Author Archives: author

An End of the COVID-19 Pandemic in Sight?

DOI: 10.31038/IDT.2021222

Abstract

We have set out to assess the data on the intensity of the COVID-19 pandemic with a view to making plausible predictions of its decline. A plot of “% COVID-19 Associated Death per Day” versus the timing and extent of the roll out of national vaccination campaigns in Sweden, Denmark, Netherlands, United Kingdom, France, Germany, Italy and USA shows that the decline in the severity of the COVID-19 pandemic was well advanced noticeably before vaccinations began or could have become a significant contributory factor. Israel is an outlier in its manifest decline pattern, yet the data also demonstrate that vaccination has had no discernible impact at all on % Deaths per Day in Israel.

Human societies throughout recorded history have been ravaged by suddenly appearing regional epidemics and in more recent centuries by epidemics that have been observed to spread globally [1,2]. The COVID-19 pandemic caused by coronavirus SARS-CoV-2 has caused serious global health emergencies and associated social and economic destruction on the citizens of many countries on a hitherto unprecedented scale. The disease emerged suddenly in Oct-Nov 2019 in Hubei region of Central China [3].

Pandemics as always emerge without any warning, cause their toll havoc and then predictably subside. They usually last in a severe form no more than a few years – as the data relating to the “Spanish Flu” of 1918-1919 clearly attests. The termination process of pandemics is not clearly understood, but it is generally assumed to be a combination of herd immunity, attenuation of the pathogen (leading to ill-defined mechanisms of endemicity) and its degradation in the physical environment. Thus, there are likely to be a wide range of factors in varying from country to country that contributes to the decline in disease severity and eventual its disappearance. We have attempted in this note to quantitatively measure the progress of the COVID-19 pandemic in a number of Northern Hemisphere countries from available public data from the time of its onset to the present day (August, 2021). We chose “% COVID-19 Associated Death per Day” as an objective end-point of the measure of severity of SARS-Co-V-2 induced disease. Such an index may reasonably allow a comparison across countries over and above country specific variable factors such as country-and region-specific technical and demographic variations in the application of the diagnostic PCR genomic test as a primary indicator of infection.

We report here a simple observation on the current status of the COVID-19 pandemic (as 15 Aug 2021) that could have a bearing on the timing of the likely end of the pandemic. We chose two straightforward metrics from data that are publicly available at Coronavirus websites (see Source Data URL links below). We selected those countries where much new Cases per Day data are available and where the Vaccination Campaign is ostensibly substantially advanced. The Cases (and Deaths) per Day by Country are at Google: Search “Coronavirus disease statistics”. Vaccination Rates by Country are Google Search “COVID-19 vaccination rates by country”. We largely chose key time points associated with the clear successive rolling epidemic peaks of new Cases per Day in each country. We then assumed a 14-day lag at that time point before the severe COVID-19 outcome of “Death” as an objective response rate (ORR) metric. These key time-point data were entered into an Excel spread sheet and primary graphic plots were developed for each country, and resulting figure of % Death per day versus % Population Vaccinated generated by standard Excel software. These primary plots were then adjusted for scale (mainly on the Y-axis for % Vaccination rate in that country) to allow a visual comparison with the % COVID-19 associated Death rate per Day at that time point.

Thus, the reference date along the X-axis in the summary country plots in Figure 1 (below) refers to the time point for new Cases per Day. The reader can draw their own conclusions but a clear trend is evident in all the data – the decline in % COVID-19 associated reported deaths was manifestly well advanced before the roll out of the intra-muscular mRNA expression vector vaccine program was begun or had become substantially advanced (e.g. significant in impact, say >20% population vaccinated). The USA is a vast country and its data may need to be analyzed State-by-State for granular trends in localized regions to become better apparent-like the countries of Europe chosen here. Israel is also a clear outlier in the basic trend – as that country did not suffer the same levels of % COVID-19 associated deaths as the others, even in the first wave in March-April 2020. However, the vaccination program on the basis of this data appears to have had no discernible impact at all on % Deaths in Israel. In many cases the waning of the death rates are seen to have progressed before the vaccination rates rose to substantial levels, probably pointing to the development of natural herd immunity as the most reasonable principal cause.

fig 1a

fig 1b

fig 1c

fig 1d

fig 1e

fig 1f

fig 1g

fig 1h

fig 1i

Figure 1: %COVID-19 Deaths per Day versus % Full Vaccination by Country at key times during the epidemic waves.

We refrain from further discussion of the many likely factors and variables that would need to be considered in a more exhaustive analysis. To conclude we leave the reader with two crucially important questions that urgently need to be dispassionately addressed. What do these plots mean for possibly heralding the termination of the pandemic? Is the long-awaited end really in sight across the world in mid-August 2021? And does a new world order beckon?

Source Data

COVID-19 Cases per Day, Deaths, Vaccination Rates 15 August 2021

Cases and Deaths per Day site.

Google: “Coronavirus disease statistics” URL is

shorturl.at/cdQS9

This gives you the “Australia” dashboard (from there you can choose your country in the menu bar scroll)

Vaccination Rates by Country Google “covid-19 vaccination rates by country”

shorturl.at/oFJS4

This gives you the “Australia” dashboard (from there you can choose your country in the menu bar scroll).

References

  1. Creighton C (1891) History of Epidemics in Great Britain. Cambridge University Press.
  2. Beveridge WIB (1977) The Last Great Plague. W. Heinemann, London.
  3. Pekar J, Worobey M, Moshiri N, Scheffler K, Wertheim JO (2021) Timing the SARS-CoV-2 index case in Hubei province. Science 372: 412-417.

Hydatid Disease during Pregnancy, the Challenging Management: Case Report and Review of Literature

DOI: 10.31038/IGOJ.2021431

Abstract

Human echinococcosis is a parasitic infestation of human by a tapeworm called Echinococcus granulosus. It can affect pregnant women at a low incidence. Mainly asymptomatic, it has a variety of presentations. Its main location is in the liver. Hydatid disease requires multidisciplinary care especially in pregnant patients. It can be treated medically or surgically according to each case.

We present a case of 27-year-old woman, G4 P3 with three previous cesarean sections, known to have hydatid cyst disease, presenting at 32 weeks of gestation, complaining of intermittent crampy right upper quadrant abdominal pain. Abdominal ultrasound done at 11 weeks of gestation, showed hepatomegaly along with a 9 cm × 6 cm mass suggestive of hydatid cyst that was followed by ultrasounds frequently. The patient was followed by a multidisciplinary team when she was then started on Albendazol 400 mg twice daily starting 32 weeks until delivery, then for two days post operatively. She did well and was discharged home in good condition.

Hydatid disease has a special consideration when associated with pregnancy. Many cases have been reported in literature yet only few reviews of literature and one meta-analysis have been reported. Management decision is quite meticulous. It depends on cystic nature and activity on one side and on the clinical picture of the patient on the other side. In all cases, cesarean section is advised. In spite of all recommendations, further prospective studies using larger samples are needed for clear-cut algorithmic guidelines for hydatid disease management in pregnancy.

Introduction

Human echinococcosis, or hydatid disease, also known as “cyst full of water” as described by Hippocrates, is a parasitic infestation of human by a tapeworm called Echinococcus granulosus [1-4]. This disease can be seen in all population including pregnant women [5,6]. Despite that, it is currently classified among the most neglected parasitic disease [1,5]. Hydatid cyst has a variety of presentations. It may remain asymptomatic for many years and may be discovered incidentally by radiography [3,4]. The most common site of hydatid cyst is the liver [4,6]. It might be found also in any part of the body including lungs, bones and soft tissues [3,5,7]. Hydatid cyst in pregnancy is rare, and usually affects the liver [3,6]. Its diagnosis in pregnancy might not be difficult, but the management is problematic [4]. It requires multidisciplinary care [2]. Both medical and surgical treatment are available but each case should be individualized due to the limited experience, lack of standardized consensus and paucity of information in the literature as only data from case reports are available [6]. For that, obstetricians should be more aware of the clinical features, diagnosis and treatment of this unusual disease [2].

Here we present a case of a pregnant woman with a huge liver hydatid disease.

Case Presentation

A 27-year-old woman G4 P3 with previous three cesarean sections, known to have hydatid cyst disease, presented to the outpatient department at 32 weeks of gestation with an intermittent crampy right upper quadrant abdominal pain, not related to oral intake, not relieved by any position, and not associated with any nausea or vomiting, anorexia, jaundice, or pruritis. She was diagnosed recently with recurrent hydatid cyst disease during pregnancy, for which she was referred to “high risk pregnancies clinic” [8-10].

Her history of hydatid disease goes back to her second pregnancy, at 6 weeks gestational age; when she underwent a laparotomy for excision of hepatic hydatid cyst, after which she didn’t receive any medical treatment. Four years later, the patient had recurrent disease which was managed by cystectomy in segments IV and VII of the liver in addition to lung cystectomy. Post operatively, the patient received Albendazole that was continued for 2 months.

Beside the hydatid disease, she was having a smooth course of pregnancy. During this pregnancy the patient was followed at an outside clinic, where serology of Echinococcus granulosus (IgG and IgM) was requested in the first trimester and came back negative. Serial abdominal ultrasounds were done. The first one, done at 11 weeks of gestation, showed a 9 cm × 6 cm lobulated cystic formation at the level of segment IV of the liver and having small wall calcifications. Repeated at 13+6 weeks of gestation, it showed: two contiguous lobulated cystic structures, at the level of the dome of the liver. The first cyst in segment VIII was extending to segment IV: 3.4 cm in transverse diameter, demonstrating peripheral hyperechoic rim that was not associated with post attenuation and most likely not corresponding to calcification. In addition, hyperechoic content was identified in the first cyst corresponding to post enhancement. It was concluded that the hyperechoic content could represent hydatid sand, and thus, this cystic structure in the context of hydatid disease was classified as CE1 according to WHO classification. The presence of a larger cyst with lobulated contours in segment VII and VIII was also noted measuring 6.5 cm × 6.5 cm with identification of anechoic content and few septations in the periphery particularly at its posterior aspect. The clear pattern of daughter cyst could not be identified thus a CE2 cyst couldn’t be suggested with certainty. The third US, done at 22 weeks of gestation, showed that the largest cyst previously seen in segment VIII was stable in size, demonstrating internal septations with identification of daughter cyst-like structures posteriorly. Moreover, when compared to previous report, the other lobulated cyst in segment VIII and IV having lobulated contours increased in size to 5 × 3.4 cm (compared to 3.4 × 3.2 cm). It was still showing a sand-like hyperechoic content, and demonstrating peripheral hyperechoic rim with posterior enhancement. The liver was enlarged to 17 cm in size.

Upon presentation, the patient had unremarkable vital signs. Her physical exam was limited due to obesity. It showed, however, right subcostal incision scar upon inspection, hepatomegaly with dullness but soft and non-tender abdomen.

The case was discussed by the multidisciplinary team members including the obstetrician, the maternal medicine, and the infectious diseases specialists. A decision to start Albendazol 400 mg twice daily till delivery (for three) weeks, was taken. Abdominal ultrasound was repeated just before cesarean section that showed three liver hydatid cysts, one of them decreasing in size from 6 cm to 5 cm, and two other stable cysts of 3 cm. Nevertheless, we couldn’t confirm if the cysts are stable or in active phase. There was no indication to operate those cysts at the time of C-section.

The patient continued medical treatment till cesarean delivery scheduled at 37 weeks; and for two days post operatively. She was did well post op and was discharged home on day two postop. The patient was seen one-week thereafter and was doing well. She continued to be followed by ID team and was planned to repeat abdominal US 6 months after delivery.

Discussion

As previously mentioned hydatid cyst disease is a parasitic infestation by a tapeworm most commonly by Echinococcus granulosus [10-15]. Contaminated food and water by feces of definitive infective host or poor hygiene in infestation areas are the main roots of exposure. The occurrence of this disease in pregnancy is low with a prevalence of 1/20,000 to 1/30,000.

Hydatid disease is mostly asymptomatic [10] but affected individuals can present with abdominal pain, abdominal mass or vague abdominal symptoms [11,14] which may mimic the usual symptoms occurring in pregnancy.

It is important to note that blood tests are nonspecific. Many serologic tests are available mainly IgG ELISA test and Indirect Hemagglutination Test [10,14], yet negative tests cannot rule out the disease.

Ultrasound is the primary diagnostic imaging tool. However, it cannot distinguish a benign cystic form from an abscess [9,11]. CT scan is the best imaging modality, being able to determine accurately the anatomical location and assess other [9,11,14].

There are five subtypes of cystic echinococcosis according to the WHO and Gharbi classification systems (Table 1).

Table 1: WHO and Gabri classification system for cystic echinococcosis cysts.

WHO-IWGE 2001

Gharbi 1981 Description

Stage

CE1 Type I Unilocular unechoic cystic lesion with double line sign Active
CE2 Type III Multiseptated, “rpsette-like” “honeycomb cyst Active
CE3 A Type II Cyst with detached membranes (water-lily-sign) Transitional
CE3 B Type III Cyst with daughter cysts in solid matrix Transitional
CE4 Type IV Cyst with heterogenous hypoechoic/hyperechoic contents. No daughter cysts Inactive
CE5 Type V Solid cyst with calcified wall Inactive

There are three management modalities depending on the activity of the cyst [11]. The first one is the surgical management requires opening the cyst, injecting a solicidal agent, evacuating the cyst and pericystectomy. It is best used for ruptured cysts, cysts with biliary fistulae, cysts compressing vital structures, cysts with secondary infection or hemorrhage, or cysts with multiple daughter cysts [11,14]. Other indications include cysts larger than 10 centimeters and superficial cysts which carry a risk of rupture [14]. Preoperative and postoperative use of Albendazole decreases the viability of cysts at the time of surgery and significantly reduces the chances of cyst recurrence. Albendazole for three 28-day courses of 10 mg/kg/day in divided doses separated by 2-week intervals post operatively is usually used [11-14]. Surgical management carries 2-25% risk of recurrence.

The second therapeutic modality is the percutaneous treatment is based on destroying the germinal layer with a solicidal agent, a process that requires puncture, aspiration, injection and reaspiration [11,14]. This method is done under CT or ultrasound guidance for CE1 and CE3-A cysts which do not contain daughter cysts [11,14]. It is avoided in complicated or superficial cysts due to the risk of rupture [11]. The last modality is the medical treatment based on Albendazole administration.

Hydatid disease has a special consideration when associated with pregnancy. Many cases have been reported in literature yet only few reviews of literature and one meta-analysis have been reported.

Hydatid disease in pregnancy is a rare condition occurring in parts of the world. It is usually diagnosed incidentally during an obstetrical ultrasound [8].

A pregnant patient may complain of abdominal discomfort and pain in the right upper quadrant area. In large cysts cases, nausea, vomiting and early satiety may be felt due to a mass effect [8].

The main challenge in pregnancy is in regards to treatment modality which is affected by cyst classification. Types 1 and 2 are usually treated by ultrasound guided percutaneous aspiration [8]. Types 3 and 4, with the exception of calcified cysts are mainly surgically treated [8]. However, due to scarcity of data, there is no standardized approach. Below, an algorithm will be stated for managing hydatid disease in pregnancy based on the only meta-analysis published on 2018 (Figure 1) [8].

fig 1

Figure 1: Approach and treatment algorithm for pregnancy complicated with Hidatid disease. HD Hydatid Disease; b HCG beta-human chorionic gonadotropin;*Ultrasound-based classification of cyst hydatid according to Gharbi et al.; PAIR percutaneous aspiration irrigation and re-aspiration (8).
Celik, S. et al. Archives of Gynecology and Obstetrics 298 (2018): 103-110.

The main medical therapy for echinococcal cysts is based on Benzimidazole, namely Albendazole. It acts on inhibiting glucose uptake by the parasite, thus generating metabolic and structural alteration leading to parasitic death. It is categorized as category C by the FDA [8]. Thus, it is not recommended for use in first trimester [8,14], yet it can be used afterwards.

According to Celik et al. a thin walled, large, peripherally located cyst in the liver is more likely to rupture than a small, centrally located cyst. Therefore, women with cysts characterized as at high risk of rupture should be referred at some point for intervention (surgery or PAIR) [8]. If no intervention is to be performed, then delivery by cesarean section is preferred. In optimal condition, a monthly close follow up is recommended. If conditions are worsened, intervention is considered after 20-24 weeks of gestation to allow for fetal maturation [8].

Concerning our patient, she started Albendazole 400 mg per os twice daily three weeks before her scheduled repeat cesarean section at 37 weeks of gestation. Her repeat ultrasound showed three cysts, one cyst decreased in size from 6 to 5 centimeters, the other two cysts were stable in size at 3 centimeters, yet nature could not be confirmed. Plan was to omit hydatid cystectomy due to stability of the patient and to continue same dose of Albendazole till delivery. She had smooth cesarean delivery and medical management was stopped two days after delivery. The patient did not manifest any symptoms afterwards.

Conclusion

In conclusion, hydatid disease is rarely combined with pregnancy. It can be primarily manifested incidentally on obstetrical ultrasound or due to abdominal pain from compression of a gravid uterus. It poses a challenge in regards to management during pregnancy. There are three modalities of management. Medical therapy using Albendazole is advised following the first trimester [8,14] either alone for stable, deep cysts or for those decreasing in size, or in conjunction with intervention aiming to shrink the mass. Percutaneous treatment is used mainly for cysts which do not have daughter cysts. Finally, surgical excision is reserved for ruptured cysts, cysts with biliary fistulae, cysts compressing vital structures, cysts with secondary infection or hemorrhage, or cysts with multiple daughter cysts. Management decision is quite meticulous. It depends on cystic nature and activity and on the stability of the patient. In all cases, cesarean section is advised [8]. In spite of all recommendations, further prospective studies are needed to put clear-cut algorithmic guidelines for hydatid disease management in pregnancy.

References

  1. Ahmed Al-Ani, Abdul-Naser Elzouki, Rashid Mazhar (2013) An Imported Case of Echinococcosis in a Pregnant Lady with Unusual Presentation. Case Reports in Infectious Diseases 2013: 753-848. [crossref]
  2. Thompson A, Chiodini PL, Stewart F (2012) Hydatid liver cyst in pregnancy: a case report. British Medical Journal 97: A65.
  3. Anandita, Shweta, Bhardwaj S, Sehra A (2015) Pregnancy with Hydatid Cyst of Liver. JCR 5: 542-545.
  4. Ghosh JK, Goyal SK, Behera MK, Dixit VK, Jain AK (2014) Hydatid Cyst of Liver Presented as Obstructive Jaundice in Pregnancy; Managed by PAIR. Journal of clinical and experimental Hepatology 4: 366-369. [crossref]
  5. Maria A Grácio, António J Santos Grácio (2019) Hydatid Disease and Pregnancy: A Short Note. Integr Gyn Obstet J 2: 1-2.
  6. Akbaş A, Daşıran F, Dagmura H, Daldal E, Özsoy Z, et al. (2019) Primary hydatid cyst localized in soft tissue during pregnancy. J Surg Case Rep 2019: rjy324.
  7. Ünalp H, Aydin Ç, Yavuzcan A, et al. (2008) Surgical treatment of hepatic hydatic disease during pregnancy: report of two cases. Gynecol Surg 5: 243-245.
  8. Celik S, Okyay O, Karaman E, Sert ÖZ, Cim N, et al. (2018) Analysis of factors affecting outcomes of pregnancy complicated by Echinococcus: an algorithm for approach and management. Arch Gynecol Obstet 298: 103-110. [crossref]
  9. Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa C (2000) Hydatid Disease: Radiologic and Pathologic Features and Complications. Hydatid Disease: Radiologic and Pathologic Features and Complications, The Journal of continuing medical education in radiology 20: 795-817. [crossref]
  10. Cennet O, Tirnaksiz MB, Dogrul A, Abbasoglu O (2019) Surgical treatment of cyst hydatid disease of the liver in the era of percutaneous treatment, HPB 21: S568eS676.
  11. Sozuer E, Akyuz M, Akbulut S (2014) Open surgery for hepatic hydatid disease. Int Surg 99: 764-769. [crossref]
  12. Shams-Ul-Bari, Arif SH, Malik AA, Khaja AR, Dass TA, et al. (2011) Role of albendazole in the management of hydatid cyst liver. Saudi J Gastroenterol 17: 343-347. [crossref]
  13. Horton RJ (1989) Chemotherapy of Echinococcus infection in man with albendazole. Trans R Soc Trop Med Hyg 83: 97-102. [crossref]
  14. Dandan I, Soweid A, Abiad F (2019) Hydatid Cysts. Medscape.
  15. Pedro M (2019) Clinical Manifestations and Diagnosis of Echinococcus.

Automated Hand Hygiene Monitoring Systems: Current Issues, Developments and Perceived Benefits

DOI: 10.31038/MIP.2021214

Abstract

Healthcare-Associated Infections (HCAIs) are among the leading causes of death in the United States affecting about one in every 20 hospitalised patients [1]. Furthermore, at least 50% of these infections are preventable [2]. Healthcare Workers (HCWs) practicing good Hand Hygiene (HH) is fundamental to preventing HCAI transmission, as HH compliance and HCAI rates are closely linked [3]. Though this association is well established, maintaining high levels of HH compliance is a perennial problem in all healthcare settings. When independently audited, HH compliance has been shown to be in the region of 50% at best [4]. Compliance is particularly poor when staff are busy and experiencing burnout [5] which has been mirrored in a recent report that found hospital transmission of COVID-19 accounted for 20-25% of cases [6]. Stressed and overworked HCWs perform less HH, thereby inadvertently increasing the risk of COVID-19 transmission and other HCAIs. Simply blaming HCWs is not the answer. Though maintaining adequate patient to staff ratios is essential, providing staff with unbiased and opportunistic feedback on their HH practice is also key to mitigating HCAI risk.

Accurately monitoring HH compliance is an important quality improvement and patient safety control strategy. Good HH compliance should be rewarded and celebrated. Equally, areas for improvement must be identified and educational resources allocated accordingly. The World Health Organisation (WHO) currently recommends that the gold standard for monitoring HH is by direct observation (DO) of HCWs using trained, independent auditors. In its technical manual, the WHO provides detailed guidance on the audit process stressing the value of immediate personalised feedback to HCWs [7]. Whilst DO is widely accessible and requires minimal financial investment, it is labour intensive and yet only produces small quantities of data [8]. A plethora of evidence demonstrates that the quality of DO data is impeded by the Hawthorne effect as well as observer and selection bias [9]. It has been estimated that the full hand hygiene audit cycle, including data input and feedback, can cost £28,800 per year in staff time using DO [10]. This could be considered a high price to pay for low quality data that ultimately gives Infection Prevention and Control (IPC) teams an unclear picture of the HCAI risk in their organisation. Whilst these issues are widely acknowledged in the IPC community, HCWs are also cognisant of the problems with DO. A survey conducted in 2020 found that 58% of 1,120 staff questioned did not strongly endorse DO as a method of monitoring HH [11]. “The Hawthorne Effect” was cited by HCWs as one of the reasons for not trusting HH data presented to them [11]. However, the same respondents were open to the introduction of innovative HH technologies. Though staff attitudes to new HH monitoring technologies have not always been reported to be so positive, other surveys have typically involved very small staff numbers and have not represented all staff groups [12,13]. Staff does appear to recognise that they change their HH behaviour when they are aware they are being audited by DO. Hence, if staff does not believe that HH compliance data reflects the real clinical environment they are working in, it then becomes easy to dismiss such skewed data and thus positive behavioural change is never achieved. Equally, getting front-line workers to buy-in to new approaches to HH monitoring, addressing their concerns about the accuracy of novel technologies and how this data will be used are also recognised as difficult challenges [14].

A number of automated hand hygiene monitoring systems (AHHMS) have been commercially developed to address these issues [15]. These systems use sensor technology to remotely monitor HH compliance, therefore reducing the need for human auditors, instead capturing large volumes of non-judgemental quantitative data. This benefit has already been realised by healthcare organisations that use AHHMS. One healthcare system was able to capture 35 million hand hygiene opportunities within the first six months of the COVID-19 pandemic [16]. The authors reported that their rich dataset allowed them to understand when changes in HH behaviour occurred and how long improvements in HH were sustained. Such robust data in similar quantities would not be achievable with DO alone, particularly when IPC staff resources were likely being diverted to COVID-19 containment measures.

There are three broad categories of AHHMS: group monitoring systems, badge-based systems, and video monitoring systems [8]. Group monitoring systems track usage of HH dispensers (soap and gel) to give an idea of HH events in a given location. Data produced from these systems can ‘nudge’ groups of staff to increase their usage of HH dispensers, but they cannot provide the personalised feedback that empowers HCWs to change their own practice [17]. Badge-based monitoring systems typically require HCWs to wear an additional tracking device that communicates with dispenser-based sensors. This extra layer of data is able to provide personalised feedback on HH behaviour both to the individual HCW, but also to managers and IPC teams. Implementing these types of AHHMS can be challenging because, due to their very nature, staff are required to wear an extra piece of equipment, which ultimately places an additional demand on staff to change their behaviour. In a study by Levin et al. [18], 44% of staff reported that wearing an additional tracking device was “inconvenient” to them. Both group monitoring and badge-based systems are usually unable to determine which WHO HH moment is being performed. They typically identify WHO moments one and four (before touching a patient and after touching a patient) [19]. This may be a useful surrogate in hospitals that have a high proportion of single rooms, however in many healthcare institutions (e.g. the National Health Service in the United Kingdom (UK)) this is not the case. Therefore, even where there is a successful implementation of an AHHMS, the continuous monitoring of HH events should be complemented by targeted DO to provide further qualitative insights into HCW HH behaviour; such as hand washing technique and types of HH opportunities missed.

Thirdly, video camera-based AHHMS can provide video footage that serves to replace human auditors. Video footage enables observation of all WHO five moments of hand hygiene and hand washing technique; however these systems have largely been confined to research rather than used commercially [20]. We expect this is due to patient privacy issues that may arise when video footage captures HH events in close proximity to patients. These privacy concerns could be alleviated through automated video auditing (AVA) which does not require storage or transfer of video data for analysis [21].

To our knowledge, there are currently 29 commercially available AHHMS, 75% of which are manufactured by companies based in the USA [15]. Over the last 10 years, uptake of these systems has remained stable, yet low, at around 4% [22,23]. A small survey of Directors of Infection Prevention and Control (DIPCs) in the UK found that these systems were perceived to be expensive and not guaranteed to produce a return on investment [15]. In order for an IPC intervention to be considered cost-effective, it should reduce HCAI incidence by 15% [24]. Therefore, evidence is needed to demonstrate that AHHMS are able to reduce HCAI rates before these systems are likely to be adopted more widely. A recent survey on this issue found that only one AHHMS has randomised control trial (RCT) level evidence supporting its ability to reduce HCAI rates [15]. Here, a group monitoring AHHMS used a specialised stepped wedge cluster RCT (SWCRCT) study design to demonstrate a significant reduction in healthcare-associated methicillin-resistant Staphylococcus aureus rates when implemented as part of a multimodal IPC strategy [25]. Other infection types showed no significant change during the study. As this was a group-based monitoring system, it could be argued that improvements in HCAI rates were limited by the inability to provide personalised feedback to HCWs. Individualised feedback, whether given publicly or privately, has been repeatedly shown to improve HH compliance [26,27]. Whilst this particular SWCRCT was a promising start, more are needed where the AHHMS is a single intervention being investigated. This will hopefully provide the evidence needed to determine whether an AHHMS is likely to be a cost-effective method of driving down HCAI rates.

Alternatively, an AHHMS can be evaluated by assessing its impact on HH compliance as a primary end-point. A 2019 review of AHHMSs found that only one system has RCT-level evidence demonstrating its ability to increase HH compliance [28]. When this badge-based system was implemented it led to a small 6.8% increase in HH compliance [29]. Non-adherence to badge-wearing was, again, an issue in this study, with 21% of participants not wearing their device as required.

Whether improved HH compliance or reduced HCAI rates (or both) are the desired end-points for such systems, more RCT-level evidence is needed for each of the 29 systems currently available in the marketplace [30]. We expect that uptake of such systems will remain patchy until the evidence base improves.

In summary, the importance of both staff consultation on new approaches to improving HH compliance, and immediate personalised feedback to staff with individualized action planning cannot be overemphasized [27,31]. Furthermore, we would suggest that goal setting with reward incentives are incorporated into HH improvement strategies if they are to effect behavioural change [32]. AHHMSs are useful tools and well placed to achieve these aims as they can provide large volumes of quantitative data offering insights to IPC teams on HCW HH behaviour. Badge-based systems promise to deliver personalised feedback to staff on their performance, yet repeated studies have shown staff to be reluctant to wear said extra badges due to the inconvenience they cause. However, new developments in AHHMS need to ensure that they have no impact on staff workflow and that personalized staff feedback on HH performance becomes the norm. In addition, more RCT-level studies are required to demonstrate the efficacy of individual AHHMSs in reducing HCAIs. This will allow IPC professionals to make informed, evidence-based procurement decisions on whether a system is likely to be cost-effective for their organisation. Overall, there should be optimism about new developments in AHHMSs provided these can be aligned with an improved research and development supporting programme.

Keywords

Hand hygiene, Automated monitoring systems, Issues, Benefits

References

  1. US Department of Health and Human Services (2013). National action plan to combat healthcare acquired infections-a road to elimination. Chapter 8: Long-Term Care facilities.
  2. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, et al. (2013). Health care–associated infections. A meta-analysis of costs and financial impact on the US healthcare system. JAMA Internal Medicine 173: 2039-2046. [crossref]
  3. Sickbert-Bennett EE, DiBiase LM, Willis TMS, Wolak ES, Weber DJ, et al. (2016) Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerging Infectious Diseases 22: 1628-1630. [crossref]
  4. Pan, SC, Tien, KL, Hung, IC, Lin, YJ, Sheng WH, et al. (2013) Compliance of Healthcare Workers with Hand Hygiene Practices: Independent Advantages of Overt and Covert Observers. PLoS ONE 8: 53746. [crossref]
  5. Manomenidis G, Panagopoulou E, Montgomery A. (2017) Job Burnout Reduces Hand Hygiene Compliance Among Nursing Staff. Journal of Patient Safety 15: 70-73. [crossref]
  6. Scientific Advisory Group for Emergencies (2021) PHE and LSHTM: The contribution of nosocomial infections to the first wave.
  7. World Health Organisation. (2009) Hand Hygiene Reference Technical Manual. Geneva, Switzerland: World Health Organisation.
  8. Boyce JM. (2019) Current issues in hand hygiene. American Journal of Infection Control 47: 46-52. [crossref]
  9. ‌Jeanes A, Coen PG, Gould D, Drey NS (2019) Validity of hand hygiene compliance measurement by observation: A systematic review. American Journal of Infection Control 47: 313-322. [crossref]
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AGP Related Evaluation of Medical Nutrition Therapy for Diabetes Management (AMEND) – A Real World Observation Study

DOI: 10.31038/EDMJ.2021522

Abstract

Purpose: To evaluate 24 hour glycaemic profile using AGP in patients with type 2 diabetes who are eligible for meal replacement therapy over a period of 14 days.

To assess whether a precise meal replacement plan as an add on to standard of care will make a difference in smoothening out post-prandial peaks and increasing time spent in the desired (70 mg/dl-180 mg/dl) range compared to baseline time in range and post-prandial blood glucose level.

Methods: Patients were mounted with AGP asked to follow the regular diet for 6 days. On the 7th day, based on the AGP report, the most troubled meal was replaced with protein rich, calorie counted, low-carb and fiber enriched meal supplement for the next 6 days. On day 14, the AGP data were collected.

Results: The analysis of full cohort (n=566) showed reduction in eA1c and eAG by 11.9% (from 7.84% to 6.90%) and 15.10% (from 178.41 mg/dL to 151.47 mg/dL), respectively when regular meal diet was compared with the replaced meal diet. The average TIR was improved by 23.56% (from 41.38 to 51.13) in full cohort, post-intervention with replaced meal.

Conclusion: The glycemic profile of patients with type 2 diabetes was improved by meal replacement therapy over period of 14 days.

Keywords

Medical nutrition therapy, Meal replacement, Diabetes, Protein supplement

Introduction

Diabetes mellitus is a non-communicable, complex and chronic lifestyle-related disorder. It demands continuous medical care with voracious risk-reduction strategies beyond modest glycaemic control. In terms of the sheer prevalence and incidence globally, it may be called a “pandemic”, although it is obviously not contagious. Malnutrition, both under- and over-nutrition, is another pandemic and the two co-exist making this a syndemic. Add to this the current COVID-19 pandemic which is more severe in uncontrolled diabetes patients and in those who are overweight or obese.

The recent IDF-2019 report shows that there were ~ 463 million adults (20-79 years) living with diabetes; by 2045 this will rise to 700 million [1]. This shows that the incidence of type 2 diabetes mellitus (T2DM) is increasing by leaps and bound across the world. In India, there were >77 million people living with diabetes in 2019, which is expected to be 101.5 million by 2030 and 134.2 million by 2045 [2]. Moreover, according to a 10-Year Follow-up of the Chennai Urban Rural Epidemiology Study (CURES), among individuals with normal glucose tolerance (NGT), the rate of conversion from prediabetes to diabetes was recorded highest at 18% [3], indicating that India may overtake China in the near future and become the diabetes capital of the world.

Since, diabetes is a metabolic disorder, food and lifestyle changes play major role in management of diabetes. Even textbooks and standard guidelines have always mentioned that lifestyle modification needs to be attempted even before metformin, and of late, medical nutrition therapy (MNT) has become a discipline by itself in the management of diabetes.

DiRECT study was the first to provide evidence from a randomised trial of a dietary and lifestyle intervention where type 2 diabetes remissions were the primary outcome [4]. The recent EASD-ADA consensus document released at the EASD meeting in Berlin in October 2018 [5] gives a lot of emphasis on MNT even before metformin.

The Ministry of Health and Family Welfare (MOHFW) has published data that Indians on an average are protein deficient (11% protein in their diet as against the requisite 15-20%, carbohydrate content in diet is >65% as against the needed 55-60%) [6].

Many studies have shown that increasing protein intake particularly by whey protein and following portion control with meal replacement plans will benefit diabetes patients by reducing postprandial blood glucose and HbA1c [4,7,8].

Whey protein has essential amino acids that improve insulin secretion as well as sensitivity and when digested, bioactive peptides are formed which have effects on the incretin axis (GLP-1, GIP), they suppress the only orexigenic hormone, Ghrelin, and increase gut anorexigenic hormones such as CCK, NPY and Peptide YY, all of which induce satiety [8-15].

The study was based on the hypothesis that when diabetic patients (uncontrolled with oral anti-diabetic drugs/insulin) were put on protein enriched, low calorie and carbohydrate counted meal replacement plan, will come towards goal HbA1c with reduction in average blood glucose, reduction in estimated A1c (glucose management indicator), and increase in time in range (TIR).

The aim of the study was to carry out a real world evaluation of Medical Nutrition Therapy (MNT) in Patients with Type 2 Diabetes (AMEND – AGP related evaluation of MEdical Nutrition therapy for Diabetes management).

The primary objective was to evaluate 24 hour glycaemic profile using AGP in patients with type 2 diabetes who are eligible for meal replacement therapy over a period of 14 days. The secondary objective was to assess whether a precise meal replacement plan as an add on to standard of care will make a difference in showing how it smoothens out post-prandial peaks and increases time spent in the desired (70 mg/dl-180 mg/dl) range compared to baseline time in range and post-prandial blood glucose level.

Subjects

The study enrolled patients with diabetes who were 18 years old male or female and preferably overweight (BMI ≥24 or metabolically obese normal weight). The newly diagnosed patients with type 2 diabetes or patients already on treatment were also eligible. Participating participants were physically and mentally able to give valid informed written consent form.

The exclusion criteria for subjects were as below. 1) HbA1c >10%, BMI >38, EGFR <45 (any one of this will not allow participants to be eligible for the study). 2) Participants suffering from any acute illness, CVD, renal complications, bowel disorders or eating disorders like anorexia or bulimia. 3) Participants who are consuming anti-psychotics, steroids or GLP-1 analogues.4) Participant whose diabetes was diagnosed > 10 years ago or who has undergone bariatric surgery. 5) Participants who are unable or unwilling to take prescribed precise meal replacement plan and/or not willing to sign the informed consent form. 6) Pregnant or lactating women, cancer patients. 7) Participants who are already on some diet plan or following fast during the study or consuming protein supplements or consuming alcohol on daily basis or are allergic to the ingredients of the Simetri meals or Prototal. 8) Participants are not allowed to make any significant change in the daily routine or physical activities.

Materials and Methods

In a real world setting, when the patient with type 2 diabetes visited the doctor, after taking the consent, they were enrolled in the routine evaluation. After completion of all screening assessments (i.e., demographic, anthropometric and clinical data) and obtaining signed informed consent forms, eligible patients were mounted with flash glucose monitoring system (Free Style Libre from Abbott  for 14 day) to check their Ambulatory Glucose Profile (AGP). Patients were given a food log sheet and asked to fill the same for the next 14 days.

The first 6 days were considered as a baseline phase where patients continued on their regular food without any major changes. The 7th day was the meal replacement phase when the patient visited the doctor and on the basis of the AGP report, investigator replaced – the most troubled meal (the one which was associated with the most post-prandial glycaemic excursions) – regular food with a customized meal replacement diet which included Simetri meals (From Eris Lifesciences – a calorie counted, protein enriched, ready to eat meal – details in supplement material) and or ProTotal (From Eris Lifesciences – a whey protein supplement – 14 gm whey protein, 6.6 gm of fibre with other macro and micronutrients). The most troubled meal was identified as the maximum post-prandial peak seen in the AGP report on day 7th. Patients were asked to consume Simetri and/or ProTotal for the next 7 days (replaced meal phase) without any change in their medications. Here, the same patient has served as the control for himself which could be more accurate than a parallel group design (inter-individual variation). Throughout the study period (14 days) the investigator did not make any change in the pharmacological treatments.

AGP device was mounted on subject by investigator on day 1 of the study. The AGP device has been carried by the subject till day 14 of the study. The data was extracted from the device by investigator in a timely manner, i.e., on day 7 and day 14.

Given the observational nature of the study, no sample size estimation was done. Statistical analysis was carried out as and when required. The level of significance was 0.05. P values of less than 0.05 were considered as a statistically significant difference.

Ethical Conduct of the Study

The clinical study protocol (Dated 01/02/2019), informed consent form, subject diary (Version No. 00,Dated 12 Apr 2019) and all other relevant study documentation were reviewed and approved by the responsible ethics committee.

The study commenced only after a written approval was obtained from the ethics committee. The study was conducted in accordance with the protocol, International Council for Harmonisation (ICH) (Step 5) ‘Guidance on Good Clinical Practice’ (E6) and ‘Declaration of Helsinki’. All associates assisting in the conduct of study were informed regarding their obligations.

Results

There were total 660 patients enrolled and out of them 566 patients were involved in the final analysis. We have divided patients in various groups for the purpose of better analysis.

Total 94 (14.24%) non-adhered patients were excluded from efficacy analysis. Non-adherent patients were defined as the one who had consumed the provided replaced meal (Simetri and Prototal) for ˂4 days. The adherence to diet was observed in 85.76% of total 660 patients.

In all patients age was found to be in a range of 20-86 years with a mean of 53.49 ± 11.80 years, mean weight was 73.77 ± 14.33 kg, and mean BMI was 27.81 ± 5.52 kg/m2. The mean HbA1c was 9.10 ± 1.66%.

a. Full cohort

The analysis of full cohort (n=566) showed reduction in average eA1c (Figure 1) from 7.84 on regular diet to 6.90 on replaced diet, indicating an eA1c (estimated A1c  – it was estimated because the total duration is only 14 days) reduction by 11.99%, p<0.001. Similarly, estimated average glucose (eAG) on regular diet was 178.41 mg/dL which reduced to an avg. of 151.47 mg/dL after following replace diet, indicating reduction by 15.10%, p<0.001. The average TIR on regular diet was 41.38 which improved to an avg. of 51.13 after following replace diet, indicating an improvement by 23.56% (Figure 2). This improvement showed statistical significant change (p ˂0.001).

fig 1

Figure 1: Full cohort analysis of eA1c.

fig 2

Figure 2: Full cohort analysis of TIR.

b. Sub-group analysis

The age group analysis (Table 1) showed that patients >60 years had better improvement in eAG and eA1c -16.73% and 13.10% respectively when compared to age group of <40 years and 40-60 years (14.35% and 11.46% vs. 14.47% and 11.54%, respectively)

The sub-group analysis for various BMI indicated that group of patients with BMI between 25 to 29.9 kg/m2 had 15.02% and 11.88% reduction in eAg and eA1c when replaced meal was consumed whereas patients with BMI ˃30 kg/m2 had comparatively less improvement in eAG (11.09%) and eA1c (8.79%) on replaced meal where p< 0.001, as shown in Table 1. However, improvement in TIR was slightly greater in patients with higher BMI (23.19% vs. 21.58%).

Analysis was also carried out based on the duration of diabetes. Patients with diabetes duration between 1 to 6 years and > 6 years showed better improvement than patients with diabetes duration <1 year. Improvement in eAG, eA1C and TIR was 15.54%, 12.33% and 24.46% respectively in patients with diabetes duration 1 to 6 years, while in patients with >6 years the improvement was by 15.46%, 12.36% and 25.82% respectively (Table 1).

When patients were divided based on the avg. baseline HbA1c < 7.5% and >7.5%, the result showed that patients whose avg. baseline HbA1c was <7.5% there was decrease in eAG from 144.25 mg/dL on regular diet to 117.27 mg/dL on replaced diet  indicating a decrease by 18.70%. In the same group, eA1c decreased by 14.14%, p<0.001. On the other hand, patients’ whose avg. baseline HbA1c was >7.5% also showed significant improvement with p<0.001 in eAG and eA1c (14.85% and 11.82% respectively).

As it was a real world study, a few of the patients were consuming either Simetri or ProTotoal and most of them were consuming both Simetri and ProTotal. There was also a small group of patients who were consuming more than two replaced diet in a day. The analysis was carried out to observe the effect of single meal replacement vs. two meal replacements in a day. As shown in the Table 1, patients consuming two replaced diets in a day showed better results in terms of all the evaluated parameters.

Table 1: eAG, e1c and TIR values of various sub-group analysis.

Subgroup

No. of subjects

eAG (mg/dL) TIR (%) eA1c (%) p value
Regular diet Replaced diet Regular diet Replaced diet Regular diet

Replaced diet

BMI<24.9 kg/m2

161

185.62 151.93 37.79 48.09 8.09 6.92

<0.001

BMI=25-29.9 kg/m2

242

173.13 147.12 43.42 52.79 7.66 6.75

<0.001

BMI > 29.9 kg/m2

151

175.46 156.01 43.25 53.28 7.74 7.06

<0.001

< 40 years

71

181.13 155.13 44.37 53.81 7.94 7.03

<0.001

40-60 years

326

181.99 155.65 39.41 48.84 7.97 7.05

<0.001

>60 years

169

170.36 141.86 43.94 54.41 7.56 6.57

<0.001

DD<1 year

28

128.99 113.63 64.43 73.39 6.12 5.59

<0.001

DD 1-6 years

179

179.19 151.34 42.32 52.67 7.87 6.9

<0.001

DD > 6 years

343

183.08 154.78 38.62 48.59 8.01 7.02

<0.001

eA1c reg diet<7.5%

295

133.97 118.46 62.06 66.27 6.3 5.75

<0.001

eA1c reg diet>7.5%

271

226.78 187.41 18.88 34.65 9.53 8.16

<0.001

One meal replacement

170

166 144.76 45.48 54.21 7.41 6.67

<0.001

Two meal replacement

392

183.82 154.28 39.74 49.96 8.03 7

<0.001

DD: Diabetes Duration.

We also evaluated patients whose one replaced meal was ProTotal to see the benefits of whey protein on eAG, eA1c and TIR. The results are presented in Table 2.

Table 2: Evaluation parameters when single replaced meal is ProTotal.

Parameters

One meal replacement with ProTotal (N=64)

eAG difference

16.68 mg/dL

% Reduction in eAG

10.23%

eA1c difference

0.17

% Reduction in eA1c

2.33%

TIR improvement

18.82%

P value

<0.001

Discussion

From the latest figures of IDF we know that India ranks second highest among people with diabetes after China [2]. The worrisome part is that as per the National Results of the SITE (Screening India’s Twin Epidemic) study, of the diabetic population already aware of their condition, almost two-of-every three (70%) had ‘uncontrolled’ diabetes (Hba1c levels >7%) [16].

This figure raises a question that in spite of availability of a vast range of pharmacological treatments, why does a patient has uncontrolled diabetes and what is the missing link? The answer can be obtained from the STARCH study [17] and PRODIGY survey [18] which showed that protein intake in India is very less and there hardly any difference exists between diets of a non-diabetic patient to that of a diabetic patient. It was observed that around 9 out of 10 consumers had a diet deficient in proteins. This was regardless of the gender and the socio-economic group [18]. Even the MoHFW (Ministry Of Health and Family Welfare) stated that Indians on an average are protein deficient (11% protein in their diet as against the requisite 15-20%) [5].

As diabetes is a metabolic and lifestyle related disease, controlling patients’ diet is one of the key success factors. In fact, lifestyle modification including MNT should be started even before metformin. Unfortunately by the time patients get diagnosed for diabetes, they have already lost 50-80% beta cell function [19]. Therefore, in this study, we asked patient to replace one or two of their meals with the specially designed, protein-enriched, carbohydrate-counted meal, without changing any pharmacological treatment.

The study enrolled a total of 660 patients. Based on the AGP report at the end of first 6 days, patients were asked to replace the most troubled meal with either Simetri or ProTotal or both for the next 7-8 days. Out of these 660 patients, 94 patients did not follow the study protocol and consumed replaced diet only for a period of <4 days. These 14.24% patients were not included in the analysis. This showed that rate of adherence to diet change was 85.76%. As diet is the hardest thing to change, the significant adherence to given product suggested that the palatability and ease of consumption for Simetri and ProTotal is very high. As it was a real world observation study, there was no control over patients’ lifestyle (food choice, exercise pattern, sleeping pattern etc.). The only change was replacing one or two meal with either ProTotal or Simetri or both and there was no strict control over what the patients consume in the entire day.

In the full cohort, eA1c was reduced by 0.94% (from 7.84% to 6.90%; % improvement 11.99%, p<0.001). The results were similar to that obtained with GLP-1 agonist in AMIGO study where exenatide 10 μg resulted in a mean HbA1c reduction of -0.8% to -0.9% [20]. As whey protein also improves GLP-1 secretion, it can mimic the action of GLP-1 agonist [8]. This indicates that, even a small change in a diet for only a short duration of 7 days has very positive impact on eA1c and if patient continues following the suggested meal replacement plan it will serve like a pharmacological therapy. Even the UKPDS study has shown that intensive glucose control can significantly reduce any diabetes related end-point [21].

As per the recommendations from the international consensus on time in range (TIR), adults with type 1 or type 2 diabetes should have >70% of TIR. In our study, when patients were on regular diet and average TIR was only 41.38% which increased to 51.13% after consuming replaced diet. This indicates that, if patients continue following the replaced diet there will be much improvement in TIR. Though in the current study, patient consumed replaced diet only for 7 days, still an increase in TIR is really significant (relative % improvement of 23.56%, p< 0.0001).

The replace diet not only improved TIR but also decreased the eAG from 178.41 mg/dL to 151.47 mg/dL, p< 0.001 in a full cohort.

The similar result were obtained when different sub-group analysis were carried out, i.e., based on the BMI, baseline HbA1c and the number of replaced meals.

There was no difference seen in male and female patients with reference to improvement. It means the replaced diet causes the similar effect on both the gender. The meal replacement period was only for short duration of days hence change in weight was not included in the evaluation parameter and measuring HbA1c was also not possible.

The results from DiRECT and DiRECT 2 studies support that total diet replacement for initial 12-20 weeks followed by gradual food reintroduction and then support for weight loss maintenance has helped type 2 diabetes patients to achieve remission and sustained it at 24 months for more than a third of people with type 2 diabetes [22].

The AMEND study results were also in line with these studies. Although the study duration was very short and hence measuring a change in body weight was not feasible, the eAG, eA1c and TIR results suggested that if the treatment was continued for longer duration, there are chances that blood glucose and HbA1c will be in the controlled range.

AMEND study results were also supported by David King (2018) study which concluded that whey protein before meals improved post-prandial glycemia, stimulated insulin release, and increased satiety in men with type 2 diabetes [23].

The protein quantity and quality of foods are contributing factors to their effects on glucose control, but foods are much more complex than a single nutrient, or even the sum of their individual nutrients. Many dietary factors, nutritive and/or bioactive, mediate the relationship between food intake and health. Lastly, in order to optimize protein intake for glucose regulation, the amount, source, and type of food product or supplement should be personalized to match to the individual’s lifestyle, medications, gluco-regulatory abilities, and disease status.

Conclusion

This AMEND study showed that the efficacy of replaced diet for calorie restriction remains a significant in humans. Although this data was only for 14 days, the study can give significant and detailed data on effect of replaced diet in patients with diabetes if therapy continues for longer period of time. Improving diet of a patient will not only help them in better management of a disease but will also be cost-effective for the country [24].

Therefore, it can be concluded from the present study that, replacing a diet with protein enriched, calorie counted meal does not only improve the blood glucose level and TIR but can also decrease eA1c significantly.

Acknowledgement

We would like to thank all physicians who have helped in the study. We would also like to extend our gratitude to CRO – Ethicare for their help in data analysis.

Declaration

Funding

Eris Lifesciences Pvt. Ltd

Conflicts of Interest/Competing Interests

Not applicable

Ethics approval

Approved. Aastha Ethics Committee has given the approval.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Each author has given their consent for publication.

Availability of data and material

Not applicable.

Code availability

Not applicable.

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  23. David K, Mark W, Matthew C, Leigh B, Emma S, Daniel W (2018) A small dose of whey protein co-ingested with mixed-macronutrient breakfast and lunch meals improves postprandial glycemia and suppresses appetite in men with type 2 diabetes: a randomized controlled trial. Am J Clin Nutr 107(4): 550-7. [crossref]
  24. Lee Y, Mozaffarian D, Sy S, Huang Y, Liu J, Wilde PE, et al. (2019) Cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid: A microsimulation study. PLoS Med 16(3): e1002761. [crossref]

About Climate, Flooding and Underwater Technologies

DOI: 10.31038/GEMS.2021335

 

Waters enclosed in reservoirs in front of hydroelectric power plants are also devoid of natural functions – they evaporate from the surface, bloom with algae, but most of it breaks on turbine blades. The destroyed and unused structure of water evaporates into the atmosphere without fulfilling its mission. These vapors are supplemented by all waters taken from nature for irrigation, technological and communal processes. There is more evaporation of such waters than evaporation from biota. The fumes emanating from other than biota can be called artificial. Their volumes, evaporation rate and quality become commensurate with natural fumes or fumes from plants and living organisms. Therefore, the climate is changing and natural disasters occur. Flood spills are a major source of artificial evaporation. How do we feel about rivers? Within the boundaries of cities and towns, we straighten the banks, cover the river beds with concrete and stones. We dump garbage and waste into the water. By their nature, rivers must regularly affect the banks – meandering or interacting with the soil. This is necessary in order to dissolve minerals, organics in water and supply them to animals and plants. Everything dissolved in water is a building material for biota. Water trapped in concrete banks loses its function. It cannot dissolve minerals from the soil in itself and convey it to the consumer. We do the greatest harm to the river by dumping waste and garbage into it. The volumes of discharges raise the river bottom quite strongly. Especially downstream of settlements. It is this circumstance that leads to the overflow of water from the coast during abnormal precipitation, devastating floods and extensive spills. To maintain the carrying capacity of the river bed, it is necessary to periodically clean the bottom of sediments or maintain the historical depth.

The existing technology of deepening the river bottom with dredges and various dredgers is quite metal-consuming, requires significant expenditures of energy, funds and pollution of coastal areas. The main energy required with these methods is spent on holding the agent itself against the current. Considering the possibility of impact on the bottom of the rivers, it is possible to find the moments when gullies and depressions are formed around the sunken ship. Is it possible to use the forces of the movement of the water itself. If we take this principle as a basis, then the simplest special device arises that will clean and deepen the bottom of the river. An ordinary parallelepiped without a bottom and ends, installed at the bottom of the river, will have almost no effect on the flow. Water freely enters one end and exits through the other. But, if a damper is installed inside it to turn the water flow to the bottom, then it becomes possible to displace the bottom particles along the flow. Moving the device downstream, these particles move further. If the device is moved forward and backward by means of a cable, an underwater longitudinal channel can be obtained. By moving it from coast to other coast, it is possible to move bottom sediments into the transverse shaft. If necessary, the shaft can be lifted to the surface. By reducing the movement of water across the entire width of the river, and by increasing the underwater channel, it is possible to increase the carrying capacity of the entire river. By diverting the main stream away from the collapsing coast, this collapse can be excluded. Thus, influencing the water flows, it becomes possible to change the river bed according to the given parameters. To preserve water for the summer, it is enough to keep the existing ratios of rifts – rapids and reaches – depressions. An increase in these volumes is achieved by a corresponding deepening of the bottom in these places. To increase the speed of the recess, a lead screw can be added to increase the flow of the impact to the bottom. Deepening to the design depth will not allow water to overflow the banks with maximum precipitation. The simplest device can prevent floods. The shown device is primitive in execution, does not require a lot of metal and is not energy intensive. The power to drive the lead screw is hundreds of times less than on dredges. Thus, the manufacture of the device is available to any coastal economy. The idea of ​​impacting the bottom by the current itself goes far beyond a simple deepening. For large river depths, it is possible to manufacture a device with a small power plant, a lead screw, autonomous control, and an underwater life support cabin. A device or Underwater Universal Machine (PUM) has been developed. The uplift and transfer of bottom sediments makes it possible to create new technologies for underwater operations. For example, gold mining. Sorting and disintegration can be carried out directly in the shown closed cavity without bringing the materials to the air. Of course, designers will have to work hard to develop new devices for such work. It becomes possible to search for and recover sunken objects goods without destroying the bottom surface. Conversely, it is possible to remove the bottom layer and transport it to the surface, for example, to obtain sapropel. Repair of underwater structures, such as pipelines, is possible. With completely closed dampers at the ends, it becomes possible to completely stop the movement of water and create an air bell. The version with a lead screw can be used for reservoirs with stagnant or sedentary water – lakes, swamps, seas.

Keywords

Artificial evaporation, Water functions, Deepening of the bottom, New technology, Underwater work.

Earth Science Needs Thorough Introspective Analysis and Renovation

DOI: 10.31038/GEMS.2021334

Abstract

Despite several breakthrough discoveries, earth science needs modification especially related to its deeper parts of the planet where temperature and pressure have been presumed to be high. Based on the concept of earth’s expansion, the author considers that the mantle of the unexpanded ocean-less earth was considerably fluid owing to incorporation of ocean-forming water. In such a globe gravitational pull from an extraterrestrial planetary body would cause expansion triggered by swelling up of the semi-fluid mantle and consequent formation of a number of expansion cracks on the crust. Through these cracks or mid-oceanic ridges extensive molten magma would expel out and deposit on both sides of the crack to form ocean basins. Matching thickness of the earth’s fluid outer core with the extent of expansion points out that owing to massive expansion original core-mantle conjunction of the planet was ruptured along which a void zone, identified as outer core of the prevalent concept, was gradually opened up. Such disposition of occurrence of two discrete geospheres separated by a virtually void zone would give rise to the phenomenon of reverse gravity in the deep interior of the planet thereby sustaining a low pressure and low temperature zone at depth.

Introduction

The author of this article, who is a geologist by love, education and commitment, while studying various features of earth science noticed that certain aspects of the studies call for introspective analysis and revamping and in a few cases rejection. Authur’s study was conducted covering right from the crustal layer of the planet to its deepest part, including the enigmatic outer core. When the first authentic map of the globe was prepared in 1570 by Abraham Ortilius [1], which conspicuously exhibited parallel shore lines between Africa and South America. The pioneer cartographer not only noted this remarkable feature, but also for the first-time proposed occurrence of continents in the past in a conjoined manner. After that several observers, such as Antonio Snider-Pellegrini [2] of France as well as Alfred Wegener [3] of Germany and several other geologists attempted for continental adjustment. However, all such models were found to be untenable from the point of strict scientific study as they had liberally distorted the boundary of the relevant continents. I. O. Yarkovskii [4] of Russia for the first-time suggested Earth’s expansion in 1888 while after that many scientists, some of them independently, conceived the idea of expansion of the Earth. In contrast to the adjustment done in an unaltered dimension of the earth, Hilgenberg [5] of Germany in 1933 showed that in a model of earth reduced to two/third of its original dimension perfect adjustment of continents could be achieved (Figure 1). This information evidently supports earth expansion theory to be a genuine concept suitable for explaining major global phenomena, while, for explaining such phenomena in a globe of unchanged dimension throughout the past geological ages requires several fabricated assumptions.

fig 1

Figure 1: O. C. Hilgenberg of Germany in 1933 showed that if the radius in a model of Earth could be reduced to two-third of its radial thickness, all the continental blocks could be adjusted in a perfect manner. It can be noted that in the primordial small Earth, there were no oceans although lakes were present. Hence, it can be conceived that at that time the ocean-forming water was associated with the Mantle turning it considerably fluid and predominantly suitable for expansion (Sen, 1984-2007).

All the World Loves a Fairytale

In “The Problems of Philosophy” Bertrand Russell [6] expressed:

“Is there any knowledge in the world which is so certain that no reasonable man could doubt it? When we have realized the obstacles in the way for a straightforward and confident answer, we shall be well launched on the study of philosophy – for philosophy is merely the attempt to answer such ultimate questions, not carelessly and dogmatically as we do in ordinary life and even in the sciences, but critically after exploring all that makes such questions puzzling, and after realizing all the vagueness and confusion that underlies our ordinary ideas”. Regarding apparently unquestionable notions, Sir Bertrand further pointed out that “Yet, all these may be reasonably doubted and all of it requires much careful discussions before we can be sure that we have stated it in a form that is wholly true.” The present author considers that many of our concepts and axioms which are extensively been applied in earth sciences for a long time as authentic and of paramount importance, require sensible evaluation, and, if necessary, modification. The author would be satisfied if he can utilize the rich scientific heritage developed through protracted studies by the scientists from all over the globe in an honest and meaningful manner avoiding fairy tale-like imagination and dogma. Since the view of constant dimension earth throughout the past geological time has been rejected as per the reasoning earlier mentioned, the concept of plate tectonics would also be automatically discarded. However, plate tectonics [7] happen to be one of the most popular views – or, perhaps the most remarkable concept ever developed in earth science that enjoys support from a large section of geo-scientists. Hence, for rejecting such a popular view it is necessary to discuss the drawbacks of the concept. Essentially plate tectonics is based on the concept of uniform earth dimension or unchanged dimension of the globe throughout the past geological ages and requires several fabricated assumptions for explaining only a few features of the earth system, restricted mainly to the crust of the planet. The concept does not convey any idea regarding the origin of continents or oceans, neither it gives information on interior of the planet. To keep the dimension of the planet constant it views that while a plate or solid continental fragment plunges into another solid part of the earth in a smooth conveyer belt like manner, in another part of the planet new plates are emerged, defying basic principles of physics. The process is operated owing to a convection current that occurs in the mantle which is solid and rigid as confirmed by propagation of seismic waves. The movement, though occurs in extremely slow manner, is capable of drifting the continents to great distances, concurrently driving a geo-dynamo, responsible for magnetic features of the planet.

Unified Global Tectonics

The concept of unified global tectonics (Sen, 1984, 1986, 2003, 2007) [8-11] has been developed based on the earth expansion theory of Hilgenberg (1933) [5] which envisages that if we could reduce the radius of the earth to two-third of its present thickness, all the continental blocks would be perfectly adjusted in the resultant small globe. Such small globe would be devoid of ocean basins although a few epicotinental seas or lakes were present. Therefore, it can be deduced that the ocean-forming water at that stage must have been associated with the mantle. Under such a set up, the original mantle material would be considerably fluid and consequently highly suitable for the manifestation of expansion, leading to continental fragmentation and various related features. The view is based on the results of experimental studies conducted by Roy and Tuttle (1961) [12] confirming depression of melting point of silicate rocks under hydrothermal and high pressure condition. As evidenced by the tidal pull of Moon, it is rational to conclude that the reason of the earth’s expansion is the gravitational pull exerted by the Moon causing periodical bulging of the semi-fluid mantle. However, with progress of the process due to escape of volatiles from the mantle consisting chiefly of water, the ocean basins would be filled up with water simultaneously reducing the fluidity of the mantle which would eventually turn into a rigid geosphere. As explained above, the Moon – responsible for causing earth’s expansion by exerting tidal pull – was originally an independent small planet which was captured by the earth when it was approaching the latter. Initially due to the Moon’s magnetic influence exerted over the magnetic core of the earth, the latter’s spatial orientation was drastically changed, causing major alteration in earth’s climatic features. It has been conceived that originally in the small earth the solid iron core and mantle – initially which was adequately fluid – were juxtaposed to each other. As has been discussed, an appropriate gravitational force from an extra-terrestrial planetary body – the Moon – was responsible for the earth’s expansion by bulging up of the semi-fluid mantle causing rupture of the original core-mantle conjunction. Also, due to such bulging of the semi-fluid mantle a number of expansion cracks – that eventually turned into mid-oceanic ridges – were produced over the solid sialic crust through which large quantum of basic magma disgorged and spread on both sides of the cracks to form ocean basins. Matching thickness of the fluid outer core with that of the extent of expansion, strongly supports the view that in consequence of prolonged expansion, along the ruptured core-mantle conjunction a void zone, identified as outer core in the prevalent concept, was gradually opened up. In due course the void zone would turn into a pseudo-fluid or virtually void geosphere owing to influx of fine particles from the adjoining mantle. The above mentioned arguments lead us to envision that two rocky and metallic geospheres separated by a non-solid and virtually void zone occur in the deep interior of the planet (Figure 2). This sort of internal setup would give rise to the phenomenon of reverse gravity generating low temperature and low pressure zones in the earth’s deep interior. This simple and down to earth concept explained here is in complete agreement with all the major fundamental features, including several hitherto unexplained ones encountered in the planetary interior. Evidences of low temperature and low pressure zones in the planet’s deep interior are exhibited in meteorites which are considered to be broken fragments of a pre-existing planet. These evidences include strong magnetic nature of some meteorites, texture of iron meteorites, presence of minerals with hydrocarbons, amino acid and water in some rocky meteorites, as well as, globular shape of chondrules – all of which unmistakably confirm low temperature and low pressure condition in the deep interior of the planet. With the new concept the picture that emerges on the interior of the earth is this that during the Precambrian era, when the planet’s core and mantle were juxtaposed to each other, extra-terrestrial magnetic influence caused movement of the iron-core, as a result of which the planet as a whole was tilted or deflected in space. Because of such alteration in spatial orientation of the planet, remarkable changes in the geographical features in various parts of the globe occurred, signatures of which, like the polar region revamping in to a hot zone and vice-versa, are documented over the global surface (Figure 3b). In contrast, when the pseudo-fluid or void geosphere attained adequate thickness due to prolonged expansion, (Figure 3d), instead of deflection of the entire earth, only its magnetic iron core started to execute smooth and secular movements, including reversal of the poles, which are precisely documented over the surface rocks (Figure 3). It is understandable that in case of expansion, the sialic super-continent would be fragmented because of development of a number of expansion cracks, followed by widespread expulsion of basaltic magma through the cracks that would occupy the new space generated along the cracks forming rudimentary ocean basins. Under such circumstances instead of collision, the fragmented parts would tend to move away from one another causing enhancement of the ocean basins. Geological records, on the other hand, confirm collisions of continental plates have actually occurred at certain places during the past geological periods. In unified global tectonics this has been attributed due to the force generated by rotation of the planet along its axis of rotation which would be maximum around the equator and minimum near the poles. This sort of force generated due to rotation or spin of the planet was not only responsible for continental collision forming colossus structures like the Himalayas but also caused major revamping of the continental fragments and ocean basins.

fig 2

Figure 2: Overall structure of the earth (not to scale) showing trend of gravitational attraction on surface and interior of the planet. At the centre of the planet the trend of gravitational attraction would be oppositely directed. With separation of original semi-fluid mantle from the iron core due to planetary expansion and formation of a virtually void zone in between – the so called outer core of the prevalent view -, it is reasonable to conceive that around the inner core oppositely or reversely directed force of gravitational attraction would prevail forming a low pressure low temperature zone at depth.

fig 3

Figure 3: Before expansion of the planet, the solid iron core and semi-fluid mantle were juxtaposed to each other (Figure 3a). Due to expansion the original core-mantle conjunction was ruptured (Figure 3b) and along the ruptured surface a void zone was developed which gradually grew into a pseudo-fluid geosphere, i.e., the earth’s fluid outer core (Figure 3c). This view supports that two geospheres of rocky and metallic composition, separated by a non-solid and virtually void zone, occur in the deep interior of the planet. Such disposition of the planet would give rise the phenomenon of reverse gravity in the planet’s deep interior and core generating low temperature and low pressure zones in the earth’s core and deeper parts. After development of the broad pseudo-fluid or virtually void geosphere (Figure 3d), the iron-core would remain within it in a suspended condition. Hence at this stage, pertaining to younger geological periods, in response to extra-terrestrial magnetic influences, new geomagnetic phenomena, like, polar wandering, pole reversal and west-ward drift could take place.

Remarks and Conclusions

The author in the book “Earth – Planet Extraordinary” has advanced the following new concepts:

  1. The globe in its present outward appearance shows occurrence of continents in disjointed form which cannot be adjusted in appropriate manner whereas in a smaller globe, reduced to two-third of its present radial dimension (Hilgenberg, 1933), proper fitting of the continents can be achieved. This unmistakably demonstrates that the earth is an expanded planet, though in case of solid and rigid condition of the mantle planetary expansion and continental drift would not be possible.
  2. The author has pointed out that since the small earth of unexpanded stage was devoid of oceans, the mantle at that stage must have been sufficiently fluid or semi-fluid owing to incorporation of ocean-forming water – an essential requirement for earth’s expansion or continental drift. The view has been developed based on the work of Roy and Tuttle (1961) [12] who showed that melting point of a silicate rock under hydrothermal and high pressure condition would be depressed or, in other words, it would develop considerable fluid characteristic.
  3. It has been postulated that a planetary body came near the earth and was eventually captured by the latter, thereby turning the former a solitary satellite of the earth, the Moon. Since then the Moon started to rotate around the earth and due to its gravitational attraction on the earth, chiefly affecting the semi-fluid mantle, caused its expansion. As the Moon was revolving around the earth and the Moon too was rotating around its own axis of rotation, the earth’s expansion was manifested in a uniform manner.
  4. It was owing to expansion earth’s solid sialic crustal cover developed a number of long sinuous cracks along which the planet’s super-continent was fragmented forming several units of continents.

References

  1. Ortelius Abraham (1570) Thesaurus Geographicus (in Latin) 3rd Edition, Antwerp Plantin. OCLC 214324616.
  2. Snider-Pellegrini Antonio (1858) La Creation et ses Mysters Devoiles, Librarie A. Franck & Dentu, Paris.
  3. Wegener Alfred (1912) Die Entstehung der kontinente, Petermann Mitteilungn, 185-195,253-256,305-309.
  4. Yarkovsky, Ivan Osipovich (1888) Hypothese cinetique de la Gravitation universelle et connexion avec la formation des elements chimiques, 134p, Moskau.
  5. Hilgenberg OC (1933) Vom Wachsenden Erdball, Berlin: Giessmann & Bartsch.
  6. Russell, Bertrand (1912) The Problems of Philosophy, Home University Library, Oxford University Press paperback, 1959 Reprinted, 1971-1972.
  7. Dietz Robert S (1977) Plate tectonics: A revolution in geology and geophysics. Tectonophysics. 38: 1-6.
  8. Sen Subhasis (1984) Unified global tectonics – a new qualitative approach in Earth sciences, Indian Science Congress, Geology and Geography Section, Ranchi, January 3-8, 71st Session, Abstract, p.23-24,.Also in Jour. Met. & Fuels 32: 20-22.
  9. Sen Subhasis (1986) A new concept on the Earth’s interior, geomagnetism and crustal fragmentation, International Symp. on Neotectonics in South Asia, Survey of India, Dehra Dun, Feb.18-21, Proceedings, p.83-94.
  10. Sen Subhasis (2003) Unified global tectonics: structure and dynamics of the total Earth system, Indian Science Congress, Earth System Sciences, Bangalore, January 3-8, 2003, 90th Session, Abstract, p.57-58,. Also in Jour. Met. & Fuels 51: 351-355.
  11. Sen Subhasis (2007) Earth – The Planet Extraordinary, Allied Publishers Ltd., New Delhi, 232.
  12. Roy R, Tuttle OF (1961) Investigation under hydrothermal conditions, In Ahrens, I.H., Rankama, A.K. and Runcorn, SK (eds.) Physics and Chemistry of the Earth 1: 138-180 Pergamon Press, New York.

A Current Practice in Nursing Care: Virtual Reality Glasses

DOI: 10.31038/AWHC.2021443

Abstract

Aim: Some nursing approaches are required to combat the problems that occur in patients due to the physical and psychosocial effects of diseases. It is aimed to address the areas where virtual reality glasses, which are frequently used as a distraction, are used as a current approach in nursing care.

Methods: The studies about virtual reality glasses in nursing care between 2008-2019 were scanned and the definition, purpose of use and the areas of use of virtual reality glasses were evaluated in the context of the role / responsibilities of the nurse and presented in the article.

Results: Diseases cause physical, social and psychological problems by affecting the daily life activities of individuals and decrease the quality of life. Current nursing care applied to control the negative effects of diseases; it increases the quality of life of individuals, their compliance with treatment, their ability to cope with the disease, and reduces the negative effects of treatment. Since the negative effects experienced by individuals during the disease cause changes in life, effective coping methods are required. As a coping method; With the use of virtual reality glasses, it is possible for the individual to move away from the situation, not to think about the disease and to feel in a different place. Virtual reality goggles can enable individuals to cope with symptoms associated with illnesses, as they are an effective tool in addressing more than one sensation at the same time and reducing sensations from around.

Conclusion: Nurses should guide the determination of the symptoms affecting patients and patients in care, and the determination of current methods to reduce these symptoms.

Keywords

Virtual reality glasses, Maintenance, Nursing

Introduction

Technological developments in health in recent years have necessitated new practices in nursing care. In care practices, nurses primarily tend to practices that will increase the quality of care and create the continuity of care. In our age, with the increase in the use of technology in the health system, different service areas have emerged and it has made it compulsory for nurses to innovate in the care they apply in order to be effective in solving health-related problems. Similar to the world, nursing practices in our country; Factors such as the increasing use of technology in the health system, innovations in information, the increase in the number of chronic patients, the symptoms caused by diseases and the elderly population [1,2]. Nurses have to follow current approaches in care and use them in practice in order to improve the quality of care they apply. For this purpose, it will contribute to the planning of nursing interventions aimed at increasing the time allocated to care, providing individualized care, ensuring the adaptation process to the disease, reducing the symptoms caused by the treatments and increasing the quality of life in health services provided by using virtual reality glasses in nursing practices [3-5].

Method of Research

Inclusion Criteria

  • The results are research on the use of virtual reality glasses in nursing care,
  • The publication language is Turkish or English,
  • Published in the last ten years (2008-2018),
  • Access to the full text. Randomized Controlled studies (RCTs) and quasi-experimental studies (YÇ) were included in the study.

Reasons for not Including in the Study

Studies examining virtual reality applications outside of nursing, observation studies and reviews were not included in the study. Due to the determination of up-to-date information, the studies carried out in the last eleven years were included in the research, and the studies conducted before 2008 were not included. Studies whose titles or abstracts are not clear, whose full texts cannot be accessed and whose publication language is not Turkish/English are not included.

Researching and Selecting Studies

Sample Definition

The studies were selected by scanning the databases of May 2019- June 2020 “Cochrane”, “OVID”, “Pubmed”, “Medline”, “Wiley Online Library”, “Google Scholar” and “YÖKSİS Theses”. Virtual reality glasses (VR), virtual reality glasses, nursing keywords were used. Master’s and doctoral theses, studies in nursing journals were also included in the research. The titles and abstracts of all studies found by electronic scanning were impartially examined by the researchers. Each of the selected articles covers research on the evaluation of methods in different areas of nursing care related to virtual reality glasses.

Discussion

The disease, which forces all the balances and harmony of individuals, appears both acutely and chronically. Both the disease and its side effects adversely affect the daily life activities of individuals and cause many problems. Especially psychosocial problems are among the problems that have the most negative impact on the individual.

Psychosocial problems that cannot be noticed in the early stages of the disease; It can negatively affect the individual’s satisfaction, quality of life, adherence to treatment, and coping with the disease and its symptoms. In addition, because of the psychosocial problems experienced by the individual, the meaning of his life, can affect their functionality and satisfaction with the place where they live [6,7].

Psychosocial problems experienced by individuals during the illness require effective coping methods because they create life changes. Current nursing interventions should be applied as a coping method in order to control and reduce the problems experienced by the individual [8]. Virtual reality glasses, one of the current nursing initiatives; It is widely used in nursing care to reduce the side effects of diseases by providing the opportunity to control health/disease conditions and to create therapeutic environments [3,9,10].

Virtual reality glasses is a computer simulation technique that allows individuals to hear and feel the sounds and stimuli with the headset they watch [9-11].

With virtual reality glasses, consisting of a pair of glasses connected to a mobile phone from a head-mounted screen, the individual gets away from the environment and concentrates his attention on the image and perceives himself as if he is in another place with this five-dimensional glasses [9,12]. The most basic feature that distinguishes virtual reality glasses from similar applications is that they make individuals feel real. Virtual reality glasses are a method of watching images taken from the computer in order to isolate the individual from real life for a while [12,13].

With the virtual reality glasses, different types of content such as 360-degree videos, games, movies and animation can be watched. Since these videos are created in 360 degrees, no matter which direction a glasses wearer looks, the feeling of being in the virtual world and being there lives. Thus, by concentrating his attention in a different place, the individual moves away from the visual, tactile and sensory stimuli around him.

It is thought that virtual reality applications reduce the physical and psychosocial effects of diseases [10]. Changing the user’s attention away from the symptoms of the disease interprets an incoming signal as well as changing the pathway, reducing symptom-related brain activity (Sil et al., 2014) [14]. In addition, using virtual reality can target cognitive and emotional pain pathways, thereby reducing pain intensity, distress, and anxiety by changing how pain signals are processed in the central nervous system. This distraction is achieved by a number of mechanisms such as editing the virtual reality image and reduced pain [15,16].

The use of virtual reality glasses in the field of health, which was originally designed for entertainment purposes, has recently increased [17,18]. With the developments in computer technologies, virtual reality is a new technique of focusing attention in another direction, which is frequently used to reduce physical and psychosocial symptoms during some applications (_nal and Canbulat, 2015; Sil et al., 2014; Guo et al.)

In the studies examined in the literature, virtual reality glasses; It is used as a current care approach in orthopedic surgery, dressing changes in patients with burns, invasive procedures, perioperative period, pain-inducing interventions, interventions such as lumbar puncture, endoscopy, labor pain, breast biopsy, arteriovenous fistula, cystoscopy and chemotherapy [3,19-24]. Virtual reality glasses, which are cheap to apply and use, have no side effects, and are effective in physical, psychological, social, emotional and spiritual healing, are a current application that can be preferred in nursing care with these features.

Sander et al (2002), in their study to determine the effect of virtual reality glasses applied during lumbar puncture in adolescents on the level of pain; virtual reality glasses during lumbar puncture for 17 patients in the study group; Only lumbar puncture was performed in 13 patients in the control group. As a result of the study, the level of pain was found to be significantly lower in the adolescents who were applied virtual reality glasses compared to the adolescents in the control group [25].

Wolitsky et al. (2005) in their study to determine the effect of virtual reality glasses on pain and anxiety levels during painful interventions in children; 10 children in the study group watched videos with virtual reality glasses for less than 5 minutes; Only the procedure was applied to 10 children in the control group. As a result of the study, it was determined that the pain and anxiety levels of the patients who were applied virtual reality glasses were significantly reduced [19].

In the study of Schneider and Hood (2007), they examined the effect of virtual reality glasses applied to patients with breast, colon and lung cancer who received first-cycle chemotherapy treatment on symptom distress, fatigue and anxiety levels; Videos were watched with virtual reality glasses during chemotherapy treatment (45-90 minutes) to 123 patients. It was observed that the application of virtual reality glasses in patients was effective in changing the perception of time and reducing the level of anxiety and fatigue, but it was not effective in relieving symptom distress [20].

Sharar et al. (2007) found that there was a significant amount of relief in their research in which they looked at the effect of virtual reality glasses on pain during physical therapy after burns [26].

Morris et al (2010) examined the effect of virtual reality glasses on pain and anxiety levels in adult burn patients receiving physiotherapy treatment; Two sessions, one in which virtual reality glasses were applied and one that was not applied, were given to 11 patients. As a result of the study, it was determined that the application of virtual reality glasses significantly reduced the level of pain and anxiety [27].

In the study of Schmitt et al. (2011) in which they examined the effect of virtual reality glasses on pain level in pediatric burn treatment,.  patients were treated with virtual reality glasses for 5 sessions. As a result of the study, it was determined that the application of virtual reality glasses significantly reduced the level of pain [28].

Schneider et al. (2011) determined that the virtual reality glasses applied to 137 breast, lung and colon cancer patients who received chemotherapy treatment is an application that attracts attention, as well as a tool that reduces the anxiety and fatigue level of the patients who are applied virtual reality glasses and makes the time pass faster in the treatment process [29].

Espinoza et al. (2012) 41-85 It was determined that virtual reality glasses applied to 33 cancer patients receiving ambulatory chemotherapy were effective in reducing depression and anxiety levels and increasing the level of happiness [30].

Banos et al. (2013) It was determined that virtual reality glasses applied to 33 cancer patients hospitalized in the oncology service increased positive emotions and decreased negative emotions [13].

JahaniShoorab et al (2015) in their study to examine the effect of virtual reality glasses on pain level during episiotomy repair in women who gave birth for the first time; Videos were watched with virtual reality glasses during episiotomy to 15 women in the study group, and only episiotomy was applied to 15 women in the control group. As a result of the study, it was determined that the level of pain in women who applied virtual reality glasses was statistically significantly reduced [31].

Guo et al (2015) in their study to examine the effect of virtual reality glasses on pain level during dressing change in patients with hand injuries; Videos were watched with virtual reality glasses during dressing change to 49 patients in the study group, and only dressings were changed to 49 patients in the control group. As a result of the study, it was determined that the pain level of patients who were applied virtual reality glasses was statistically significantly reduced [14].

In the study conducted by Karaman (2016) to examine the effect of virtual reality glasses applied during breast biopsy in women on pain and anxiety levels; During the breast biopsy procedure, 30 women in the study group watched videos with virtual reality glasses, and 30 women in the control group underwent routine breast biopsy. As a result of the study, pain and anxiety levels of women who were applied virtual reality glasses were found to be significantly lower than women in the control group [23].

Ryu et al (2018) in their study to examine the effect of virtual reality glasses applied in the preoperative period on the level of anxiety in children; A 4-minute virtual reality video showing the operating room and describing the perioperative process was watched by 43 patients in the study group, and a routine explanation was given to 43 patients in the control group about the perioperative period. As a result of the study, the anxiety level of children who were applied virtual reality glasses was found to be significantly lower than the children in the control group [32].

In the study conducted by Chen et al. (2019) to examine the effect of virtual reality glasses applied during intravenous injection in the emergency room on the level of fear and pain in school-age (7-12 years old) children; In the study group, 18 children were watched by virtual reality glasses during the intravenous injection procedure, and only intravenous injection was applied to 18 children in the control group. As a result of the study, the fear and pain scores of the children who were applied virtual reality glasses were found to be significantly lower than the children in the control group [33-37].

Conclusion

Nursing; While it used to be a profession only for providing care and comfort, the changes in nursing have focused on preventing diseases and promoting health, and it has increasingly expanded roles. In parallel with the changing innovations and the system, it has become necessary to apply current approaches in nursing care in order to fulfill the expectations of the world. Since virtual reality glasses, which is one of the current approaches, is a tool that provides the ability to stimulate more than one sense at the same time and reduce the senses coming from the environment, it can help individuals to cope with the symptoms of the disease by diverting their attention.

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Estimation of CYP3A4*1B Single Nucleotide Polymorphism Using Target-Assembled In-Situ Detection by Synthetic DNA-Mounted Excimers

DOI: 10.31038/MIP.2021212

Abstract

CYP3A4*1B is a single nucleotide polymorphism of CYP3A4 and is associated with prostate cancer which exhibits higher nifedipine oxidase activity in liver. This research provides details of the effects of structural variation and medium effects for the recently reported split-oligonucleotide (tandem) probe system for excimers-based fluorescence detection of DNA. In this approach the detection system is split at a molecular level into signal-silent components, which must be assembled correctly into a specific 3-dimensional structure to ensure close proximity of the excimer partners and the consequent excimer fluorescence emission on excitation. The model system consists of two 11-mer oligonucleotides, complementary to adjacent sites of a 22-mer DNA target. Each oligonucleotide probe is equipped with functions able to form an excimer on correct, contiguous hybridization. The extremely rigorous structural demands for excimer formation and emission required careful structural design of partners for excimer formation, which are here described. This study demonstrates that the excimer formed emitted at ~480 nm with a large Stokes shift (~130-140 nm).

Keywords

DNA probe systems, Excimers, DNA detection, Fluorescence, CYP3A4*1B, Stokes shift

Introduction

Reversible hybridisation of complementary polynucleotides is essential to the biological processes of replication, transcription, and translation. Physical studies of nucleic acid hybridisation are required for understanding these biological processes on a molecular level. The physical characterisation of nucleic acid hybridisation is essential for predicting the performance of nucleic acids in vitro, for instance, in hybridisation assays used to detect specific polynucleotide sequences.

Fluorescence measurements present an improved sensitive measure of nucleic acid concentration compared to conventional solution-phase detection techniques. Additionally, the sensitivity of fluorophores to their environments offers a means by which to differentiate hybridised from unhybridised nucleic acids without resorting to separation techniques. This was first demonstrated by attaching different fluorescent labels to the termini of oligonucleotides, which hybridise to adjacent regions on a complementary strand of DNA. Appropriate selection of fluorophores led to a detectable signal between the labels on hybridisation of the two-labeled strands to their complementary strand. For example, split-probe systems based on excimer fluorescence were first described by Ebata [1-3], who attached pyrene to the 5′-terminus of one oligonucleotide probe and to the 3′-terminus of the other oligonucleotide probe. The probes bound to adjacent regions of the target, bringing the pyrene molecules into close proximity, forming an excimer [4,5]. Excimer emission from oligonucleotides containing 5-(1-pyrenylethynyl)uracil [6], trans-stilbene [7], and perylene [8] have also been reported.

Numerous genetic diseases have been found to result from a change of a single DNA base pair. These single nucleotide polymorphisms (SNP) may cause changes in the amino acid sequence of important proteins [9,10]. Methods sensitive to single base-pair mutations for the fast screening of patient samples to identify disease-causing mutations will be essential for diagnosis, prevention and treatment. Usually hybridisation analysis is used, where a short, probe oligonucleotide (15-20 base pairs) bearing some kind of label (e.g. fluorophore) hybridises to complementary base pairs in DNA or RNA. The nucleic acids required for analysis can be recovered from a variety of biological samples including blood, saliva, urine, stool, nasopharyngeal secretions or tissues [11-13]. Highly specific, simple, and accessible methods are needed to meet the accurate requirements of single nucleotide detection in pharmacogenomic studies, linkage analysis, and the detection of pathogens. Recently there has been a move away from radioactive labels to fluorescence.

It has been reported [14] that an emissive exciplex can be formed by juxtaposition of two different externally oriented exciplex-forming partners (pyrene and naphthalene) at the interface (nick region) of tandem oligonucleotides forming a duplex of some kind on hybridization with their complementary target strand. We have been mainly interested in using excimer fluorescence signals to study the hybridisation between two fluorophore-labeled complementary DNA strands, as shown in Figure 1. Attaching fluorescent labels (pyrene and pyrene in Figure 1) to the probe of complementary DNA strands showed strong interactions between particular fluorophore pairs on hybridisation. Split-probe systems based on two 11 mer probe strands were investigated in this paper using the base sequences shown in Figure 1.

In the split-probe model system (Figure 1) two 11-mer probe oligonucleotides labelled with 1-pyrenylmethylamine (Pyrene) attached to 3′ and 5′ terminal phosphate groups. Hybridization of these probes to a complementary 22-mer oligonucleotide target resulted in correct orientation of the two pyrenes excimer-partners. Excitation of the pyrenylmethylamino partner at 350 nm led to the structure of an excited-state complex (excimer) with the pyrene partner. This excimer emitted at a longer wavelength of 480 nm (Stokes shift 130 nm) as compared with a mixture of unhybridisedsplit-probes. The excimer emission was particularly preferred by the use of trifluoroethanol as co-solvent (80 % v/v) [14].

fig 1

Figure 1: Base sequences of the split-probe systems.

The split-probe model system used in this study containing 22-mer target sequence which corresponds to a region of the CYP3A4 major genome (3′-AGCGGAGAGAGGACGGGAACAG-5′) and complementary 11 mer probes(5′-TCGCCTCTCTC-pyrene and pyrene-CTGCCCTTGTC-3′). CYP3A4*1B (-392A>G, rs2740574) is a CYP3A4 polymorphism and it is the frequently studied proximal promoter variant which occurs in White human populations at around 2-9% but at elevated frequencies in Africans including Libyans [15-17]. We now report how this excimer strategy can permit detection of an allelic variant of the human CYP3A4*1B gene sequence.

Single-nucleotide polymorphisms (SNPs) in genes coding for cytochrome P450 (CYP) enzymes have been linked to many diseases and to inter-individual differences in the efficiency and toxicity of many drugs. Thirty seven CYP3A4 variants, with amino-acid changes located in coding regions, have been identified among the different ethnic populations (www.pharmvar.org/gene/CYP3A4). For example, CYP3A4*1B allele (CYP3A4-V, rs2740574), a −392A>G transition in the promoter region, has been reported to be considerably connected with HIV infection [18], increased threat of hormone negative breast cancer(missing estrogen, progesterone receptors) [19], prostate cancer [20] and increased risk for developing leukemia after epipodophyllotoxin therapy [21]. Also, theCYP3A4*1B allele causes amino acid substitution affecting the metabolism of a range of drugs such as Nifidipine and Carbamazepine which leads to altered enzyme activity and drug sensitivity, e.g. the mutant enzyme results in impaired metabolism [22,23].

Materials and Methods

The excimer constructs used standard DNA base/sugar structures in both complementary probes. The targets were a part of the CYP3A4 chromosome 7 sequence band q22.1 (Genbankcode[ENSG00000160868 nucleotides r=7:99354604-99381888]: 3′-AGCGGAGAGAGGACGGGAACAG-5′ (the bold base provided the SNP location G>A). The ExciProbes had the sequence (X1) p-5′-CTGCCCTTGTC-3′ and (X2) 5′-TCGCCTCTCTC-3′-p. The probes were supplied with a free 3’ or 5’-phosphate group (p). Reagents of the highest quality available and DNA probes and DNA targets were purchased from Sigma-Aldrich (Paris France,). Distilled water was further purified by ion exchange and charcoal using a MilliQ system (Millipore Ltd, UK). Tris buffer was prepared from analytical reagent grade materials. pH was measured using a Hanna(Lisbon, Portugal)HI 9321 microprocessor pH meter, calibrated with standard buffers (Sigma-Aldrich) at 20°C.

HPLC

HPLC purification of probes was performed on an Agilent 1100 Series HPLC system (California, USA), consisting of a quaternary pump with solvent degasser, a diode-array module for multi-wavelength signal detection using an Agilent 1100 Series UV-visible detector and an Agilent 1100 Series fluorescence detector for on-line acquisition of excitation/emission spectra. The system had a manual injector and thermostatted column compartment with two heat exchangers for solvent pre-heating. The HPLC system was operated by Agilent HPLC 2D ChemStation Software. Depending on the purification performed, the columns used were: Zorbax Eclipse X DB-C8 column (California, USA) (length 25 cm, inner diameter 4.6 mm, particle size 5μm), or a Luna C18 (2) column (California, USA) (length 25 cm, inner diameter 4.6 mm, particle size 5 μm) with elution using an increasing gradient (0–50%) of acetonitrile in water (fraction detection at 260, 280, and 340 nm).

UV-Visible Spectrophotometry

UV–visible absorption spectra were measured at 20°C on a Cary-Varian 1E UV–visible spectrophotometer (London, UK.) with a Peltier-thermostatted cuvette holder and Cary 1E operating system/2 (version 3) and CARY1 software. Quantification of the oligonucleotide components used millimolar extinction coefficients (e260) of 99.0 for ExciProbe (X1), 94.6 for ExciProbe (X2). The extinction coefficients were calculated by the nearest neighbour method [24] and the contribution of the exci-partners was neglected.

Spectrophotofluorimetry

Fluorescence emission/excitation spectra were recorded in 4-sided quartz thermostatted cuvettes using a Peltier-controlled-temperature Cary-Eclipse, spectrofluorophotometer (London, UK). All experiments were carried out at 5°C. Hybridisation: Duplex formation was induced by sequential addition of ExciProbe(X1) and ExciProbe (X2). The mole ratio of all oligonucleotides ExciProbe (X1)and ExciProbe (X2) used were 1:1, the concentration of each component was2.5 µM. Tris buffer was added either with or without 80% TFE and thevolume made up to 1000 µl with deionized water. Excitation wavelengths of 340 nm (for the pyrene monomer) and 350 nm (for the full two probes and the target) were used, at slit width of5 nm and recorded in the range of 350-650 nm. Emission spectra were recorded after each sequential addition of each component to record the change in emission of each addition. A baseline spectrum of buffer and water or buffer, water and 80% TFE was always carried out before start of the measurement. After each addition the solution was left to equilibrate for 6 minutes in the fluorescence spectrophotometer and emission spectra were recorded until no change in the fluorescence spectra was seen to ensure it had been reached. The sequence of experiments was first using ExciProbe (X1) then ExciProbe (X2). Control experiments were conducted using firstly ExciProbe (X1) followed by the 3’-free oligonucleotide probe and finally the complementary target. All spectra were buffer corrected.

Control Experiments

Control experiments were carried out in 80% TFE/Tris buffer as for the experimental systems using the standard method described above. The control experiment was performed to confirm whether the obtained excimer emission is a result of such background effects or arise from the hypothesised excimer structures. Then fluorescence melting curve experiments (based on excitation 350 nm and emission 480 nm for the excimer) were performed using a Cary Eclipse fluorescence spectrophotometer by measuring the change in fluorescence intensity for the excimer with melting temperature(Tm). Tm was also determined spectrophotometrically by measuring the change in absorbance at 260 nm with temperature. Tm was determined either by taking the point at half the curve height or using the first derivative method.

Synthesis and Oligonucleotide Modification

Attachments of 1-pyrenemethylamine to oligonucleotide probes were as described in [14,25]. One equivalent of 1-pyrenemethylamine was attached via phosphoramide links to the terminal 5’-phosphate of (X1) p-5′-CTGCCCTTGTC-3′ probe and to the 3’-phosphate of (X2) 5′-TCGCCTCTCTC-3′-p. To the cetyltrimethyl ammonium salts of the oligonucleotides (~1 micromole) dissolved in N, N-dimethylformamide (200 µl) were added triphenyl phosphine (80 mg, 300 µmol) and 2,2′-dipyridyl disulfide (70 mg, 318 µmol), and the reaction mixture was incubated at 37°C for 10 min. 4-N’,N’-Dimethylaminopyridine (40 mg, 329 µmol) was added, the reaction mixture incubated for a further 12 minutes at 37°C and 1-pyrenemethylamine hydrochloride (4 mg, 14.9 μmol, dissolved in 100 µl of N, N-dimethylformamide and three microliter triethylamine) added. The mixture of the reaction was incubated at 37°C for full day (24 hours) product then was purified using reverse-phase HPLC (eluted by 0.05 M LiClO4 with a gradient from 0 to 60 % acetonitrile).

CYP3A4*1B Single Nucleotide Polymorphism

Split-probe systems were used to investigate the effect of SNP in the CYP3A4*1B target sequence on excimer emission compared to the normal-type target. Experiment was carried out in 80% TFE/Tris buffer at 5°C. The sequence of addition was: ExciProbe (X1), ExciProbe (X2), and finally 22 mer mutant-target oligonucleotide (CYP3A4*1B). All spectra were buffer-corrected.

Results

Excimer Formation Using Terminally Located Probe Systems

Fluorescence studies were made for solutions of ExciProbe (X1) and ExciProbe (X2) oligonucleotides with both probes complementary to each other (Figure 1). Figure 2 shows the excitation and emission spectra for (A) the ExciProbe (X1) and ExciProbe (X2) in 80% TFE/Tris buffer (0.01 M Tris, 0.1 M NaCl, pH 8.4), at5°C, (B) ExciProbe (X1) and ExciProbe (X2) hybridised to the 22-mer target oligonucleotide. On excitation at 350 nm, the 3′-pyrenyl ExciProbe (X1) and 5′-pyrenyl ExciProbe (X2) showed fluorescence typical of pyrene LES emission (lmax = 376, 395 nm). Addition of the complementary target resulted in immediate quenching of the LES emission at 395 nm to less than one-third of its original value and the appearance of a new, broad emission band (lmax = 480 nm) characteristic of pyrene excimer fluorescence after the full terminally located system had formed)[1,2,26]. Addition of the two probes to the target also caused a slight red shift in both excitation (from 342 nm to 349 nm) and emission (from 376 nm to 378 nm; λex 350 nm) spectra, consistent with duplex formation [1,2,26].

fig 2

Figure 2: Excitation and emission spectra of the split-oligonucleotide (tandem) probe system A 5′-pyrenyl ExciProbe (X1) and 3′-pyrenyl ExciProbe (X2), B ExciProbe (X1), 3′-pyrenyl ExciProbe (X2) and the complementary target (full system)in 80% TFE/0.01 M Tris, 0.1 M NaCl, pH 8.4) at 5°C. Component concentrations were 2.5 μM (equimolar).

Control Experiments for the Terminally Located Excimer System

Control experiments on a 1:1 mixture of 5′-pyrenyl ExciProbe (X1) and 3′-pyrenyl ExciProbe probe (X2) oligonucleotides were carried out in 80% TFE/0.01 M Tris, 0.1 M NaCl, pH 8.4 to determine if the fluorescence was from pyrene interacting as an excimer with the intended pyrene exci-partner, or an interaction with bases of the oligonucleotides. The 5′-pyrenyl ExciProbe (X1) showed no band at 480 nm in the absence of the target oligonucleotide (Figure 3). Addition of the complementary oligonucleotide target to ExciProbe (X1) resulted in a slight shift in λmax of LES emission to 379 nm, consistent with hybridisation of the probe with the complementary target. However, no marked 480 nm band was seen, even after heating the system to 70°C and re-annealing by slowly cooling back to 5°C. The weak fluorescence emission at 480 nm for the control duplex (before and after heating cooling, Figure 3) on duplex formation appeared real and could be related to exciplex formation, due to intra-molecular interaction of pyrene within the assembled duplex. However, relative to the full system with both 3′- and 5′-pyrenyl groups (Figure 3) the emission at 480 nm is insignificant.

fig 3

Figure 3: Emission spectra for control terminally located system A 5′-pyrenyl ExciProbe (X1) oligonucleotide, B 3′-pyrenyl ExciProbe (X2) and the 22 mer target in 80% TFE/10 mM Tris, 0.1 M NaCl, pH 8.4 at 5°C. Excitation wavelength 350 nm, slitwidth 5 nm. Equimolar component concentration was 2.5 μM.

CYP3A4*1B Single Nucleotide Polymorphism

The excimer emission was detected (broadband at ~480 nm) for normal target and showed strong emission at 480 nm (545 relative fluorescence intensity) compared to the mutated target (220 relative fluorescence intensity) around 2.5 fold (Figure 4).

fig 4

Figure 4: Emission spectra comparing the normal target A, CYP3A4) with the mutated target B, CYP3A4*1B) in 80% TFE/ Tris buffer (10 mM Tris, 0.1 M NaCl, pH 8.4) at 5°C after heating the samples to 90°C. Spectra were recorded when emission intensity had reached a maximum after 10 minutes at 5°C. Excitation was at 350 nm, slitwidth 5 nm. Spectra, buffer-corrected, are scaled to LES emission (378.9 nm).

Melting Temperatures of SNP

Melting curve experiments were performed spectrophotometrically at A260 and estimated by using the first derivative method. The melting temperatures (Tm) for normal CYP3A4 target was 76.9 ±0.8°C and 75.0 ±0.8°C for CYP3A4*1B, respectively. The melting temperature at 260 nm for systems was performed in 80% TFE/Tris buffer (10 mM Tris, 0.1 M NaCl, pH 8.4). Control experiments for Tm were carried out in 80% TFE/Tris buffer. In addition, similar thermal results were obtained using fluorescence melting curve experiments based on excitation 350 nm and emission 480 nm for the excimer. The fluorescence thermal study was performed using a Cary Eclipse fluorescence spectrophotometer by measuring the change in fluorescence intensity for the excimer with temperature.

Discussion

Confirmation of Duplex Formation

In our experiments of hybridising the two 11 mer probes to the complementary target in phosphate buffer (pH 7.0) containing 0.1 M NaCI, the pyrene moieties of the two probes came into close proximity, and an excimer band at 480 nm was generated. This result is consistent with results obtained by [27] who used a system that incorporated a pyrene-modified nucleotide at the 5′-end of one probe and a pyrene-modified nucleotide at the 3′-end of the other [27]. Figure 2 shows fluorescence typical of pyrene local excited state (LES) emission (lmax = 376, 395 nm) for a 5′-pyrenyl ExciProbe (X1) labelled oligonucleotide alone. The emission spectrum obtained is similar to that obtained in the literature using10 mM phosphate buffer (pH 7.0) 20 % v/v DMF, 0.2 M NaCl at 25°C and gave lmax = 377, 396 nm [1,2,26]. Addition of the 5′-pyrenyl ExciProbe (X1) to the 3′-pyrenyl ExciProbe (X2) target resulted in immediate quenching of the LES emission at 395 nm to less than one-third of its original value and the appearance of a new, broad emission band atlmax = 480 nm characteristic of pyrene excimer fluorescence (Figure 2).

Melting experiments provide further strong evidence of duplex formation. The split-probe systems showed sigmoid single-transition melting curves spectrophotometrically (A260 or A350) or spectrofluorometrically from fluorescence intensity at 340 nm for the LES (lex) and 376 nm (lem) for thepyrene monomer and at 350 nm for LES (lex) and 480 nm (lem) for the excimer (data not shown). Additional evidence of duplex formation comes from the emission spectra, as one probe oligonucleotide alone did not give an excimer signal in the absence of the other complementary probe. Further evidence of duplex formation and reversibility came from experiments using a heating and cooling cycle. Experiments of terminally located probe systems at different temperatures showed that the excimer intensity decreased when the temperature increased and eventually disappeared. This process is reversible, providing further evidence of duplex formation. A better-formed duplex structure probably enables the exci-partners to be better positioned for excimer formation. The reappearance of the excimer spectra on re-cooling indicates that no destruction of the components occurs on heating the system.

Evidence of Excimer Formation

The red-shifted structureless band at ~480 nm is characteristic of excimer emission, but could be due to interaction of the exci-partners with each other or nucleobases as pyrene are able to form an exciplex with certain nucleotide bases, especially guanine and to a lesser extent thymidine [28,29]. Also some oligonucleotide sequences show weak exciplex emission from pyrene attached to their 5′-termini in the absence of any added (complementary) oligonucleotide [30]. Thus, it is important to establish for the terminally located system the origin of the emission at 480nm. Heating the system caused the excimer emission intensity to decrease due to dissociation of the duplex structure. On re-cooling the system excimer emission reappeared. The Tm values by fluorescence and UV-visible methods were similar and of the magnitude expected for such a system (22-mer duplex) [31].

CYP3A4*1B Single Nucleotide Polymorphism

The search for sequences that differ in only one or two nucleobases needs tools to detect nucleic acid sequences that have high performance, speed, simplicity, and low cost. There have been many different techniques developed to identify the mutations in nucleic acid sequences. Techniques based on matched/mismatched-duplex stabilities, restriction cleavage, ligation, nucleotide incorporation, mass spectrometry and direct sequencing have been reviewed [32,33]. The DNA split-probe system of CYP3A4*1B was able to discriminate between perfectly matched CYP3A4 and mismatched CYP3A4*1B targets. Several split-oligonucleotide systems have been reported to discriminate between SNPs. These include the ligation method of Landegen [34], nanoparticle probes[35,36] and the template-directed ligation method [37,38]. The split-probe excimer system of Paris [39] was found to be sensitive to a single-base mutation in the target, positioned four base pairs from the 3′-junction. In the Paris study the addition of the unmutated target to the pyrene probes resulted in an increase in 490 nm emission as well as a 4.7-fold decrease in 398 nm monomer emission. The resulting excimer:monomer ratio was 0.04, very different to that for the sequence with a single-base point mutation which was 2.7 [39].

In the present study the duplexes containing GAGAACG/CTCCTGC mismatch is significantly destabilized compared with its correctly paired parent. Amber and Znosko [40] studied the thermodynamics of A/G mismatches in different nearest-neighbour contexts. They found a penalty (energy loos) of 1.2 kcal/mol for replacing a G-C base pair with either an A-U or G-U base pair. For both CYP3A4 (normal target) and CYP3A4*1B (mismatched target) showed a sigmoidal melting profile, typical of the dsDNA to ssDNA transition, providing further evidence of tandem duplex formation. The Tm values of CYP3A4*1B are less to those of the fully matched, consistent with literature studies performed on different sequences under identical conditions[25]. Duplexes of CYP3A4*1B (mismatched target) with mismatches of G/A in the twelve position from the 3′ and 5′ ends, respectively, showed significantly lower Tm than CYP3A4 (normal target). These results indicate that the ∆G contribution of a single G/A mismatch and the position of the mismatch are crucial to duplex stability and consistent with the literature [41,42]. The ∆G contribution of a single G/A mismatch to duplex stability was studied by [43] who found that ∆G is dependent on the neighbouring base pairs and ranges from +1.16 kcal/mol (for the context TGA/AAT) to -0.78 kcal/mol (for the context GGC/CAG). Allawi [43] also showed that the nearest neighbour model is applicable to internal G/T mismatches in DNA. In their study of G/T mismatches, the most stable trimer sequence containing a G/T mismatch was -1.05 kcal/mol for CGC/GTG and the least stable was +1.05 kcal/mol for AGA/TTT. On average, when the closing Watson-Crick pair on the 5′ side of the mismatch is an A/T or a G/C pair, G/A mismatches are more stable than G/T mismatches by about 0.40 and 0.30 kcal/mol, respectively [43,44]. When the 5′ closing pair is a T/A or a C/G, then G/T mismatches are more stable than G/A mismatches by 0.54 and 0.75 kcal/mol, respectively. Evidently, the different hydrogen-bonding and stacking in G/T and G/A mismatches results in different thermodynamic trends and the energy and structural information are the compositions of the following variables, such as bond angle energies, bond energies, planarity energies, dihedral angle energies, Van der Waals energies or/and electrostatic energies. These results indicate that duplexes containing mismatches are considerably destabilized (Figure 5) compared with their correctly paired parent the extent being dependent on the base composition and sequence of the oligonucleotide as well as on the type and location of the mismatch. The mismatch of DNA leads to alterations of amino acid properties and can cause a change in protein structure [45,46]. Consequently, SNP may affect enzyme activity through the modification of protein structure and function [47].

fig 5

Figure 5: Pentamer of DNA Duplexes of theCYP3A4 gene. A: matched CYP3A4 target (AGGAC/TCCTG), B: CYP3A4*1B target (AGAAC/TCCTG). The hydrogen bonds are represented using green broken lines. The figure was obtained with the help ofthe molecular visualization tool (Discovery Studio Visualizer software 4.1).

Conclusion

Our results evaluate the first case of an oligonucleotide split probe system based on excimer fluorescence emission for detection of CYP3A4*1B single nucleotide polymorphism. Further studies will be necessary to understand the details of the split probe system structure which determine the formation of the excimer for CYP3A4 single nucleotide polymorphism. Based on fluorescence and spectrophotometric results, the split probe system is selective enough to detect single base mutations of CYP3A4*1B with good sensitivity and therefore could be used to detect other mutations using an excimer system.

Acknowledgement

The authors gratefully acknowledge the support and valuable suggestions obtained from Sir Khaled AB Diab (Judicial Expertise and Research Centre, Tripoli, Libya Tripoli, Libya).

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Could Ultrasound Inactivate COVID-19 in the Environment and in the Air, Thus Preventing the Spread of the Pandemic?

DOI: 10.31038/IMROJ.2021635

Abstract

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also called COVID-19, started by Wuhan, China, in 2019, has caused a pandemic which has quickly involved the entire world and raised public health concerns. The scientific community is actively exploring treatments that would potentially be effective in combating COVID-19. Viral infections, especially those that are transmitted by air, are the most contagious infectious diseases and cause major biological, clinical and socioeconomic problems worldwide. COVID-19 spreads in the air and therefore rapidly contagious, thus finding appropriate and timely treatment to cure the entire population and above all to prevent transmission between individuals, is extremely necessary in a short time. Considerable efforts are being made to seek therapy on the infected human being, in fact several drugs already used in the past for SARS or HIV-1 are tested, in what is called a drug repositioning or label off strategy, but it is very important to prevent contagion before other individuals are infected, and especially the most fragile ones, even to decongest the structures of the health system also to avoid neglecting other pathologies as unfortunately is happening in this pandemic period. High intensity ultrasound is becoming important and more widely used in the food industry for microorganisms decontamination and is one of the new technologies that have been suggested as an alternative to current heat treatments for microbial inactivation, including viruses. Also for synergistically enhanced elimination of organic pollutants and pathogenic microorganisms from water since the early 2000s, dual-frequency ultrasound has received much attention. Here, my hypothesis consist to use ultrasound, as a valid prevention clean mean, which propagates well in the air, such as respiratory viruses, to fight the COVID-19 expansion in the air environment, and thus block the transmission from one individual to another, especially indoors and also from objects to individuals. Ultrasoud are also used in the Protein misfolding cyclic amplification (PMCA) technique used to amplify prions. The growing chain of misfolded protein is then blasted with ultrasound by sonication, breaking it down into smaller chains and so rapidly increasing the amount of abnormal protein available to cause conversions. Ultrasounds are waves with frequencies between 20 kHz and 20 MHz, well known have effects on molecular structures of various microorganisms, even viruses, but are not harmful to humans, and so could potentially damage also the new Coronavirus, COVID-19 especially by damaging the superficial spike S-glycoprotein that the virus uses to enter cells and infect them, and block or slow down the epidemic which is destroying many human lives. Experimentally, COVID-19 and its variants, can be treated with ultrasonic waves at different exposure times, then Vero E6 cells (African green monkey kidney cells) permissive to the SARS-CoV-2, are infected in vitro with the treated virus with ultrasounds and tested for efficacy of on the suppression of activity of COVID-19 and therefore for the decrease or block of infectivity. After a possible positive outcome of the laboratory experimentation, ultrasounds can be applied in closed environments frequented by people including homes, offices, supermarkets, schools, buses, subways to purify the air and avoid the spread of contagion.

Keywords

COVID-19, Virology, Ultrasound, Enviroments, Prevention

Introduction

The COVID-19 pandemic represents the greatest global public health crisis since the pandemic influenza outbreak of 1918, a bit more than a century ago. The novel coronavirus disease 2019 (COVID-19) has resulted in the deaths of more than 248 000 persons worldwide as of May 4, 2020, on the same date in New York more than 19 400 individuals have died [1]. Research is under way to identify vaccines and therapeutics for COVID-19, including repurposing of medications. Facing a new and unknown virus, antiviral agents previously used to treat other infections such as SARS and Middle East Respiratory Syndrome (MERS), have been considered as the first potential candidates for first-line therapy to treat COVID-19. Chloroquine and hydroxychloroquine, old drugs used in the treatment of malaria and inhibitors of protease of HIV-1 have been previously studied, where evidence of efficacy has been found and they have anti coronavirus characteristics in vitro [2,3]. The findings support the insight that chloroquine/hydroxychloroquine have efficacy in the treatment of COVID-19 [4]. Therefore, based on evidence from in vitro studies on the suppression of activity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other coronavirus strains, interest increased in the use of hydroxychloroquine and chloroquine with the possible addition of azithromycin for the treatment of COVID-19 [5,6]. At the same time, a great number of clinical trials have been launched to investigate the potential efficacy therapies for COVID-19 highlighting the urgent need to get as quickly as possible high-quality evidence. This new virus, COVID-19, such as respiratory viruses, spreads in the air, and therefore also rapidly contagious therefore, finding effective and timely treatment to cure the entire population or better still, prevent contagion, is a very difficult task. For so much we must find alternative and effective methods also for the prevention of global spread as well as for the cure in order not to collapse the health system.

Hypothesis

My hypothesis here consist to use ultrasound, as a valid prevention mean, which propagates well in the air, to fight the SARS-CoV-2 in environments, especially indoors, and it is well known have effects on molecular structures of various microorganisms, including viruses, but they are not harmful to humans. Ultrasound is one of the new technologies that have been suggested as an alternative to current heat treatments for microbial inactivation [7,8]. Ultrasound is defined as a sonic wave at frequencies over the threshold human hearing. Ultrasonic waves are generally classified by their frequency and their wavelength. Waves with frequencies between 20 and 40 kHz are considered as high-energy or high-power ultrasound Figure 1 [8].

fig 1

Figure 1: Diagram of the approximate frequencies corresponding to ultrasounds according to their field of application. Source Wikipedia.

High intensity ultrasound is becoming important and more widely used in the food industry for microorganisms decontamination. This sterilization technique has been evaluated to improve food safety and to replace common processing with chemical additive compounds. The efficiency of a horn-type power ultrasound treatment (300 W and 600 W, 28 kHz, 10-30 min) on Listeria monocytogenes, Bacillus cereus, Escherichia coli, Salmonella typhimurium bacteria suspensions and phytoviruses was examined in this study [9]. The results of this study showed that ultrasonic treatment can be used to eliminate vegetative cells of gram-positive and gram-negative bacteria from 1.59 to 3.4 log in bacterial suspensions and some phytoviruses in fruits [9]. Also for treatment and disinfection of water dual-frequency ultrasound since the early 2000s, dual-frequency ultrasound (DFUS) has received much interest [10]. Elimination of organic pollutants and pathogenic microorganisms from water occurs indirectly by generating reactive oxygen species (ROS) induced through exposure the water to DFUS [10]. The nonlinear dynamics of microbubbles upon DFUS exposure produces additional frequencies, such as harmonics, subharmonics, ultraharmonics and combination frequencies. These increase the probability of bubbles collapse, thereby enhancing cavitation and generating more reactive oxygen species for advanced oxidation processes (AOPs) [10]. The protein misfolding cyclic amplification (PMCA) mimics in vitro the process of prion propagation, which occurs in vivo [11]. PMCA requires the incubation of prions with an excess of Pr(PC) (a normal glycophosphatidyl-anchored glycoprotein) in a test tube, which is placed in a dedicated sonicator and subjected to a process of cyclically repeated phases of sonication and incubation. Brains of healthy animals are used as a source of Pr(PC) [12]. During the incubation phase, PrP(Sc) (abnormal form of the prion protein) forces PrPC to change conformation and aggregate. The sonication fragments these aggregates into small species that act as seeds able to promote further PrPC conversion. Therefore the ultrasounds act at the molecular level to determine the cleavage of the aggregates. Based on these reasons my hypothesis consist of using ultrasounds to counteract the new pandemic from COVID 19, which could weaken, the viral envelope constituted by a phospholipid bilayer of pericapsid and therefore through, for example, causing a conformational change of the spike S-glycoprotein receptor, which it uses to bind to the human ACE2 receptor to enter cells. S glycoprotein is fundamental to mediate the membrane fusion required for virus entry and cell fusion. Ultrasound travels in the air, like COVID-19 does, so above all in closed environments, including homes, offices, supermarkets, schools, buses, subway, where the greatest contact occurs among the people, it could prevent the transmission from one individual to another in case of close contact, sneezing, coughing or breathing, thus avoiding contagion and the spread of the pandemic. The hypothesis is therefore to destroy the COVID-19 in the air contained in the microdroplets or in fine dust from environmental pollution, and also as soon as it comes into contact with the upper airways of humans, in such a way as to block or decrease its replication and therefore the viral load.

Experimental Protocol

Undergo the virus COVID-19 to a determined TCID50, to ultrasound at different exposure times: from a few seconds to a minute to test its immediate effectiveness of the ultrasound waves to inactivate the virus, then 10 min, and 15 min (the latter, estimated minimum time for the infection to occur between individuals at a distance of less than one meter). Then 3 h, 6 h, 12 h, 24 h, 48 h and 72 h of exposure of the virus to ultrasound.

The Vero E6 cells (African green monkey kidney cells) [13] permissive to the SARS-CoV-2, will be respectively infected to a certain MOI, with the different samples virus treated with ultrasounds at the different times listed above. Then infected Vero E6 cells will be analyzed with MTT assay for to test the eventual inhibition of the cytopathic effect as well as a control of uninfected cells (mock infection), and a control virus of cells infected with the virus not treated with ultrasonic waves.

Consequences of the Hypothesis and Discussion

The transmission of infection can happen by main route, one is from the virus on the surfaces and other is infection from the droplets from the sneeze and cough skin flakes [14-16]. Each of these processes generates aerosol droplets of different size and initial speed. When a person sneeze or coughs, talks loud, ejecting the droplets is released which is of 1 mm in diameter which falls on the ground within a minute [13], but the microdroplets remain through the air for several hours which are smaller than 10 micrometer. They are small and light drifting through the air and stays and does not drift from air for a period of time [17]. Have been observed that there is high risk of spread of infection in closed room or in a class room. For example, in a closed room of 10 people, if a person coughs once there is spread of 1,000 droplet with most of them fall on the ground in a minute whereas the microdroplet spreads in a very high volume for long period. Accordingly my hypothesis to use ultrasounds could be taken into consideration as they spread through the air where there are also the viral particles, but they are not harmful to human health, instead they could damage the molecular structures of pathogenic microorganisms including viruses and in particular potentially, also COVID-19 cause of the ongoing pandemic. The ultrasounds could therefore also be used to heal the environment in closed places because it has been seen that the virus remains in the air for several hours through microdroplets so in places where there are people it could act as a barrier to avoid contagion from a person to another in case of sneezing, coughing or just breathing but also from objects with virus to individuals. Ultimately, the use of ultrasound as an alternative and supportive means, even at relatively low costs, could prevent the further spread of COVID-19 and therefore block the pandemic curve, for a desirable recovery from the collapse of the world health system and from immense efforts of health workers. The application of this hypothesis could be of considerable impact and inspiration if developed and solve several health and socio-economic problems that unfortunately we are witnessing.

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Multiple Target Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Neurofeedback for Complete Resolution of Severe OCD, Bipolar Depression, and Anxiety

DOI: 10.31038/JNNC.2021433

 

Obsessive compulsive disorder (OCD) is a prevalent disabling condition and often comorbid with depression, anxiety, and high suicide rates. First line treatments of OCD such as Selective Serotonin Reuptake Inhibitors (SSRIs) and dopamine antagonists, and mood stabilizers fail to treat OCD in up to 60% of patients [1]. Transcranial magnetic stimulation has emerged as a non-pharmacological alternative for treatment of OCD and several case reports and randomized trials have shown positive response although the efficacy of r TMS remains low at approximately 35% with little positive effects on reversing comorbities including symptoms of depression and anxiety [2]. The most effective stimulation parameters, cortical targets, and type of coil (figure of eight, H-coil, cone, or deep) for rTMS have not been established. Investigators report positive outcomes with stimulation of the right Orbitofrontal Cortex (OFC), Supplementary Motor Area (SMA), and Anterior Cingulate Cortex (ACC) [2,3]. Recently, deep r tms directed at ACC has show significant benefit [4]. In addition, neurofeedback, also known as ‘EEG biofeedback’, has been established as an effective treatment of various psychological and neuropsychiatric disorders including OCD, anxiety, and depression [5,6]. Accordingly, I hypothesize that a more formidable outcome can be achieved in patients suffering from OCD accompanied by comorbidities when: 1) multiple cortical targets are stimulated under one treatment regimen; 2) multiple stimulation parameters are utilized in response to patient report of outcome; and 3) neurofeedback is used in conjunction with rTMS. This ‘combination approach’ was in fact, found to be significantly effective in treatment of pervasive spectrum disorder, e.g. autism and early signs of dementia [7,8]. Here, I present the first case report of patient with severe OCD, anxiety, and depression who showed marked improvement and resolution of OCD, anxiety, and depression following completing total of 41 sessions of rTMS and 15 sessions of ‘Z-score neurofeedback’.

Patient is 33-year-old male diagnosed with over 15 years of OCD, generalized anxiety, and bipolar depression. Patient has undergone trials of Serotonin Reuptake Inhibitors (SSRIs), mood stabilizers including lithium and valproic acid, and benzodiazepines including lorazepam. At time of presentation to my clinic, patient’s primary symptoms included obsessive thoughts with facial and skin contamination, recurrent feeling of self-guilt, marked difficulty with anxiety in dark environments, agoraphobia, poor self-worth, and extreme spells of depression, manic, and hypomanic episodes. In addition, patient displayed severe hypochondriasis with respect to various disorders including motor neuron disease, multiple sclerosis, and infections. Moreover, patient experienced various somatic symptoms including non-specific vibratory sensations of mouth, trunk, and extremities. At onset, Yale Brown Obsessive Compulsive Score (Y-BOCS) was 19, Burn’s anxiety score was 36, Burn’s depression score was 22, and PHQ-9 of 10. Risks and benefits of rTMS including off-label use of rTMS parameters were discussed in detail with patient and written signed consent obtained. A brain MRI was obtained to include skin fiduciary markers for navigation software (The Neural Navigator, Brain Science Tools, Utrechet, Netherlands) 1mm sagittal and axial T1 MRI images were processed and segmented to identify several cortical targets including: left and right Dorsolateral Prefrontal Cortex (DLPFC), right OFC, left Dorsomedial Prefrontal Cortex (DMPFC), and ACC. On initial visit and every 5-6 visits, the Motor Threshold (MT) was determined as the intensity required to active the left Abductor Policis Brevis (APB) and/or the First Dorsal Interosseus (FDI) on the contralateral hand on average of 5 of 10 single pulse trials directed at left motor cortex per visual inspection. Patient was interviewed and underwent daily rTMS sessions using varying targets and stimulation parameters (see table). The rTMS stimulation parameters were chosen based on current trial evidence for treatment of OCD, depression, and anxiety and patient’s daily report of signs and symptoms. All stimulations were performed using figure-of-eight coil (Neurosoft, Ltd. Ivanovo, Russian Federation) rTMS machine. Cortical targets included SMA, left DLPFC, right DLPFC, left DMPFC, ACC, and right OFC. Cortical targets were identified and marked using navigation software.

table

Neurofeedback was done using Neuroguide ‘Z-Score LORETA’ neurofeedback software by collecting and editing 4 minutes of baseline EEG and creating a ‘symptoms checklist match’ (for detail of procedure see Thatcher & Lubar, Z Score Neurofeedback: Clinical Applications, 2015; Thatcher, Latest Developments in Live Z-Score Training: Symptom Check List, Phase Reset, and Loreta Z-Score Biofeedback, 2013) [9,10]. Each session consistent of five 5-minute rounds for total of approximately 25-30 minutes. Dry, wireless, headset (DSI-24, Wearable Sensing, San Diego, CA, USA) was used to gather EEG recordings and conduct neurofeedback sessions. Patient underwent neurofeedback approximately two times per week, usually prior to or after r TMS sessions. Patient showed progressive and marked improvement in, OCD, anxiety, and depression. Y-BOCS scores showed 63% improvement (19 to 7), Burn’s depression showed 86% improvement (22 to 3), Burn’s anxiety showed 72% improvement (36 to 10), and PHQ-9 showed 70% improvement (from 10 to 3). Patient reported complete reversal of agoraphobia, self-contamination delusions, and depression. He reported feeling quite comfortable with going to large dark movie theater, avoiding washing rituals, denied panic attacks in provocative environments (e.g. driving), and developed markedly improved mood. The clinical improvements were noticeable by father and other close relatives. Although we delivered higher intensity of stimulation and overall larger total daily pulses, patient reported no significant adverse effects and did not experience seizures. To our knowledge, this is first report of 1) applying rTMS to multiple (e.g. more than 2) cortical targets on one patient with each utilizing separate stimulation protocols, and 2) adding neurofeedback to treatment regimen leading to marked improvement and resolution of OCD together with anxiety and depression.

The rationale behind use of various cortical targets is to modulate several circuits that may be contributing to OCD and comorbidities including abnormal connectivity and/or neuronal hyperactivity within cortical-striate-thalamic-cortical circuits–currently the leading working model regarding the pathophysiology of OCD [4]. One randomized, sham-controlled study showed modest improvements in OCD (29% reduction on Y-BOCS) and depression (48% on HAM-D) symptoms after 14 sequential 1 Hz stimluation sessions targeting left DLPFC and SMA [11,12]. Additional randomized sham-controlled studies applying a multi-target approach and in combination with neurofeedback will be helpful and can potentially significanly increase the efficacy rate of treatment.

Keywords

Generalized anxiety disorder, Multiple targets rTMS, Neurofeedback, Obsessive compulsive disorder, Repetitive transcranial magnetic stimulation

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