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Epidemiological and Anatomopathological Profile of Breast Cancers in Mauritania

DOI: 10.31038/AWHC.2022531

Abstract

The incidence of breast cancer in women is on the rise worldwide, including in developing countries. The objective of this study was to describe the epidemiological, clinical, and histological characteristics of breast cancer in women in Mauritania. Data were collected from 60 female patients monitored and treated at the National Hospital Center (NHC) and Military Hospital Center (MHC) in Nouakchott. The variables studied were age, parity, age at first pregnancy and menarche, place of residence, socioeconomic status, medical coverage, tumor site, Scarff Bloom and Richardson histoprognostic grade, location, Tumor Nodes Metastasis stage, molecular phenotype, and lymph node involvement. The average patient age was 48.71 ± 12.45 years, ranging from 17 to 70 years. Regarding histological types, invasive ductal carcinoma was the most frequently encountered (70% of cases). Immunohistochemical profile analysis revealed that 44% of the tumors were luminal A type, 24% were triple-negative type, and 22% were luminal B type. Our results also revealed that smoking patients had more grade III tumors, and that age was significantly correlated with disease stage (p=0.047) and molecular classification (p=0.0011). The characteristics of breast cancer in Mauritania do not differ from those in other developing countries.

Keywords

Cancer, Breast, Epidemiology, Mauritania

Introduction

Cancer is a major public health problem, and according to the World Health Organization, it is the second leading cause of death worldwide, causing 8.8 million deaths in 2015. Nearly one in six deaths worldwide are due to cancer. According to the latest WHO estimates, the number of cancer deaths is expected to continue to rise, and to exceed 11 million people per year by 2030.

Breast cancer is the most common malignant tumor type in women worldwide, and its incidence continues to increase, particularly in the 35-55 age group [1]. Mauritania ranks first in terms of breast cancer incidence and mortality among women [2]. According to some studies [3,4], this pathology is indeed the first cancer in women, although its frequency varies according to ethnicity, and it remains a major source of female mortality, as diagnoses are usually made at an advanced stage.

Several risk factors for the development of breast cancer have been recognized, including family history of breast cancer, advanced age, early puberty, late menopause, nulliparity, and obesity. However, no factor directly linked to its onset has been identified, except for the hereditary transmission of the BRCA 1 and 2 genes, which have been implicated in 5-10% of cases of breast cancer cases since Bittner’s discovery. In addition, many viruses are suspected to cause breast cancer [5]. This prospective study aimed to highlight the epidemiological, clinical, and histological characteristics of breast cancer in Mauritanian women.

Methods and Materials

This is a descriptive study of sixty patients. The study included patients newly admitted to the National Hospital Centers (NHC) and Military Hospital Centers (MHC) in Nouakchott for the treatment of breast cancer. All histologically confirmed malignant breast tumors were included in this study. The following variables were studied: age, parity, age at first pregnancy and menarche, place of residence, socioeconomic status, medical coverage, tumor site, Scarff Bloom and Richardson histoprognostic grade, location, TNM stage, molecular phenotype, and lymph node involvement. The data were collected by consulting hospitalization records, which are kept in the archives on a pre-established sheet. Data entry and analyses were performed using Microsoft Office Excel and RStudio, respectively. Correlations between certain factors, such as the grade, stage, presence or absence of metastasis, molecular classification, tobacco consumption, and patient age were analyzed in this study. In particular, the presence of a relationship between grade and tobacco consumption was investigated.

Results

Sixty patients with breast cancer were included in this study. The average age was 48.71 ± 12.45 years, ranging from 17-70 years. The average age of menarche was 12.66 ± 1.21 years, ranging from 11-16 years. The mean age at first pregnancy was 21.89 ± 3.02. The average number of births was 1.32 ± 0.60. Two of the patients were nulliparous. Overall, 43.33% were White Moors, 35% were Black Moors, 10% were Fulani, 8.33% were Wolof, and 3.33% were Soninke. A total of 53.33% of patients lived in rural areas; 71.66% of the patients were married, and 81.66% had a low socioeconomic level. A total of 56.66% of women had no social security coverage, and 11.66% of the patients were smokers. Only 5% of the patients were physically active, and 93.33% of patients had palpable nodules.

In our series, the most marked clinical tumor size according to the TNM classification was T2 (74,98%) (Figure 1). Of the tumors, 65% were stage IIA and 28.33% were stage IIB (Figure 2). The SBR grade II was the most represented in our series (73.33%) (Figure 3). The right breast alone was the most frequently affected (58.33%), followed by the left breast alone (36.66%), and bilateral location (5%).

fig 1

Figure 1: Distribution of cases by TNM classification

fig 2

Figure 2: Distribution of cases by disease stage

fig 3

Figure 3: Distribution of cases according to grade

Histological analysis showed that invasive ductal carcinoma (70% of cases) was the most frequent type (Table 1). Regarding immunohistochemical profiles, the analysis revealed that 44% of the tumors were luminal A type, 24% triple-negative type, and 22% luminal B type (Table 2). Of these patients, 51.33% had undergone chemotherapy. Local recurrence was observed in 41.66% of patients and regional recurrence in 1.66% of patients. Of these patients, 16.66% presented with metastasis. 97% of patients are alive during hospitalization (Figure 4).

Table 1: Case distribution according to histological groups

Histology

Adenofibroma

IC

DC

NSC

SC

MC

DC (L)

PC

DC (R)

Number

1

1

2

6

1

1

42

5

1

Frequency

1.66

1.66

3.33

10

1.66

1.66

70

8.33

1.66

IC: Invasive Carcinoma; DC: Ductal Carcinoma; NSC: Non-specific Carcinoma; SC: Sarcoma Carcinoma; MC: Mixed Carcinoma; PC: Phyllodes Carcinoma; CRC: Cribiform Carcinoma

Table 2: Distribution of biological subtypes

Phenotype

HER2+

Luminal A

Luminal B

Triple negative

RP+ RE- HER2+

RP+ RE- HER2-

Number

3

22

11

12

1

1

Frequency

6

44

22

24

2

2

fig 4

Figure 4: Patient mortality distribution. Yes: alive; No: dead

The results are shown in Figures 5-10. Patients who smoked had more grade III tumors. In addition, age was significantly correlated with disease stage (p=0.047) and molecular classification (p=0.0011).

fig 5

Figure 5: Correlation between age and grade

fig 6

Figure 6: Correlation between age and stage

fig 7

Figure 7: Correlation between age and molecular classification

fig 8

Figure 8: Correlation between age and presence of metastasis

fig 9

Figure 9: Correlation between age and tobacco consumption

fig 10

Figure 10: Histological grade according to tobacco consumption

Discussion

We enrolled 60 patients with newly diagnosed breast cancer. The 40-50 age group accounts for 36.66% of women affected by this pathology. The median age at the time of diagnosis was 48.71 years. This does conflicts with the data obtained in France (mean age: 61 years) [6], and in Algeria (average age: 50 years) [5]. The average age at menarche was 12.66 years in this study. The literature data are consistent with those of our study; we found that more than half (58.33%) of our patients had their first period at ≤12 years, and puberty before 12 years is known to increase the risk of breast cancer in adulthood through longer exposure to estrogen. The incidence of nulliparity was low in the present study. However, our patients were not multiparous and the majority (71.66%) only had one child. However, a higher number of children appeared to have a protective effect [7].

Breast cancer diagnoses often occur at a late stage, which could be due to insufficient health education and the poor socioeconomic status of the population. Of our patients, 16.66% were in a metastatic stage at the time of diagnosis. Considering these factors, it is clear that screening and awareness campaigns should be launched and strengthened to help resolved these problems. Of the patients, 93.33% discovered the disease through self-examination of a nodule. In 58.33% of cases, the tumor involved the right breast. The predominance of cancer in one breast over the other can be explained by breastfeeding habits [8]. In the literature, breast cancer is generally unilateral and rarely affects both the breasts. This was confirmed by our study, in which bilateral localization representing only 5%.

A relatively high number of young patients experience additional problems in terms of care. Indeed, several studies [9-12] have reported that breast cancer in young women tends to be more aggressive with a higher frequency of grade III SBR classification and negative estrogen receptors; in our study 20% of the patients were young (<40 years). Measurement of tumor size, both clinically and macroscopically, is an important prognostic element for therapeutic management. In our series, we noticed a slight decrease in advanced T3 and T4 forms compared to the results found in the studies by Mesmoudi [13] and Marrakech [14]. The T2 form was the most common (74.98%). The histological type was identified in all patients; invasive epithelial tumors were the most frequent, with infiltrating ductal carcinoma occurring in 70% of the cases.

Many studies have established that patients with locoregional metastases have poorer prognoses than those without lymph node involvement. Overall, ten-year survival is 70% when there is no lymph node involvement, and 25-30% in the presence of neoplastic invasion of the lymph nodes [15]. In our series, 96.66% of patients had lymph node invasion, and an average of two nodes were affected. All studies showed that metastatic risk and survival are strongly correlated with grade, regardless of the grading system used, and SBR grade III was associated with poorer prognosis than grades I and II. In the present study, grade II tumors had a predominance of 73.33%. Hormonal estrogen receptors are markers of tumor differentiation, whereas progesterone receptor positivity reflects the functionality of estrogen receptors. Hormonal receptors are prognostic factors because their expression is an indicator of good prognosis and is especially predictive of the response to hormone treatment [16]. Hormone receptors were studied in our patients, and 24% were triple negative.

Conclusion

Late diagnosis continues to worsen the prognosis for this cancer. The other findings in terms of epidemiological, clinical, and histopathological aspects were similar to those of previous studies in developing countries. Through this study, we concluded the following: 1) the rate of tumors diagnosed at a late stage remains relatively high; 2) the rate of tumors with a high histoprognostic grade and histological lymph node invasion remains significant; 3) invasive epithelial tumors are the predominate type of breast cancer. Breast cancer remains a serious pathology that is difficult to overcome, and its management remains hindered by socioeconomic conditions; therefore, a screening policy at a cost affordable to the population should be implemented and the awareness campaigns should be continued.

References

  1. Parkin DM, Whelan SL, Ferlay J, Teppo L, et al. (2002) Cancer Incidence in Five Continents: Volume VIII. Lyon: International Agency for Research on Cancer 155. [crossref]
  2. Ferlay J, Ervik M, Lam F, Colombet M, et al. (2020) Global Cancer Obser-Vatory: Cancer Today. International Agency for Research on Cancer; Lyon, France.
  3. Baba ND, Sauvaget C (2013) Le cancer en Mauritanie: résultats sur 10 ans du registre hospitalier de Nouakchott. Pan Afr Med J 14: 149. [crossref]
  4. Mohamed S (2017) Étude Épidémiologique de cancers en Mauritanie. Mémoire de Master Université de Nouakchott AL Asriya.
  5. Bouzbid S, Aouras H, Djeddi H, Yassi F (2014) Le cancer du sein chez la femme dans le département d’Annaba, Algérie. Revue d’Épidémiologie et de Santé Publique 62: S215.
  6. World Health Organization. Morocco: Incidence, Mortality and Prevalence by cancer site. Globocan 2018. Accessed 23 November 2019.
  7. Pathak DR, Speizer FE, Willet WC, Rosner B, et al. (1986) Parity and breast cancer risk: possible effect on age at diagnosis. Int J Cancer 37: 21-25. [crossref]
  8. Bonafos M, De Canelier R (1971) Cancers génitaux de la femme algérienne. Revue Afrique Noire 18: 235-240.
  9. Bakkali H, Marchal C, Lesur-Schwander J, Verhaeghe L (2003) Le cancer du sein chez la femme de 30 ans et moins. Cancer/radiothérapie 7: 153-159.
  10. Tabbane F, El May A, Hachiche M, Bahi J, et al. (1985) Breast cancer in women under 30 years of age. Breast Cancer Res Treat 6: 137-144.
  11. Althuis MD, Brogan DD, Coates RJ, Daling JR, et al. (2003) Breast cancers among very premenopausal women (United States). Cancer Causes Control 14: 151-160. [crossref]
  12. De Jesus MA, Fujita M, Kim KS, Goldson AL (2003) Retrospective analysis of breast cancer among young African American females. Breast Cancer Res Treat 78: 81-87. [crossref]
  13. Menikhar I (2017) Cancer du sein étude rétrospective à propos de 270 cas au CHU Ibn-Rochd de Casablanca. Casablanca-Maroc. Faculté de médecine et de pharmacie de Casablanca.
  14. Bouaalloucha S (2012) Le profil épidémiologique et clinique du cancer du sein chez la femme au CHU Mohammed VI de Marrakech. Marrakech- Maroc. Faculté de médecine et de pharmacie Marrakech.
  15. Galant C, Berliere M, Leconte I, Marbaix E (2010) Nouveautés dans les facteurs histopronostiques des cancers du sein. Imag. de la Femme 20: 9-17.
  16. Moise N, Hery M, Serin D, Spielmann M (2005) Cancer du sein: Compte-rendu du cours supérieur francophone de cancérologie. Saint Paul de Vence: Springer Paris. [crossref]

Inferior Hip Dislocation during Treatment of Developmental Dislocation of Hip – A Rare Complication from Hip Abduction Splint: A Case Report and Review of Literatures

DOI: 10.31038/IJOT.2022523

Abstract

Background: DDH constitutes a group of conditions involving hip sublaxation and dislocation. It is mandatory for management of these cases to be followed by aftercare with Braces. Some complications may develop during follow-up in hip spica or hip brace.

Introduction: DDH encompasses a spectrum of diseases that includes dysplasia (a shallow or underdeveloped acetabulum), subluxation, and dislocation. These conditions are commonly seen with arthrogryposis, myelomeningocele, and Larsen’s syndrome. Cases of developmental dislocation of the hip (DDH) still occur after walking age because of Late or missed diagnosis and failed conservative treatment. Lack of follow-up leads to a lot of complications.

Case presentation: 4years old female child admitted to our hospital complaining of limbing and had neglected history of right DDH. She w managed by derotation femoral osteotomy and hip spica cast with smooth follow-up recovery. At 12 weeks an abduction hip brace was advised but follow-up last for few weeks. When returned back and during routine x-ray inferior dislocation was noticed. Patient planned for surgery and hip Spica cast. Follow-up passed smoothly for 12 months then the Spica cast replaced by Abduction hip brace. The reduction was confirmed by good x-ray.

Discussion: Bracing is an important step in follow-up treatment program of DDH. Loss of reduction as a complication may occur during follow-up regimen. Inferior hip dislocation in the hip abduction brace is a rare complication and rarely mentioned in the literatures. Avoidance of this complication can be achieved by having good orthotics in the hospital and applying the brace under supervision of the orthopedic surgeon. Immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip position.

Conclusion: Inferior hip subluxation in the hip brace rarely occurs as a complication during follow-up program of DDH treatment. Early recognition of this complication and reduction of the flexion angle led to a stable dislocation of the hip.

Keywords

Developmental hip dislocation, Dysplasia, Hip spica, Hip brace

Introduction

Developmental hip dysplasia (DDH) encompasses a spectrum of conditions that include dysplasia (a flat or underdeveloped acetabulum), subluxation, or dislocation. There is also a teratologic hip that is dislocated in utero and irreducible on neonatal examination. It has a pseudo-acetabulum, and is associated with neuromuscular and genetic disorders. These disorders are common in arthrogryposis, myelomeningocele, and Larsen syndrome. Cases of developmental hip dislocation (DDH) continue to occur even after walking age owing to late diagnosis or failure of conservative treatment [1]. Conservative or surgical treatment for DDH needs aftercare for braces. Lack of aftercare leads to a lot of complications related to Spica Casting – hip abduction braces (Figure 1). These complications involve compression of femoral nerve due to hyperflexion, inferior dislocation, skin detachment and the most important one is avascular necrosis of femoral head. Care of the cast or the brace should bear attention to the fully reducible hip, child not attempting to stand, close regular follow-up (every 1-2 weeks) by imaging and adjustments of the brace when necessary by the surgeon[2-3]. Pavlik Harness Failure may occur due to: Improper application and follow-up by the physician, inadequate initial reduction, failure to recognize persistent dislocation and poor parent compliance. The risk factors predispose to Pavilk harness failures include: bilateral hip dislocation, age greater than seven weeks prior to initiation of treatment with the harness and lack of Ortolani sign at initial examination.

fig 1

Figure 1: Spica Casting – hip abduction braces

Case Presentation

Four years female child presented to the orthopedic department of El-Hussein University Hospital with painless limping, limb shortening and radiographs showed a neglected right DDH. The patient was scheduled for surgery (femoral shortening with derotation osteotomy) and hip spica. Recovery was smooth and follow-up care was good. At 12 months the hip Spica was removed and the patient was advised to have an abduction hip brace. She went to a place outside the hospital and the technician applied the brace. The patient did not come back to the hospital to continue the follow-up program. After 6 weeks the child’s parents returned back to our hospital to make sure of the condition. Unfortunly plain x-ray showed strange inferior dislocation of hip (Figure 2a and 2b) and CT confirmed the diagnosis Figure 3.

fig 2

Figure 2: X-ray showing strange inferior dislocation of hip

fig 3

Figure 3: CT diagnosis

Plan of Management

The patient was scheduled for operative intervention. Closed reduction was an attempt first but failed as there was a band of elasticity feeling preventing relocation of the hip. We decided to go to open intervention.

Operative Details

We used the same incision. The operative findings revealed the femoral head was buttonholed in the capsule that preventing reduction. The capsule was release and the head was relocated easily to the acetabulum. The position was checked by C-arm and hip Spica applied for 4 weeks. The abduction hip splint was applied by the orthopedic surgeon and an immediate X-ray was done and confirmed the good reduction (Figure 4). The postoperative course was uneventful, with no early or late infection being observed. The results were evaluated according to modified McKay criteria, Severin radiological criteria, and Bucholtz – Ogden system of AVN grading after a mean follow-up for 6 months. In the last follow-up, the Clinical Evaluation patient reported no significant hip pain, and radiologically no signs of dislocation or AVN (Figure 5).

fig 4

Figure 4: X-ray of abduction hip splint

fig 5

Figure 5: Radiologically no signs of dislocation or AVN

Discussion

Bracing is considered a gold standard in treating Developmental Dysplasia of the Hip (DDH) in infants less than 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. The brace eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilize the hip joint [4]. The use of excessive force or exceeding the safe zone to maintain hip position can lead to complications, such as femoral nerve palsy and avascular necrosis (AVN) [5-6]. Inferior dislocation (obturator dislocation) from the abduction brace rarely mentioned in literature. Rombouts and Kaelin [3] mention two cases of inferior dislocation but in a neonate due to the Pavlik harness. Also, they reviewed the literatures and mentioned Five cases of inferior (obturator) dislocation complicating the treatment of developmental dislocation of the hip that had been reported previously [7-10]. Only one of these cases was in a neonate [10]. Pediatric orthopedic surgeons have been aware of the problem but no one has studied it fully to declare why it happens and there were no studies to follow up and report on the final results for children with this complication. Ramsey et al. [11] emphasized that adequate hip flexion must be obtainable so that the femoral head is directed towards the triradiate cartilage. Excessive hip flexion, however, directs the metaphysis of femur to come below the triradiate cartilage and may produce an inferior (obturator) dislocation. This complication is classified as grade IIIb according to the Clavien-Dindo classification [12] (Intervention under general anesthesia). To avoid this complication we need to have good orthotics in the hospital, application of the brace should be under the supervision of the orthopedic surgeon, immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip. In our case and after open reduction; a hip spica cast was applied and followed for 4 weeks. After that an abduction brace was applied carefully by the surgeon and under C-arm image control to verify the proper location of the hip. The brace was gradually weaned over a period of several months [13].

Conclusion

Abduction brace can cause inferior hip dislocation during treatment of DDH. Gentle manipulation may be tried and if failed go for open reduction. Closed monitoring of the brace is mandatory. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip joint.

Abbreviations

DDH: Developmental Dysplasia of Hip; AVN: Avascular Necrosis

References

  1. Gulati V, Eseonu K, Sayani J, Ismail N, Uzoigwe C, et al. (2013) Developmental dysplasia of the hip in the newborn: A systematic review. World J Orthop 4: 32-41. [crossref]
  2. Viere RG, Birch JG, Herring JA, Roach JW, Johnston CE (1990) Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment. J Bone Joint Surg Am 72: 238-244. [crossref]
  3. Rombouts JJ, Kaelin A (1992) Inferior (obturator) dislocation of the hip in neonates. A complication of treatment by Pavlik harness. J Bone Joint Surg Br 74: 708-710. [crossref]
  4. Merchant R, Singh A, Dala-Ali B (2021) Principles of Bracing in early management of Developmental Dysplasia of Hip.Indian Journal of Orthopaedics 55: 1417-1427. [crossref]
  5. Tiruveedhula M, Reading I, Clarke N (2015) Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis. Journal of Pediatric Orthopedics 35: 140-143. [crossref]
  6. Pool RD, Foster BK, Paterson DC (1986)Avascular necrosis in congenital hip dislocation. The significance of splintage. J Bone Joint Surg Br 68: 427-430. [crossref]
  7. Lloyd-Roberts GC, Swann M (1966)Pitfalls in the management of congenital dislocation of the hip.J Bone Joint Surg Br 48: 666-681. [crossref]
  8. Mubarak S, Steven G, Raymond V, Bert McKinnon, David Sutherland D (1981) Pitfalls in the Use of the Pavlik Harness for Treatment of Congenital Dysplasia, Subluxation, and Dislocation of the Hip. J Bone Joint Surg 63: 1239-1248. [crossref]
  9. Mendez AA, Keret D, MacEwen GD (1990) Obturator dislocation as a complication of closed reduction of the congenitally dislocated hip: a report of two cases.J Pediatr Orthop 10: 265-269. [crossref]
  10. Langkamer V, Clarke G, Witherow P (1991) Complications of splintage in congenital dislocation of the hip. Archives of Disease in Childhood 66: 1322-1325.
  11. Ramsey PL, Lasser S, MacEwen GD (1976) Congenital dislocation of the hip. Use of the Pavlik harness in the child during the first six months of life. J Bone Joint Surg 58: 1000-1004. [crossref]
  12. Dindo D, Demartines N, Clavien PA (2004)Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg 240: 205-213.
  13. Emara K, Kersh MA, Hayyawi FA (2019) Duration of immobilization after developmental dysplasia of the hip and open reduction surgery. Int Orthop 43: 405-409. [crossref]

Lupus Pancreatitis in City Rheumatological Consultation in Bamako (Mali)

DOI: 10.31038/IJOT.2022522

Abstract

Lupus pancreatitis is a rare but potentially severe entity. It is a visceral complication of multifactorial and poorly elucidated pathogenesis. The diagnosis combines two of the three criteria: typical pain, the elevation of pancreatic enzymes above three time’s normal, and imaging. Improved prognosis depends on early diagnosis and efficient treatment. We describe the diagnostic approach and clinical features of a 19-year-old melanoderma patient.

Keywords

Pancreatitis, Systemic Lupus, Mali

Introduction

Described for the first time in 1939 by Reifeinstein et al [1], pancreatitis is a rare visceral manifestation during Systemic Lupus Erythematosus (SLE). Its incidence varies from 0.4 to 1.1 cases per 1000 lupus per year. Early diagnosis is pledge of an efficient therapy (corticosteroids and immunosuppressants) to ensure a good prognosis. We report our first observation in a melanoderma subject suffering from SLE in severe flare [2-4].

Observation

A 19-year-old girl had been followed for 45 days for SLE and chronic endoscopic gastritis. The diagnosis of SLE was based on the EULAR/ACR 2019 classification criteria (presence of antinuclear antibodies, malar rash, alopecia, synovitis, fever, leuco-neutropenia). The therapy included prednisone (10 mg/day) and azathioprine (100 mg/day). She is hospitalized in emergency for transfixing epigastric pain, abdominal pain, diarrhea, incoercible vomiting and fever. The physical examination noted patient lying in trunk’s anteflexion, feverish at 40°c, epigastric defense and distended abdomen, with much rumbling. SLE activity was very high with a SLEDAI score of 24. Biological assessment revealed inflammatory syndrome (CRP at 150 mg/L, ESR at 110 mm), amylasemia at 392 IU/L and lipasemia at 853 IU/L. Liver tests and stool examinations were normal. The chest-abdominal-pelvic CT-scan was normal. The diagnosis adopted is lupus pancreatitis after having eliminated other causes (biliary lithiasis, toxic, traumatic, drug and neoplastic). She received a bolus of methylprednisone, parenteral analgesics, isocoagulation and rehydration. She underwent a strict 48 hours diet. The evolution was favorable to 5th day hospitalization with apyrexia and pain amendment. The relay by oral corticosteroids and hydroxychloroquine was instituted.

Discussion

The occurrence of pancreatitis can complicate the evolution of connectivitis, vasculitis and granulomatosis. Pancreatic involvement during SLE is rare. Its incidence varies from 0.4 to 1.1 cases per 1000 lupus per year. It can be concomitant with other lupus disorders in 50% of cases, inaugural and revealing in 11% of cases, or a potentially serious complication. It was subsequent in our patient, which is a particularity. The pathogenesis of this pancreatitis is not well understood. It is multifactorial; difficult to separate what amounts to vasculitis, thrombosis in the context of anti-phospholipid syndrome, or iatrogenic or concomitant complications. The diagnosis is based on the association of two of the following three criteria: • Typical pain • Increased pancreatic enzymes above three times normal • Computed tomography (CT) imaging, remnography (MRI) or ultrasound [5-7]. Pancreatic pain is relieved by anteflexion of the trunk (pancreatic position) and aspirin. In our patient, epigastric pain incorrectly labelled as gastritis by digestive endoscopy could lead to mistake. The classic aspirin therapy test was not done for fear of a hypothetical gastric perforation. However, any abdominal pain syndrome and/or vomiting in a lupus context suggest lupus pancreatitis. The elevation of lipasemia is of a better diagnostic specificity because lipase is exclusively pancreatic. The elevation of protein C Reactive has an interest in prognosis but she suggested looking for infectious etiology in the patient. CT-scan has proved to be the reference examination in the diagnosis but the pancreas can be normal in 14 to 29% of cases as in our patient. The drug toxicity in this case of azathioprine and prednisone can be invoked initially acute pancreatitis [8,9]. However, the chronology of evident clinical signs in our patient minimizes iatrogenia. Many observations in the literature raise the difficulty of specifying the exact etiology of lupus pancreatitis, even autopsy studies are often non-contributory [10]. Most authors proceed by excluding other possible etiological factors and improving symptomatology with anti-inflammatory treatment to indirectly retain, responsibility for SLE. Efficient therapeutic management depends on early diagnosis for a good prognosis. Methylprednisone bolus having improved the patient, a relay with oral corticosteroids and substitution of azathioprine with synthetic antimalarials (hydroxychloroquine) was decided.

Conclusion

Most lupus pancreatitis has been described in leukoderma subjects. However, our first observation in melanoderma does not suggest any singularity. In all cases, the best prognosis depends on early diagnosis and efficient management.

References

  1. Papo T, Le Tchi HD, Godeau P, Piette JC (1997) Pancreatitis and systemic diseases. Gastroenterol Clin Biol 21: 768-775. [crossref]
  2. Kefi A, Kammoun S, Jaziri F (2019) Lupus pancreatitis: a rare but potentially serious disease! Revmed 40: A105-A214.
  3. Aringer M, Costenbader K, Daikh D (2019) European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol 7: 1400-1412. [crossref]
  4. Bombardier C, Gladman DD, Urowitz MB(1992) Derivation of the SLEDAI. A disease activity index for lupus patients. Arthritis & Rheumatism 35: 630-640. [crossref]
  5. Alaoui M, Ammouri W, Bourkia M (2018) Acute lupus pancreatitis: About 18 cases. Revmed 39: A23-A102.
  6. Jebali A, Gharsallah G, Klii R (2014) Acute pancreatitis and haemopagocytic syndrome during a lupic outbreak. Revmed 35S: A96-A200.
  7. Ben DB, Aydi Z, Boussema F (2012) Lupus pancreatitis: a series of 6 cases. J Afr Hepatol Gastroenterol 6: 169-174. [crossref]
  8. Agostini S, Durieux O, Mirabel T (2000) Chronic pancreatitis. Encycl Méd Chir Radiodiagnostic – Digestive System 33: 652-A-10.
  9. Bléry M, Tasu JP, Rocher L (2002) Imaging of acute pancreatitis. Encycl Méd Chir Radiodiagnostic – Digestive System 33: 651-A-10.
  10. Uchida K, Okazaki K, Konishi Y (2000) Clinical analysis of autoimmune-related pancreatitis. Am J Gastroenterol 95: 2788-94.

The Effect of Loading of Bioactive Glass in Desensitizing Polishing Pastes on Tubular Occlusion

DOI: 10.31038/JDMR.2022611

Abstract

Objective: To determine 1) the most effective loading of the bioactive glass in a prophylactic polishing paste containing Bioactive glass particles that provides a more effective tubular occlusion and 2) the ideal application time required to achieve this objective using an in-office rotary cup with a fixed pressure and speed.

Materials and Methods: 60 dentine discs were divided equally into 15 groups treated with 0%, 5.0%, 15.0% and 25.0% bioactive glass loading respectively and Nupro® at different applications (30, 60 and 120 seconds). Dentine permeability (Percentage flow rate) of each specimen was measured using a modified Pashley hydraulic conductance model at four different time points: (1) before toothpaste application, (2) after toothpaste application, (3) after saliva immersion and (4) after an acid challenge. Data were analysed by ANOVA to determine whether there were any significant differences with the control group (Nupro®) compared to the test groups at three different time intervals (30, 60 and 120 seconds). 20 dentine discs were analysed to observe the surface tubular occlusive effect following application of the various loadings at different times using scanning electron microscope (SEM).

Results: There was an increased percentage fluid flow rate (FR) reduction with increasing bioactive glass loading (0.0%, 5.0%, 15.0%, 25.0%) compared to the control material Nupro®. The 25% bioactive glass loading was the most effective in reducing fluid flow at the various time points although there were no significant differences between the 15% and 25% glass loading. The 25.0% bioactive glass loading at 120 seconds also demonstrated effective tubular occlusion compared to the control prophylaxis paste. A comparison between the control and the various glass loadings at the various time points using SEM demonstrated increasing tubule occlusion with increasing time of application. Tubular occlusion also increased following artificial saliva immersion but decreased following an acidic challenge.

Conclusions: Increasing the bioactive glass loading resulted in a greater fluid flow rate reduction with an increase of time of applications. Overall, the most effective application was with the 25% loaded bioactive glass at 120 seconds although the application of the 15% loaded bioactive glass prophylaxis paste for 30 seconds demonstrated effective tubular occlusion and fluid flow reduction.

Keywords

Bioactive glass, Desensitising polishing pastes, Tubular occlusion, Hydraulic conductance

Introduction

According to Hench 45S5 bioactive glass was developed as a bone ceramic [1] which was also used to  improve  periodontal bone  regeneration in bony defects caused by periodontal disease-(PerioGlas®) [2].  Several investigators [3-6] have also evaluated a bioactive glass (45S5) as a desensitizing toothpaste without fluoride. More recently bioactive glass-based toothpastes have been developed for over the counter (OTC) products. These products include NovaMin® (GlaxoSmithKline [GSK]) containing fluoride and BioMinF™ (Biomin Technologies Ltd) although the surface deposits on the exposed dentine are different with. NovaMin® producing a hydroxy carbonate like apatite (HCA) layer whereas BioMinF™ provides a fluoroapatite layer, which is more resistant to an acid challenge [7]. Bioactive glass (45S5) has also been incorporated into a prophylactic polishing paste (in-office dental procedure) to remove stain and reduce dentine hypersensitivity (DH) (Nupro®). Previously there were limited published data regarding the ideal loading concentration of bioactive glass into either toothpaste or polishing paste formulations although Tie et al. [8] reported that a 5% glass loading was the ideal concentration for a toothpaste formulation. Sauro et al. [9] compared dentine permeability in vitro for both prophylactic and air-polishing procedures and concluded that a Sylc bioactive glass (Sylc™; OSspray, London, UK) was more effective in reducing dentine permeability  in both the polishing paste and air-polishing systems compared to  the controls. Milleman et al. [10] compared a Nupro® Sensodyne prophylaxis paste with Novamin® for the treatment of DH in a 4-week clinical study and concluded that the reduction in DH was statistically significantly compared to the group receiving a standard prophylaxis paste. No differences were, however detected between the two NovaMin® polishing pastes with and without fluoride. Neuhaus et al. [11] also conducted a double-blinded  randomised  clinical  trial and concluded that a 15% NovaMin® loading with and without fluoride had the same immediate DH effect for 28 days following root surface debridement (RSD). A systematic review by Zhu et al. [12] concluded that the prophylaxis paste containing 15% calcium sodium phosphosilicate was favoured over the negative control at reducing post-periodontal therapy DH (root sensitivity), although the level of evidence was categorized as “low”.

Aim

The aim(s) of the present study, therefore, was to 1) to determine the most ideal loading for a bioactive desensitising polishing paste with the most tubular occlusion and 2) to determine the effect of the application time (30s, 60s, 120s) and the effect of an acidic challenge on each of the experimental bioactive glass prophylactic polishing pastes with the percentage of loading (0%, 5%, 15%, and 25%).

Materials and Methods

This exploratory study was based on two objectives. The first part of the study was designed to choose the ideal abrasivity of the pumice that would be incorporated into prophy-paste formulations using white light profilometry has been previously described by Hussain  et al. [13]. The second part of the study evaluated selected pastes to determine their effectiveness in tubular occlusion using scanning electron microscopy (SEM) and hydraulic conductance (Fluid flow) techniques and is the focus of this paper.

Preparation of Materials

Collection of Teeth

A total of 120 extracted, caries free human premolars and molars were collected from  the  walk-in  dental  polyclinics  from  Kuwait in 2017 after obtaining verbal consent from patients for the use of their teeth in research. The teeth were stored in a small container of Listerine mouthwash (Johnson and Johnson, UK) and brought to the UK by Hamad Hussain (HFH) under QMUL guidelines UK. The teeth were transferred and stored in a 70% concentration Ethanol solution in a specimen container at room temperature within the Department of Dental Physical Sciences Unit at Mile End, London in accordance with HTA regulations.

Preparation of Mid Coronal Dentine Sections

90 non-carious human premolars, and molars were selected and prepared into dentine disc specimens of 1.2 mm thickness as described by Tie et al. [8] using an automatic precision cutting machine (Struers Accutom 5, Denmark). The dentine discs were then ground using a Kemet 4 machine (Kemet Maidstone Kent ME15 9NJ UK) followed by polishing with three different silicon carbide papers in a descending order of abrasive coarseness, starting from carbide paper grade P600, P1000 to P2500. The polishing was considered complete when the discs were polished to a thickness of 1.0 mm. The thickness of the discs was monitored constantly using a digital micrometer to avoid over polishing.

Etching of Dentine Sections

The etching of dentine discs was performed prior to using the discs for the experimental steps. This was performed by immersing the discs into 6% w/w citric acid solution for two-minutes. The discs were ultrasonicated with deionized water in an ultrasonic bath for 30 seconds to remove any residual acid using the methodology described by Tie et al. [8].

Artificial Saliva Preparation

Artificial saliva was prepared using the following constituents: 2.24 grams of KCl, 1.36 grams of KH2 PO4, 0.76 grams NaCl, 0.44 grams of CaCl2 .2H2 O, 2.2 grams of porcine Mucin and 0.2 grams of NaN3 (all Sigma-Aldrich, UK) which was mixed with 800 grams of deionized water in a 1 litre volumetric flask. The mixture was stirred using a magnetic hotplate stirrer for 30 minutes until all reagents were fully dissolved. The mixture’s pH was then adjusted to 6.5 at room temperature using a pH meter (Oakton, Netherlands) by adding 0.5 M of KOH sequentially until the desired pH was obtained. Separately, 0.5 M of KOH was previously prepared by mixing 1.40 grams of KOH (Sigma-Aldrich, UK) in 50 ml deionized water. The final mixture was made up with deionized water to 1 litre. The produced artificial saliva solution was kept in a fridge set at 5°C until required and used within 2 weeks of preparation [8].

Preparation of the Prototype Bioactive Glass Polishing Paste

The bioactive glass used in the prophy-paste formula was BioMin F which was manufactured by Cera Dynamics Ltd Stoke UK and is the same glass powder used by Biomin Technologies Limited, UK in toothpaste formulations. The composition of the Bioactive Glass is shown in Table 1. The material was stored at room temperature in a closed dry container until required.

Table 1: Composition of the Bioactive Glass used in the prophy paste

table 1

Preparation of the Prophylaxis Polishing-Paste for the Different Bioactive Glass Loading

The composition of prophy-paste components that was prepared in the laboratory was based on the components’ range of the Safety Data Sheet number 801363 of Nupro® Sensodyne® Prophylaxis Paste with Novamin® (GSK). Initially this consistency (viscosity) of this formula was poor and therefore the formula was modified as shown in Table 2. Materials were measured separately, and mixed using a metal spatula, and then stored at room temperature until required.

Table 2: Composition of both loaded and unloaded prophy-paste to produce 90 grams that was used during the main study

table 2

The final loading percentages of both the formulated Biomin prophylaxis polishing paste and pumice control are shown in Table 3.

Table 3: Loading percentages of both the formulated Biomin prophylaxis polishing prophy-paste and pumice control

table 3

Methodology

Preparation of Samples and Procedures

The experimental sample was composed of 60 teeth that were adequately prepared on the dentine discs following a specific protocol before starting the experimentation.

Scanning Electron Microscopy

15 out of 20 etched stored dentine discs were used in this study. A prophylaxis polishing-paste was applied on the discs at the different proportions of the bioactive glass (0%, 5%, 15%, 25% and, Nupro® control) and for the different times (30s, 60s, 120s) using a portable prophylaxis polishing handheld device (Table 3). Three-dentine discs were assigned for every prophylaxis polishing-paste group. Each disc was fractured into equal halves using orthodontic pliers to provide two sections. One dentine disc was used for (1) untreated control and (2) treated with a prophy-paste for 30 seconds. The second one was used for (3) treated with the same prophylaxis polishing-paste for 60 seconds and (4) treated with the same prophy-paste for 120 seconds. The third dentine disc that was halved was used for (5) treated with the same prophylaxis polishing- paste, salivary immersion, and one-minute in an acid challenge and (6) treated with the same prophylaxis polishing-paste, salivary immersion and a two-minute acid challenge. The five groups were tested using the same protocol. The same process was also used when treating the dentine discs for hydraulic conductance procedure (Table 4).

Table 4: The number of discs by percentage (%) glass loading and the time of application

table 4

Prior to the SEM analysis and visualisation, the specimens were prepared for drying, mounting, and coating. After applying the treatment to all specimens, they were placed in a vacuum desiccator to dry. Each specimen was then mounted on a metal stub using double sided carbon tape. Finally, the specimens were coated with gold-palladium using a sputter coater. After the specimens were prepared by the three above steps, they were visualised using SEM (FEI Inspect F SEM, USA) at different magnification of x1000 and 10,000. The working distance, which is the distance between the specimen and the source beam was maintained at  a fixed 10mm) for all the specimens with a working voltage at 20kV [6].

Hydraulic Conductance (FRR Values)

Based on the design developed by Outhwaite, et al. [14,15], a modified Pashley hydraulic conductance was used in the study to measure dentine permeability (Lp).

45 teeth (molar) were used for the evaluation of hydraulic conductance (Lp) following initial immersion in 6% citric acid for two minutes, teeth were divided into the test groups (1, 2 and 3). Baseline fluid flow (FR) measurements were recorded prior to the application of the test and control prophylaxis polishing pastes at  the designated timings and loadings. Following application of the designated prophylaxis polishing paste and timings the discs were rinsed in deionised water for 10 seconds and placed in the modified Pashley conductance system and FR measurements were recorded. All teeth were subsequently immersed in 10ml of artificial saliva for 30 seconds, rinsed and immersed in 30ml of 6% citric acid for one and two minutes and a final set of FR measurements were recorded. The teeth were subsequently air dried and prepared for SEM evaluation (500x, 1000x, 5000x and 10,000x magnification)

Analysis of the dentinal permeability measurement was conducted as follows [8]:

a) Percentage flow reduction after treatment with the polishing paste.
for 1

b) Percentage flow reduction after treatment with the polishing paste and immersion in artificial saliva.

for 2

c) Percentage flow reduction after treatment with polishing paste, immersion in artificial saliva and acid challenge.

for 3

where V0 = Dentine permeability at baseline (after acid etch)

V1 = Dentine permeability immediately after polishing paste application

V2 = Dentine permeability following immersion in artificial saliva

V3 = Dentine permeability following acid challenge

Statistical Analysis

Mean, standard deviation with 95% C.I.: for each variable was assessed. for the total sample used in the explorative study. A one- way ANOVA was estimated to compare flow rate, FR, means between the different loading groups at a specific time of application as well as assessing the effect of time of application for a specific loading of the bioactive glass. Bonferroni´s post-hoc test was used as a multiple comparison test, to control the propagation of a Type-I error. A two- way ANOVA with between subjects’ factors, the loading group and time of application was also used to explore the interactions and obtain the overall conclusions regarding the effect of both factors.  In view of the low numbers of disks used in this explorative study    a complementary non-parametric Brunner-Langer model was employed Distributions (not means) of FR rates were compared using an ATS-test (ANOVA-type).

Results

The permeability of the dentine tubules in  the  dentine  discs was tested and previously established as a laboratory technique to measure the fluid rate reduction using hydraulic conductance [14,15]. The reduction of the fluid flow at the three different experimental applications (FR1 after application, FR2 after immersion in saliva, FR3 after an acid challenge) on a disc at the different loading of the bioactive glass from 0.0%, 5.0%, 15.0%, to 25.0% is shown in Table 4 and Figures 1-3 respectively. The effect of application time (30s, 60s and 120s) vs. % loading, immersion in saliva, following an acid challenge was also analysed. For example, following polishing the dentine disc for one minute, there was a gradual pattern in the percentage fluid flow reduction. The pattern of the reduction did not however exist at 0% to 5% although it showed a steady increase in Lp. There was however a significant change in the pattern increasing the reduction’s flow once the glass loading was more than 15% (at 25% loading) It was clear that after applying the prophylaxis polishing-paste for a minute, the fluid flow was reduced. There was slightly more reduction after immersing the disc in artificial saliva for an hour. Whereas a two-minute acidic challenge increased the fluid flow (Table 5).

fig 1

Figure 1: Comparison of flow rates reduction by Group (application: 30 seconds)

fig 2

Figure 2: Flow rate reduction FR1 values by the loading group after paste application at time=30s

fig 3

Figure 3: Flow rate reduction values (FR2) by loading group following saliva immersion (time=30s)

Table 5: Flow rates reduction by Group (application time: 30 seconds)

table 5

Analysis of the selected loading at 30 seconds using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 5. The 25% Bioactive glass loading provided significantly more reduction than any other concentration (p<0.001). The same analytical methodology was employed throughout the study (Table 6).

Table 6: FR1 values by loading group at the time of application=30 s: results of multiple comparisons by Bonferroni´s test

table 6

FR2: After Saliva Immersion

The FR mean was 1.19 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With the 5%- glass loading the mean increased to 39.20 ± 0.09%. Higher loading levels (15% and 25%) involved new increments to 63.01% ± 0.05 and 72.99 ± 0.49%. The fluid flow reduction of the Nupro®   solution values increased to 62.55 ± 0.05%. Therefore, the optimal tubular occlusion occurred using a 25%-loading of the Bioactive glass (Figure 3).

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 6. There were significant differences between the groups. Loading at 25% was the most effective. Nupro® had similar values to a 15% glass loading of bioactive glass (Table 7):

Table 7: FR2 values by loading group at the time of application=30 s: results of multiple comparisons Bonferroni´s test

table 7

FR3: After an Acid Challenge

The FR mean was 0.83 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With a 5%-proportion of glass the mean increased to 36.91 ± 0.08%. At the higher loading levels (15% and 25%) the FR reduction increased to 62.44% ± 0.05 and 72.49 ± 0.05% respectively. The Nupro®  solution FR value was 61.96 ± 0.05%. Therefore, the optimal tubular occlusion took place using a 25%-loading of Bioactive glass (Figure 4).

fig 4

Figure 4: Flow rate reduction values (R3) by loading group after an acid challenge at time=30s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 7. There were significant differences between the groups. Loading at 25% was the most effective.

Analysis of FR at Time of Application=60 s

The following Table 8 and Figure 5 show the basic statistics of fluid flow reduction, FR, values over the experiment period after 60s of paste application (Table 9):

Table 8: FR3 values by loading group at the time of application=30 s: results of multiple comparisons Bonferroni´s test

table 8

fig 5

Figure 5: Flow rate reduction values by loading group at the time of application=60s

FR1: After Prophy-Paste Application

The FR mean was -5.74 ± 0.02% if no bioactive glass was incorporated into the prophy-paste glass. With the 5%-loading, this reduction increased to 39.39 ± 0.09%. At the higher loading levels (15% and 25%) the FR reduction values increased to 67.53% ± 0.05 and 74.94 ± 0.04% respectively. The Nupro®  solution FR values were 63.20 ± 0.05%. The 25%-loading of bioactive glass provided the maximum tubular occlusion values (Figure 6).

fig 6

Figure 6: flow rate FR1 reduction values by loading group after paste application at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 9. There were significant differences between groups. The glass loading at 25% was the most effective (Table 10).

Table 9: Comparison of the flow reduction rate vales by Group (application: 60 s)

table 9

Table 10: FR1 reduction values by loading group at the time of application=60 s: results of multiple comparisons Bonferroni´s test

table 10

FR2: After Saliva Immersion

The FR mean was 0.84 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With 5%-loading, the FR reduction values increased to 41.18 ± 0.09%. At the higher loading levels (15% and 25%) involved new increments to 70.83 ± 0.05% and 77.17 ± 0.06%. Nupro® solution involved 65.78 ± 0.05%. Again, the 25%-loading of bioactive glass was associated with an increase in tubular occlusion (Figure 7).

fig 7

Figure 7: Flow rate FR2 reduction values by loading group after saliva immersion at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 10. There were significant differences between the groups. The loading at 25% of bioactive glass was the most effective (Table 11).

Table 11: FR2 reduction values by loading group at the time of application=60 s: results of multiple comparisons Bonferroni´s test

table 11

FR3: After an Acid Challenge

The FR mean value was 0.48 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With the 5%-proportion the mean reduction increased to 39.35 ± 0.09%. The higher loading levels (15% and 25%) reduction increased to 70.52 ± 0.05% and 77.02 ± 0.04% respectively. The Nupro®   solution values were 65.41 ± 0.05%. Therefore, the optimal tubular occlusion occurred using a 25%-loading of bioactive glass (Figure 8).

fig 8

Figure 8: Flow rate FR3 reduction values by loading group after an acid challenge at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 11. There were significant differences between the groups. 25% Bioactive glass loading was the most effective (Table 12).

Table 12: FR3 values by loading group at time of the application=60 s: results of multiple comparisons Bonferroni´s test

table 12

Analysis of FR Values at the Time of Application=120 s

Table 13 and Figure 9 show the basic statistics of the FR reduction values over the experiment after 120s of paste application:

fig 9

Figure 9: Flow rate reduction values by loading group at the time of application=120s

Table 13: Flow rate reduction values by group (application: 120 s)

table 13

FR1: After Prophy-Paste Application

The FR mean was -9.92 ± 0.03% if no bioactive glass was incorporated into the prophy-paste. With 5%-loading, the FR reduction increased to 40.84 ± 0.09%. The higher loading levels (15% and 25%) increased the reduction to 70.54 ± 0.05% and 77.74 ± 0.04%. Nupro®  solution involved 67.30 ± 0.05%. 25%-loading was associated to the maximum power of occlusion (Figure 10).

fig 10

Figure 10: Flow rate FR1 reduction values by loading group at time of application=120s

Analysis of the selected loading following a 120 second application time using a one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 13. There were significant differences between the groups. Loading at 25% was the most effective.

FR2: After Saliva Immersion

FR mean was 0.36 ± 0.00% if no bioactive glass was present. With 5%-loading, the reduction of fluid flow increased to 43.08 ± 0.09%. Higher loading levels (15% and 25%) involved newer reduction increments to 73.11 ± 0.04% and 79.23 ± 0.04%. Nupro® solution involved 70.55 ± 0.05%. The 25%-loading was associated to the maximum power of occlusion (Figure 11).

fig 11

Figure 11: Flow rate FR2 reduction values by loading group after saliva immersion at time=120s

Analysis of the selected loading following saliva immersion using a one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 14. There were significant differences between the groups. Loading at 25% was the most effective (Table 15).

Table 14: FR1 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 14

Table 15: FR2 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 15

FR3: After an Acid Challenge

FR mean was 0.12 ± 0.00% if no bioactive glass was present. With 5%-proportion mean reduction increased to 41.43 ± 0.09%. Higher loading levels (15% and 25%) involved new reduction increments to 72.91 ± 0.04% and 79.15 ± 0.04%. Nupro® solution involved 70.31 ± 0.05%. Therefore, the optimal tubular occlusion took place using 25%-loading (Figure 12).

fig 12

Figure 12: Flow rate FR3 reduction values by loading group after an acid challenge at time=120s

Analysis of the selected loading following an acid challenge using one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 16. There were significant differences between groups. Loading at 25% was the most effective.

Table 16: FR3 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 16

Analysis of FR at Loading=0%

Table 17 highlights the basic statistics of FR over the experiment following 0%-bioactive glass paste application:

Table 17: Flow rate reduction values by time of application (0% loading)

table 17

FR1: After Prophy-Paste Application

The FR1 mean was -5.05 ± 0.02% within discs treated for 30s, -5.74 ± 0.02% in discs treated 60s and, finally, -9.92 ± 0.03% for the longest duration 120s (Table 16).

Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 1.19 ± 0.00% within discs treated for 30s, 0.84 ± 0.00% in discs treated 60s and, finally, 0.36 ± 0.00% for the longest duration 120s (Table 16). Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 0.83 ± 0.00% within discs treated for 30s, 0.48 ± 0.00% in discs treated 60s and, finally, 0.12 ± 0.00% for the longest duration 120s (Table 16). Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

Analysis of FR at Loading=5%

Table 18 provides the basics statistics of FR reduction values over the experiment following a 5%-bioactive glass paste application:

FR1: After Prophy-Paste Application

The FR1 mean was 37.77 ± 0.08% within discs treated for 30s, 39.39 ± 0.09% in discs treated 60s and, finally, 40.84 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 39.20 ± 0.09% within discs treated for 30s, 41.18 ± 0.09% in discs treated 60s and, finally, 43.08 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 36.91 ± 0.08% within discs treated for 30s, 39.35 ± 0.09% in discs treated 60s and, finally, 41.43 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Loading=15%

Table 19 provides the basics statistics of FR over the experiment after 15%-bioactive glass paste application:

Table 19: Flow rates reduction values by time of application (15% loading)

table 19

FR1: After Prophy-Paste Application

The FR1 mean was 60.86 ± 0.05% within discs treated for 30s, 67.53 ± 0.05% in discs treated 60s and, finally, 70.54 ± 0.05% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Table 18: Flow rate reduction values by time of application (5% loading)

table 18

FR2: After Saliva Immersion

The FR2 mean was 63.01 ± 0.05% within discs treated for 30s, 70.83 ± 0.05% in discs treated 60s and, finally, 73.11 ± 0.04% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 62.44 ± 0.05% within discs treated for 30s, 70.52 ± 0.05% in discs treated 60s and, finally, 72.91 ± 0.04% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Loading=25%

Table 20 provides the basics statistics of FR over the experiment after 25%-bioactive glass paste application:

Table 20: Flow rates reduction values by time of application 25% loading

table 20

FR1: After Prophy-Paste Application

FR mean was 70.68 ± 0.05% within discs treated for 30s, 74.94 ± 0.04% in discs treated 60s and, finally, 77.74 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

FR mean was 72.99 ± 0.49% within discs treated for 30s, 77.17 ± 0.06% in discs treated 60s and, finally, 79.23 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After Acid Challenge

The FR3 mean was 72.49 ± 0.05% within discs treated for 30s, 77.02 ± 0.04% in discs treated 60s and, finally, 79.15 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Nupro® Group

Table 21 provides the basics statistics of FR over the experiment following the Nupro® paste application:

FR1: After Prophy-Paste Application

The FR1 mean was 57.11 ± 0.05% within discs treated for 30s, 63.20 ± 0.05% in discs treated 60s and, finally, 67.30 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 62.55 ± 0.05% within discs treated for 30s, 65.78 ± 0.05% in discs treated 60s and, finally, 70.55 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 61.96 ± 0.05% within discs treated for 30s, 65.41 ± 0.05% in discs treated 60s and, finally, 70.31 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR by Both Loading and Time of Application

The analysis of the results would indicate that 1) the higher the bioactive glass loading resulted in a greater potential to occlude the tubules and 2) the longer time of application resulted in a greater potential to occlude the tubules.

Data as displayed in Figures 12-14 (FR 1-3) were used to determine whether the benefits of a high glass loading was similar for all conditions at the time of application and whether the benefit of a longer time of application was similar for all glass loading conditions. A more general statistical model was estimated to assess the interaction between both factors. The results indicated that for all flow rate reductions (FR1-3) by loading group and time of application (F-test of 2-way ANOVA.) clearly demonstrated that differences between the time of application were significant for any loading (Figure 14). This model concludes that differences are even more apparent as the glass loading was increased (p<0.001, interaction) (Figure 15).

fig 13

Figure 13: Flow rate FR2 reduction values by loading group and time of application

fig 14

Figure 14: Flow rate FR3 reduction values by loading group and time of application

fig 15

Figure 15: The relative effects from the Brunner-Langer model of the different prophy-paste loading through the three treatment FR1, FR2 and FR3 and different times 30, 60 and 120 seconds

The relative effects from the Brunner-Langer model of the different prophy-paste loading through the three treatment regimens (FR1, FR2 and FR3) and the different application times (30, 60 and 120 seconds) was also analyzed (Figure 16).

fig 16

Figure 16: Summarizes the results regarding both 15% loaded glass and Nupro® groups through the three treatment modalities FR1, FR2 and FR3 at three different times (30, 60 and 120 seconds).

This above figure demonstrates that the magnitude of the FR to the different elements (paste, saliva, acid) depends specifically in the % loading and time of application. There was a high inter-correlation involving all factors included in the analysis. In other words, the higher the bioactive glass loading was, the higher the positive effect of polishing a longer time. Alternatively, for longer times of application, the slope of the increment of FR rate is higher, that is an increment of loading involves a higher impact. For example, a 15% loaded bioactive glass showed the best effect when applied to samples for 30 seconds.

The results of the model confirmed that the pattern of FR changes depends specifically on the conditions of both loading and time of application.

Comparison between the 15%-Glass Loading and the Nupro® Polishing Paste

This comparison is important since these two products share    the same proportion of glass but are manufactured differently. For example, the 15% Bioglas loading is an experimental paste whereas the Nupro® paste is an established commercial product. Table 21 and Figure 16 compares the results between the 15% glass loading and Nupro® group at different times (30s, 60s and 120s) (Table 22).

Table 21: Flow rates reduction values by time of application (Nupro® group)

table 21

Table 22: Comparison between the 15% glass loading and Nupro® group at different times (30 s, 60 s and 120 s)

table 22

Comparison of the FR rates by loading group (15% vs. Nupro®) at different times of application: using a 2-sample t-test indicated that there were significant differences for every comparison apart from the 30s application. The results of the analysis suggested that a 15%-glass loading was better (higher FR reduction value) than the Nupro® paste (for each time and phase) (Figure 17).

fig 17

Figure 17: a-e Comparison of different prophylaxis polishing-pastes assessed in the study; 0%, 5%, 15%, 25% loaded glass and a Nupro® control at 10,000x magnification

Scanning Electron Microscope (SEM).

The surface morphologies of each dentine disc were evaluated under the scanning electron microscopy at x1000 (1k) and x10000 (10k) magnifications at different stages of treatment. For viewing the occlusal characteristic of dentine tubules, the discs were mounted flat on the stub. Each dentine disc was viewed after (1) acid etching as a control, (2) 30 seconds of a prophy-paste application, (3) 60 seconds after a prophy-paste application, (4) 120 seconds after a prophy paste application, (5) 1-minute of an acid challenge after 1-hour of salivary immersion and (6) 2-minutes of an acid challenge after 1-hour of salivary immersion.

Effect of a 0%, 5%, 15%, 25% and a Nupro® control) loading of prophylaxis polishing-paste:

In the control group where the dentine disc was etched for 2 minutes with citric acid no tubular occlusion was evident and the  open dentinal tubules were observed. Immediately after 30 seconds of applying a prophylaxis polishing-paste of 0% loading, the surface had some particles on the outer surface as well as inside the dentinal tubules, although the dentinal tubules were open. Increasing the time to 1-minue and 2 minutes with the same loading in different tooth samples, more particles were deposited over the surface of the disc, but the dentinal tubules could still be observed. When the discs were challenged in an acidic environment for one-minute and two-minutes after the discs were treated for 60 seconds and immersed for an hour in artificial saliva, there were fewer scattered particles on the dentine surface compared to the previously treated disc for a minute. Furthermore, more dentinal tubules were visualised after two-minutes of an acidic challenge (Figure 17a). Increasing the application time of 5.0% loaded prophy-paste from 30 seconds, 60 seconds to 120 seconds resulted in more scattered particles over the dentinal surface with fewer open dentinal tubules were at the 2-minutes of prophy-paste application interval. By way of comparison following increasing the time in an acidic challenge solution after 1 minute of prophy-paste treatment resulted in fewer scattered particles over the dentine surface although there were more opened dentinal tubules observed (Figure 17b). It appeared there was a pattern established when increasing the application time, since more occluded dentinal tubules were observed. After treating the sample for 30 seconds when applying the 15% loaded prophy-paste, more scattered particles and some obvious signs of angular shaped particles which appeared to be bioactive glass were noted. Once the application time increased to 60 seconds and 120 seconds, more glass particles were observed and the whole disc surface was covered with a dense layer of the material. Once the disc was placed in citric acid for 1-minute and 2-minutes, the dense layer was washed away although the prophylaxis polishing- paste material was observed inside the dentinal tubules (Figure 17c). By increasing the loading of the bioactive glass and application time, more occluded dentinal tubules were observed. After 30 seconds of application of a 25% loading, a dense layer covering the external surface of the sample was observed. No differences were noticed when applying the 25% loaded bioactive glass at 1-minue and 2-minutes. When the sample was placed as part of an acidic challenge for 1-minute, the dense layer of the material was noticed. Once the acidic challenge time increased to 2-minutes however, the orifices of the blocked dentinal tubules were observed (Figure 17d). The Nupro® control followed the same pattern as the 15% loaded prophy-paste where a dense layer was observed after 1-minute of application. When exposed to an acidic challenge, it was evident that the dense layer formed at the external surface was affected in a similar manner to the 15% loaded prophy-paste when applied after 2-minutes (Figure 17e).

Discussion

Bioactive glass has been previously used as an active ingredient in a desensitizing prophy-paste to treat DH by blocking dentinal tubules [3-6]. The use of bioactive glass products has been reported for its effectiveness in blocking dentinal tubules in a desensitising toothpaste in reducing DH [3-6] as well as an active ingredient in prophylaxis polishing pastes. Although Bioactive glass products have been incorporated in both toothpaste and prophylactic polishing pastes [12] there appears to be limited data regarding the actual percentage of the loading of Bioactive glass for a desensitizing prophylactic polishing paste as well as the time requirement for use in an in-office application. Neuhaus et al. [11] conducted a double-blinded randomised clinical trial and concluded that a 15% NovaMin® loading with and without fluoride had the same immediate DH effect for 28 days following root surface debridement (RSD). For this reason, fluoride was not incorporated into the prophy-paste formulation, however Brauer et al. [16] suggested that incorporating fluoride into dental materials bioglass formulations would be beneficial since the formed fluoroapatite layer may improve in withstanding an acidic challenge.

The effectiveness of the different loading of bioactive glass at 0.0%, 5.0%, 15%, 25% and Nupro® from Sensodyne® from Densply was investigated in the present study. Nupro® was used in the study as it was commercially available as a prophy-paste and as such was used as a control when comparing the various loading of bioactive glass in novel prophy-paste preparations in its effect on fluid flow and tubular occlusion. The other issue to be evaluated in the present study was to choose the ideal time of paste application as there was available data evidenced in the published literature. In the present study three different application times namely 30 seconds, 60 seconds and 120 seconds were selected. Due to the limited number of extracted teeth available for this study it was not possible to investigate other higher percentage loading of bioactive glass or different times and this could therefore be part of a future study. There were numerous limitations and difficulties, however when using these two techniques. Firstly, the individual tooth has unique characteristics when comparing the dentine tubules within a mid-coronal section of dentine (dentine disc). There was also a problem with source of the teeth as the age, tooth pathology and collection procedures as well as regional variations and differences with the tooth itself [17,18] which may account in turn to the regional variation in fluid flow through dentine [10]. These factors however, made standardization of the dentine discs difficult to achieve. To overcome this issue or at least minimise these effects Mordan et al. [19] developed methodology to standardize the evaluation of the dentine disc by limiting the area of evaluation to the centre of each disc and sectioning the disc into a test and control section for comparison.

Dentine Permeability Evaluation

The results of the first treatment phase which included applying the different loading of bioactive glass in prophy-pastes for different times showed a reduction in dentine permeability except for the 0% bioactive glass loading. There was however some occlusion of the dentinal tubules in the cross-section samples using SEM. According to Gillam et al. [6], this may be due to the presence of silica in a polishing paste, or toothpaste, it may also be possible for the extra- fine pumice to play a role in blocking the dentinal tubules. Although these effects were insignificant when comparing the hydraulic conductance measurements. The results also indicated that increasing the application time influenced both tubular occlusion and flow rate (FR).

When applying the 5% glass loading of bioactive glass at 30 seconds, the fluid flow was reduced by 37.77%. As the glass loading increased to 15% the fluid flow was reduced to 60.87%. When comparing the 15% glass loading with Nupro®, Nupro® showed less fluid flow reduction (57.11%). At the 25% glass loading a 70% flow rate, FR, reduction was noted. A similar pattern was noticed when applying the different glass loading of the prophy paste at different times namely 60 seconds and 120 seconds where the highest reduction of 77.7% of fluid flow occurred at 120 seconds when using the 25% loading of bioactive glass. Furthermore, when comparing Nupro® with the 15% loading, the 15% loading showed a fluid flow reduction at the three different time applications. Moreover, the benefit of a longer application time (60-120s) was evident at the 15%-loading compared to a shorter application time (30s) (Figure 16).

Immediately after the prophylaxis polishing paste application, the same specimens were immersed in artificial saliva for an hour. Reduction of fluid flow in all specimens was statistically significant (Figure 4.38). The optimum occlusion was noticed with the 25% loading with a 120 second application time (Figure 16). There was a slight increase in tubular occlusion at the 0% loading which suggested some effects of the artificial saliva as previously indicated above.

The final treatment involved challenging the specimens in a 6% citric acid solution for two minutes after the prophy-paste application with the dentine disc placed in the hydraulic conductance  cell.  Citric acid was used in the present study due to its weak acidity that resembled fruit juices freely commercially available and consumed orally on a regular basis by consumers. Citric acid has an erosive effect unlike the neutralising effect of saliva and will remove the precipitated layer opening the dentinal tubules thereby increasing the flow rate within the tubules. The FR values of all groups were reduced following the immersion in an acid solution although the 25% bioactive glass loading appeared to withstand the effects of this challenge better than the other groups showing the least amount of opening dentinal tubules when compared with the rest of the groups (Figure 15).

When the Brunner-Langer model applied to verify the relative effect magnitude of FR to the different elements (paste, saliva, acid) depending specifically on the loading and time of application. There was a high inter-correlation involving all factors included in the analysis. In conclusion, the greater bioactive glass loading together with an increased application time, the greater the effect on tubular occlusion and flow rate. On the other hand, the 15% loaded bioactive glass showed the best effect when applied on samples for 30 seconds (Figure 16). One of the main issues, however, to consider when discussing the results was the low sample size used in the present study and for future studies a larger sample size is recommended.

SEM Analysis

SEM was used to magnify and amplify the specimens under magnification of x1000 and x10,000. The images were grouped together for comparison purposes. These were first etched with 6% citric acid to remove the smear layer which opened the dentinal tubules as observed in the control groups. All the specimens with the different bioactive glass loading and application times together with the Nupro® control were analysed using SEM (Figure 17a-e).

All groups with the different loading of bioactive glass 0%, 5%, 15%, 25% and Nupro® produced a precipitated layer on the dentine disc surface. The specimens of 0% prophy-paste of bio-active glass at 30, 60 and 120 seconds showed some occlusion of the dentinal tubules that was possibly due to the 5% of the silica used in the patent composition of the prophy-paste. Also, the extra-fine pumice which is a highly vesicular silica was used in the ingredient, its particle size was smaller than the dentinal tubules which may induce some tubular occlusion. On increasing the loading of bioactive glass in the other groups from 5% to 25%, more precipitation and blocking of the dentinal tubules was observed particularly at the higher glass loading. The 5% loading had a lower density of the precipitation layer, and the dentinal tubules were partially blocked. The 15% loading however showed a much higher coverage of the dentinal tubules with great reduction in its size. At the 25% loading, no dentinal tubules were observed, and the whole surface of the specimen was covered with a dense precipitation layer (Figures 17a-e). When comparing the Nupro® prophy-paste used as a control with the other loading bioactive glass prophy paste groups, the 15% and 25% loaded SEMs showed a superior effect on occluding the dentinal tubules (Figure 17c-e). Increasing the time from 30 seconds, 60 seconds to 120 seconds had an impact on the tubular occlusion. These results would suggest that using a higher loading of bioactive glass together with increasing the application time would have a major effect on the degree of tubular occlusion. It was evident from the study that the 25% bioactive glass and 2 minutes application time was the most ideal formulation for a prophy-paste an observation that was also supported by the reductions in FR in the hydraulic conductance experiment. By way of comparison there was little evidence of tubular occlusion in the 0% loading prophy-paste at 30 seconds. The samples were then immersed in saliva for an hour prior to an acidic challenge with 6% citric acid for one minute and two minutes following a one- minute application with the different loading of bioactive glass and Nupro® as a control. When the specimens were immersed in saliva and then challenged in 6% citric acid for one minute, no further effect on tubular occlusion was observed due to the density of the precipitated layer on the dentine surface particularly in the high loading groups (15%, 25%) and the Nupro® control. On the other hand, challenging the specimens for two minutes showed a slight reduction effect on tubular occlusion although this effect varied between the groups.

The same effect was observed in the 0% and 5% loading of bioactive specimens with the removal of some of the surface deposit exposing the dentinal tubule orifices (opening) as compared with the 15%, 25% loading and Nupro® groups. The resistance of the surface precipitation following an acidic challenge can be explained by the formation of a fluoro-apatite layer which is more resistant to an acidic challenge rather than a hydroxy-carbonated layer formed by the Nupro® control.

Conclusions

Increasing the bioactive glass loading resulted in a greater fluid flow rate reduction with an increase of time of applications. Overall, the most effective application was with the 25% loaded bioactive glass at 120 seconds although the application of the 15% loaded bioactive glass prophylaxis paste for 30 seconds demonstrated effective tubular occlusion and fluid flow reduction. The incorporation of bioactive glass into a prophylactic-polishing paste may be advantageous in reducing DH following both non-surgical and surgical periodontal treatment in that it may be an effective tubular occludent. Clinical studies however should be conducted to evaluate whether incorporated a novel bioactive glass at the recommended loadings from this in vitro study would be an effective desensitizing agent in the treatment of DH.

References

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  2. Hamad N, Karpukhina N, Gillam D, Hill R (2021) Quantifying the Effect of Adding Alkaline Phosphatase Enzyme to Silicate/Phosphate Glass Mixtures to Enhance Bone Regeneration. Journal of Dental and Maxillofacial Research 4(3).
  3. Litkowski L, Hack GD, Sheaffer HB and Greenspan DC (1997) ‘Occlusion of dentin tubules by 45S5 Bioglass®’. Bioceramics 10: 411-414.
  4. Litkowski L and Greenspan DC (2010) ‘A clinical study of the effect of calcium sodium phosphosilicate on dentin hypersensitivity–proof of principle’. J Clin Dent 21(3): 77-81. [crossref]
  5. Gillam DG, Tang JY, Mordan NJ and Newman HN (1998) The Effects of a Novel Bioglass Dentifrice on Dentine Sensitivity. A Scanning Electron Microscopy Investigation. Scanning 20: 257-258. [Crossref]
  6. Gillam DG, Tang JY, Mordan NJ and Newman HN (2002) ‘The effects of a novel Bioglass dentifrice on dentine sensitivity: a scanning electron microscopy investigation’. J Oral Rehabil 29(4): 305-313. [crossref]
  7. Hill R, Brauer D, Gillam DG, Karpukhina N, Bushby A, and Mneime M (2011) Inventors; Queen Mary and Westfield College, UK, assignee, Bioactive glass composition.
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  10. Milleman JL, Milleman KR, Clark CE, Mongiello KA, Simonton TC, et al. (2012) NUPRO sensodyne prophylaxis paste with NovaMin for the treatment of dentin hypersensitivity: a 4-week clinical Am J Dent 25: 262-268. [crossref]
  11. Neuhaus K, Milleman J, Milleman K, Mongiello K, Simonton T, et al. (2013) ‘Effectiveness of a calcium sodium phosphosilicate containing prophylaxis paste in reducing dentine hypersensitivity immediately and 4 weeks after a single application: a double-blind randomized controlled trial’. J Clin Perio 40(4): 349-357. [crossref]
  12. Zhu M, Li J, Chen B, Mei L, Yao L, Tian J, and Li H (2014) ‘The Effect of Calcium Sodium Phosphosilicate on Dentin Hypersensitivity: A Systematic Review and Meta- Analysis’, Chinese Journal of Evidence-Based Medicine 14(9): 1126-1130.
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  19. Mordan NJ, Barber PM, Gillam DG (1997) The dentine disc. A review of its applicability as a model for the in vitro testing of dentine hypersensitivity. J Oral Rehabil 24(2): 148-156. [crossref]

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

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.

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

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.

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Knowledge of Risks of Preeclampsia and Its Contributing Variables in Imo State

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

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

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

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.

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