparable with previously done study by Seyho Cem Yucetas et al. (2012) as 1.95. In our study, the average functional severity score at 3 months was 1.68 and the average DML at 6 months post-operative was 4.6mS which is comparable with the results obtained in study done by Heybeli et al. (2002) as 1.5 and 4.7 mS respectively. Majority of patients in our study had no complications. 2 patients experienced persistent symtoms (8%). In other studies inadequate symptom relief ranged from 2% to 3.8%. 1 patient (4%) in our study had has superficial infection. The percentage of infection ranged from 0% to 1.9% in other studies.

One weakness of our study is the group of the patients is small. In addition, the follow up may be too short. However, for a preliminary report, the result is quite encouraging, i.e., the procedure improves the symptom of the patients even in short term follow-up and improve the cosmetic appearance compare to a long incision. We hope to collect more patients and carry out longer follow-up in the future [25-29].

Conclusion

Mini open carpal tunnel release is an effective procedure which gives excellent symptomatic and functional outcome with very few complications. The mini open technique gives an additional advantage of less operative time, less wound related complications, improved cosmesis and quicker return to routine activity as compared to the open release.

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