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Cometary Origin of COVID-19

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DOI: 10.31038/IDT.2021212

Abstract

The evidence for the cometary origin then rapid global spread of COVID-19 through 2020 is critically reviewed. We outline why it is an alternative plausible scientific explanation to the current bat/pangolin animal jump theories. In our view this explanation is consistent with all the available temporal unfolding scientific data (genomic, immunologic, epidemiologic, geophysical, astrophysical and astrobiological). Thus COVID-19 arrived as infective cryopreserved virions in cometary meteoritic dust clouds from space in a bolide strike in the stratosphere over China on October 11 2019. Prevailing high-level and low-level wind systems then globally distributed the infective viral dust clouds, striking different regions at different times. Given this possibility, a new space challenge for mankind is to develop near-Earth early warning biological surveillance (and mitigation) systems for incoming cosmic in-falls of micro-organisms and viruses from the cometary dust and meteorite streams that our planet routinely encounters as it orbits the Sun.

Since it first emerged in Wuhan, China in late November into December 2019 the coronavirus pandemic due to COVID-19 (SARS-CoV-2) has been engulfing the world with considerable economic and health impact targeting mainly our elderly co-morbid citizens with clear deficits mainly in type I and type III interferon inducible anti-viral immunity [1-5].

How credible then is our conclusion, embodied in our title, that the COVID-19 pandemic could have arrived from space? The journal has invited us to outline this evidence for an extra-terrestrial origin, which we began publishing from early 2020 [6-10] and then in a mid-year review which appeared in November 2020 [11]. Our initial focus has been to explain the key events of the first months of the pandemic so as to understand its origin and rapid global spread. We marshalled not only the geophysical and temporal global epidemiological evidence [6-8,12], the prior knowledge from astrophysical and astrobiological evidence [13-16] but also gained insight into the genetic adaptation strategy of the virus, based on APOBEC and ADAR deaminase driven responses in infected subjects. These host innate immune responses designed to mutate and thus cripple the viral RNA genome actually helps steer viral haplotype diversification for optimal replicative efficacy. We view this as a ribo-switching host-parasite selection process for the fittest transmissible RNA haplotypic genome in a subject host [12,17].

Our short narrative summary of one possible scenario not considered as mainstream thinking goes like this: A life-bearing loosely held carbonaceous cometary bolide arrived in the stratosphere over Jilin in North East China on the night of Oct 11 2019. This well-documented and widely observed event is recorded at the Space.com website. The viral-laden cometary dust particles and clumps (typically micron size) were released prior to the fireball in a fragmentation process, and they began their expected slow descent from the stratosphere in the 40° N Latitude band (30-50°). Over the next month some of this cometary-meteorite dust cloud was brought down to ground by local weather precipitation (rain) targeting the central Chinese city of Wuhan in Hubei province. This event, within another month, ignited by mass simultaneous infective exposure caused the explosive rise of COVID-19 cases through January in Wuhan and its wider contaminated regions. About 30% of all such infections were demonstrably not connected to any food or wet market [18,19]. However much of the upper troposphere/stratosphere viral laden dust remained there in the East to West (E-W) jet streams and was distributed around the globe at great speed (jet-streams circle the globe in ~ 3 days at speeds 150-200 km/hr). We speculate that explosive outbreaks on the ground of human person-to-person (P-to-P) passaged COVID-19 viruses could have created a secondary rising plume of viral-laden pollution and dust [20,21] over Wuhan and Hubei province containing trillions of dust-associated COVID-19 virions. We think that this plume was then carried by the lower level West to East (W-E) prevailing wind systems across the Pacific (Max Wallis, pers comm) engaging cruise ships through February in the South China Sea and Sea of Japan (Diamond Princess, Westerdam). This mode of transfer, including early first wave in-falls in South Korea and Japan and, by mid-February, to the US West Coast [7], could explain the virus outbreak on the Grand Princess cruise ship sailing out of San Francisco. This scenario for the Grand Princess outbreak has supportive genetic evidence as the main COVID-19 haplotype in infected passengers was identical to the unmutated (and lightly mutated) L haplotype that dominated the Wuhan outbreak [12,22]. The deposits in the higher E-W jet streams could have been brought down by capricious local weather conditions during early-mid March 2020 in Tehran/Qom, Lombardy/Italy and Spain, and then on the 40° N Latitude band to engage New York City as our earlier analysis had predicted [7,8].

The explosive outbreaks at widely dispersed global sites are consistent with this scenario. Further, they happened at great speed, with exponential growth rates of case numbers per day, that defied initial expectations of P-to-P spreading with the expected 1-2 week infection incubation periods. Aerial infective in-fall by viral laden dust over large population centres seems the most logical explanation for the simultaneous infections with little evidence of delay due to incubation time. The same explosive apparent simultaneous large-scale outbreaks occurred in clearly documented cases of deck crew members on ships at sea [17,23] and in the remote Chilean Bernardo O’Higgins Army Station in Antarctica in late December 2020 [24]. In a similar vein, the island of Sri Lanka flat lined in case numbers for many months with hardly any cases, and became suddenly engaged in a mass outbreak of over a 1000 COVID-19 cases in the period Oct 4-6 [10] and see also Sri Lanka at the Google URL search link below [25].

By March into April part of the E-W 40° N jet stream transporting the dust clouds was diverted into South America, particularly Brazil by prevailing Atlantic ocean wind systems [9]. From there on the prevailing wind systems of the Southern Hemisphere became engaged as the principal carriers of the infalling viral laden dust clouds. The high profile infective outbreaks were those in June through September occurring predominantly in South Africa and Victoria Australia, which coincidently are on the same prevailing W-E 40° S Latitude band (the French Polynesian Islands became engaged several months later from September). The latter interpretation for Victoria, Australia, is at odds with the prevailing local belief that the 2nd Wave outbreak was caused by hotel quarantine “escapees into the community”. This claim infers that infected travellers to Melbourne in March-April from Northern Hemisphere zones inadvertently spread the virus into the community where after several months these “escapee” variants then ignited the 2nd Wave in late June 2020. However, our evaluation of the publicly available Victorian case incidence data and the publicly available COVID-19 genomic sequence data leads to a qualified and quite different explanation which is also consistent with the viral laden dust cloud in-fall interpretation.

Interested readers can perform their own survey of the global COVID-19 cases per day patterns since early 2020 to the present at the Google URL site listed below to verify our claims [25]. It is evident that the disease has now spread all over the globe to all major continents and regions. At the time of writing (April-May 2021) a major in-fall has occurred over India and regions which we speculate is a down draft off the 40° N latitude band on the southern side of the Himalayan Mountains. But it is an exceedingly patchy pattern worldwide as discussed extensively in Hoyle and Wickramasinghe [13] again recently in Wickramasinghe et al [10] and as is evident in the Figures and Supplementary data to be found in Steele and Lindley [12] and Steele et al. [11,17]. Thus epidemics begin and end at different times in different regions and reach different intensities. In our view this behaviour reflects globally dispersed fragmented viral laden dust clouds brought haphazardly and capriciously to ground by local meteorological conditions. Certain regions may not experience a real in-fall event, and this is borne out in islands like Taiwan despite its closeness to China. The vagaries of local weather, prevailing winds, and chance in-fall of viral-laden dust clouds combine to present a capricious pattern of attack.

So in the ongoing pandemic, outbreaks around the globe have their own sudden beginnings and endings, yet major regions on the N 40° Latitude band (North America, Europe Asia Minor and the Indian subcontinent) have experienced several “Waves” already, or by the scenario considered here, separate “wash down” events from the troposphere. An interesting feature across all regions where a clear single mode of in-fall can be discerned is an unmistakable symmetrical bell-shaped curve, such as happened for the 2nd Wave in Victoria Australia, 1st Wave in South Africa, and the 1st Wave in Pakistan. There are many instances of this type if one cares to Google survey the case incident patterns per day across the globe [25]. Despite the height of the peak or intensity of the epidemic in individual instances, it is remarkable that the base of the symmetrical curve stretches typically over 2-3 months. The simplest interpretation is that this reflects the decay time of the virions in the physical environment, which remains remarkably the same across the globe.

With respect to the symmetrical nature of the bell-shaped curves describing the distributions of cases per day seen in such well documented epidemics such as the Victorian 2nd Wave an important deduction can be drawn about the impact of extreme ‘lockdown’ social distancing measures aimed at reducing viral reproduction rate Ro to less than 1. We have statistically analysed the Gaussian features of the Victorian 2nd Wave (which peaked on August 1-2, 2020). The best Gaussian fit with R2 gives 0.8999 which implies an almost perfect statistical fit to a symmetrical bell-shaped curve. Such a result would be consistent with the epidemic curve being overwhelmingly dominated by the growth and decay of a localised atmospheric in-fall event. The hard Stage 4 lockdown in Victoria came into effect on August 2, 2020. Given this perfect symmetry we conclude that the hard lock down measures had little impact, if any, on the course of the 2nd Wave COVID-19 epidemic in Victoria, Australia. This conclusion is consistent with the independent analyses of the impact of extreme lockdown measures on the course of the COVID-19 lockdowns introduced in a number of States in the USA during 2020 [26].

The patterns we have discussed apply generally to the manner in which suddenly emergent pandemics run their course throughout history [13]. It seems plausible to us that many might be a combination of wash down from the troposphere, leading to population wide exposures, eventually inducing herd immunity and a natural decay of the virions in the environment. However, we admit that there are many unknowns and that there are alternative explanations for these effects. Yet, on some specific details presented to us, the scenario presented here is a possible new reality that will need much future research.

Thus, from our viewpoint, the bulk of the key global evidence is consistent with an extra-terrestrial origin of COVID-19. Are there alternative explanations for the sudden origin and rapid global spread of the pandemic? We have dealt with this issue at some length [17], and there is one possible yet highly unlikely scientific explanation, and a bio weapon conspiracy theory explanation. Both are discussed in detail in Steele et al [17], but it is the zoonotic theory that can be dealt with rationally and scientifically, namely that COVID-19 arose in a jump from an animal reservoir, either in one or two steps or in combination, with SARS CoV related variants growing in bats and/or pangolins. In reviewing all the known related bat and pangolin SARS-CoV-like sequences the closest possible precursors are 96.2 % similar to the COVID-19 Hu-1 reference sequence (29903 nt). To get an exact match, in the normal haplotype range for globally dispersed COVID-19 of 99.98% sequence similarity [12,17] this involves>1100 specific nucleotide changes in the precursor to get such an exact COVID-19 match. These numbers imply super astronomical odds against a successful jump. Indeed, even if we are generous and assume only a 1% difference (which has not been seen in the wild) this gives odds of one successful mutational jump in 10180 trials, which also is a super astronomical number, far exceeding the molecular, and statistical, resources of the known universe. In our view a zoonotic explanation for the origin of COVID-19, although a valid scientific concept, is implausible on the current evidence [17].

This leaves us then with an alternative plausible scientific explanation that is consistent with the available data: the arrival of COVID-19 as infective cryopreserved virions in cometary meteoritic dust clouds from space. Given this possibility, a new space challenge for mankind is to develop near-Earth early warning biological surveillance (and mitigation) systems for incoming cosmic in-falls of micro-organisms and viruses from the cometary dust and meteorite streams that our planet routinely encounters as it orbits the Sun.

Acknowledgement

We acknowledge for discussion and contributions in development of ideas in this and earlier articles, Stephen G Coulson, Max K Wallis, Brig Klyce, Predrag Slijepcevic, Alexander Kondakov, Dayal T Wickramasinghe, George Howard, Herbert Rebhan, Pat Carnegie, Ananda Nimalasuriya and Milton Wainwright

References

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  2. Blanco-Melo D, Nilsson-Payant BE, Liu WC, Uhl S, Hoagland D, et al. (2020) Imbalanced Host Response to SARS-CoV-2 Drives Development of COVID-19. Cell 181: 1036-1045. [crossref]
  3. Hadjadj J, Yatim N, Barnabei L, Corneau A, Boussier J, et al. (2020) Impaired type I interferon activity and exacerbated inflammatory responses in severe Covid-19 patients. Science 369: 718-724. [crossref]
  4. Netea MG, Giamarellos-Bourboulis EJ, Domı ́nguez-Andre ́s J, Curtis N, van Crevel R, et al. (2020) Trained Immunity: a tool for reducing susceptibility to and the severity of SARS-CoV-2 infection Cell 181: 969- 977. [crossref]
  5. Lucas C, Wong P, Klein J, Castro TBR, Silva J, et al. (2020) Longitudinal analyses reveal immunological misfiring in severe COVID-19. Nature. 584: 463-469.
  6. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Comments on the Origin and Spread of the 2019 Coronavirus. Virology: Current Research 4:1.
  7. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Growing Evidence against Global Infection-Driven by Person-to-Person Transfer of COVID-19. Virology: Current Research 4:1.
  8. Wickramasinghe NC, Steele EJ, Gorczynski RM, Temple R, Tokoro G, et al. (2020) Predicting the Future Trajectory of COVID-19. Virology: Current Research 4:1.
  9. Wickramasinghe NC, Wallis MK, Coulson SG, Kondakov A, Steele EJ, et al. Intercontinental Spread of COVID-19 on Global Wind Systems. Virology: Current Research 4:1.
  10. Wickramasinghe NC, Steele EJ, Nimalasuriya A, Gorczynki RM, Tokoro G, et al. (2020) Seasonality of Respiratory Viruses Including SARS-CoV-2. Virology: Current Research 4:2.
  11. Steele EJ, Gorczynski RM, Lindley RA, Tokoro G, Temple R, et al. (2020) Origin of new emergent Coronavirus and Candida fungal diseases- Terrestrial or Cosmic? Advances in Genetics 106: 75-100. [crossref]
  12. Steele EJ, Lindley RA (2020) Analysis of APOBEC and ADAR deaminase-driven Riboswitch Haplotypes in COVID-19 RNA strain variants and the implications for vaccine design. Research Reports Vol 4.
  13. Hoyle F, Wickramasinghe NC (1979) Diseases from Space. JM Dent Ltd, London.
  14. Hoyle F, Wickramasinghe NC (2000) Astronomical Origins of Life: Steps Towards Panspermia. Klower Academic Publishers, Dordrechl, Netherlands.
  15. Steele EJ, Al-Mufti S, Augustyn KA, Chandrajith R, Coghlan JP, et al. (2018) Cause of Cambrian Explosion: Terrestrial or Cosmic? Prog Biophys Mol Biol 136: 3-23. [crossref]
  16. Steele EJ, Gorczynski RM, Lindley RA, Liu Y, Temple R, (2019) et al. Lamarck and Panspermia – On the Efficient Spread of Living Systems Throughout the Cosmos. Prog Biophys Mol Biol 149: 10 -32.
  17. Steele EJ, Gorczynski RM, Rebhan H, Carnegie P, Temple R, et al. (2020) Implications of haplotype switching for the origin and global spread of COVID-19. Virology: Current Research 4: 2. Supplementary data at: https://www.hilarispublisher.com/open-access/implications-of-haplotype-switching-for-the-origin-and-global-spread-of-covid19.pdf
  18. Huang C, Wang Y, Li X, Zhao J, Ren L, et al. (2020) Clinical Features of Patients Infected with 2019 Novel Coronavirus in Wuhan. Lancet 395: 497-506.
  19. Cohen J (2020) Wuhan seafood market may not be source of novel virus spreading globally. Science Vol 367.
  20. Coccia M (2020) Factors determining the diffusion of COVID-19 and suggested strategy to prevent future accelerated viral infectivity similar to COVID. Science of the Total Environment 729: 138474. [crossref]
  21. Martelletti L, Martelletti P (2020) Air Pollution and the Novel Covid-19 Disease: a Putative Disease Risk Factor. SN Compr Clin Med 2: 383-387.
  22. Andersen K (2020) Clock and TMRCA based on 27 genomes. Novel 2019 coronavirus. http://virological.org/t/clock-and- tmrca-based-on-27-genomes/347
  23. Howard GA, Wickramasinghe NC, Rebhan H, Steele EJ, Reginald M, et al. (2020) Mid-Ocean Outbreaks of COVID-19 with Tell-Tale Signs of Aerial Incidence Virology: Current Research 4: 2.
  24. Antartica Base: The remote Chilean Army Base in Antartica suddenly became engaged in late December 2020 by multiple simultaneous COVID-19 cases https://www.bbc.com/news/world-latin-america-55410065; https://www.abc.net.au/news/2020-12-23/more-covid-cases-linked-to-chilean-antarctic-base/13009706
  25. Google: “Coronavirus disease statistics” URL is https://bit.ly/3vxbD5i This gives you the “Australia” dashboard (from there you can choose your country in the menu bar scroll)
  26. Luskin DL (2020) The failed experiment of COVID-19 lockdowns. The Wall Street Journal.

Accumulation Rates Using the 210Pb Dating Method in a Sediment Core of the Cispatá Bay, a Marine Protected Area in the Southwestern Colombian Caribbean

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DOI: 10.31038/GEMS.2021322

Abstract

Sedimentation rates in coastal environments are controlled by different natural processes and could be affected by anthropic activities. To evaluate how was the evolution of the sedimentation along recent time, one sedimentary core (P01-BDC) from the Cispata bay was collected and analyzed to determine the sediment accumulation rates by 210Pb dating. Using the constant flux (CF) model and validating by the activity of 137Cs, the mass accumulation rates varied from 0.02 g cm-2 year-1 during 1888 until 0.29 g cm-2 year-1 in 2019. Increasing low sedimentation rates in a transitional estuarine -marine environment with variable fluvial sediment supply was explained by changes in the salinity due to the relocation of the main tributary of the bay.

Keywords

Sediment accumulation rates, Pb-210, Marine protected area, Colombian Caribbean

Introduction

Coastal zones are essential and integral components of the land since they constitute critical areas for environmental, economic, and social well-being. These environments have unique characteristics because of the exchange of matter and energy between the atmosphere, the land, and the sea, those which promote the development of coastal ecosystems and habitats such as estuaries, deltas, beaches, among others [1,2]. Estuaries are inlets open to coastal oceans that receive freshwater inputs and increasingly face the effects of climate change, including sea-level rise, habitat loss, hurricanes, and anthropic effects such as changes in land use, pollution, among others [1-3]. These stressors affect the distribution and behavior of animal and plant species, chemical components, and sedimentation processes [2] Sedimentation in estuaries is driven by runoff from hydrographic basins and tidal currents that vary with different time scales, it is one of the most relevant management challenges since it can negatively affect the environment by modifying flood regimes, and circulation and water quality [3]. On the Colombian Caribbean coast, in the southwest of the Morrosquillo Gulf is the Cispatá Bay, an estuary made up of fine sediments and some coral fossil deposits [4]. The Cispatá bay was formed from the evolution of the deltaic lagoon system of the Sinú River, whose flow is thrown into the Caribbean Sea through three mouths, Corea, Tinajones, and Los Llanos [5]. This river ended up in the Cispatá Bay until 1938, beginning its avulsion in the Tinajones area, whose mouth opened completely around 1945. Since then, different disturbances to the flow regime of the Sinú River have caused changes in the hydrodynamics and the contribution of sediments to the Cispatá Bay [6]. Using 210Pb technique, we dated a sediment core collected in Cispatá bay in 2019 to evaluate the temporal trends of sediment accumulation rates (SAR) in the last century, under the hypothesis that changes in the input of sediments to the bay are related to the changes in the channel of the Sinú River. The results achieved will be valuable to understand the role of changes in the Sinú River delta, erosive processes, textural features, and pollution trends.

Methodology

Area of Study

Cispatá Bay is located in the Colombian Caribbean Coast, enclosed in The Mestizos peninsula on the western side of the Morrosquillo Gulf (Figure 1), Cordoba department, between 09°25′12″–09°20′8″N and 75°47′37″–75°55′30″W [7,8]. The Bay is a Holocene depositional landform formed by Rio Sinú before its diversion occurred between 1937 and 1945, when the Tinajones delta started to grow [6]. Rio Sinú is one of the most important fluvial systems of the Colombian Caribbean, draining the Andes with a total length of about 415 km and is a very intervened catchment area of 17,000 km2. Its mean discharge is about 398.09 m3/s (max. 858.2 m3/s, min. 29.1 m3/s) [9] and its sediment load is estimated to be in the order of 4.2 million t/y [10]. The bay has a tropical climate affected by Intertropical Convergence (ITC) annual displacements between the latitudes 5°S and 15°N, which produces an arid xerophytic savanna climate, with annual mean temperatures of 28.3°C (max. 28.8°C in January and April; min. 27.9°C in October and November). Mean annual rainfall is about 1230 mm, with 3.3 mm in January and 177.6 mm in September (data for Monteria from IDEAM [11]. During the dry season (from December to April), north-east and north Trade winds prevail with speeds between 4 and 23 kt, whereas the wet season (from August to November) is characterized by calms and slow winds mostly from the west and south-west. Cispatá Bay is surrounded by a dense mangrove forest where some urban settlements live on fishing and wood production [12]. The surrounded areas have shown in the last years an increment in anthropic activities like agriculture, large variety of commercial fishing and tourism, as well as, some industrial activities such as an oil port which is located approximately 12 km from the Cispatá Bay [13]. This mangrove ecosystem also has the potential of saving high amounts of blue carbon [14], being in this way an important area for climate change politics.

FIG 1

Figure 1: Dated core in the study area, Cispatá Bay Colombian Caribbean.

Sample Collection

Sediment cores were collected in three different points of the Bahia de Cispatá in September of 2019, using a gravity corer UWITECTM with a transparent liner (1,2 m long, 8.5 cm inner diameter). The depth of the water was around 1,8 m. The cores were immediately transported to the laboratory, where they were extruded and subsampled every 1 cm. The mass of each section was recorded before and after drying at 40°C. Sediments were ground to powder by using agate mortar and pestle. The samples were stored in polyethylene bags and the analysis were carried out at the Marine Environmental Quality – LABCAM of INVEMAR. The core collected at 9°24’54,2” (N) – 75°48’35,2” (W) (point P01-BDC, Figure 1) had a length of 72 cm and was dated with 210Pb. The activities are expressed on a dry weight basis.

Laboratory Analyses

Total 210Pb activities (210PbTot) in the core were estimated by measuring the activity of its daughter product 210Po assuming secular equilibrium between the two isotopes by alpha spectrometry [15,16]. Accuracy was evaluated by measuring a certified reference material DL1-A (Uranium -Thorium Ore DL1-A, Canada Centre for Mineral and Energy Technology) for 210Pb. Polonium isotopes were measured using a silicon surface barrier (EG&G Ortec Mod. ENS-U450) α-spectrometer. This detector is characterized by high energy resolution, low background, and stability. Discs were measured until achieving less than 5% of uncertainty in the 210Po counting rate, according to IAEA [20]. Standard gamma spectrometry was used to measure 137Cs via its emission at 662 keV and 226Ra (supported 210Pb) by the activity of 214Pb at 295 keV and 351 keV [17]. Samples were placed and measured in a coaxial type (8 cm diameter) high-purity germanium detector (HPGe) from CANBERRA and counted for one week. Energy and efficiency calibrations were made using a certified reference material DL1-A (Uranium -Thorium Ore DL1-A, Canada Centre for Mineral and Energy Technology) for 210Pb and 226Ra, IAEA-375 (Radionuclides and trace elements in soil) for 137Cs, and 40K in a high purity (≥99.5%) salt KCl salt (manufactured for Merck)

Data Processing

Constant flux (CF) of 210Pb model was used. In the CF model non-linearities of the 210Pb profile are interpreted assuming a constant net rate of supply of unsupported 210Pb (210Pbuns) from sea-water to the sediment, irrespective of changes which may have occurred in the net dry mass sedimentation rate [18]. Supported value (210Pbsup) is determined by two methods: first one by averaging the 210Pb activities in the base of the core where they become constant [19] and second one by the activity of 226Ra measured by gamma spectrometry. Then, unsupported value (210Pbuns) is obtained by subtracting 210Pbsup from 210PbTot. This model allows to estimate the age of the sediment as well as the mass accumulation rates (MAR) and sediment accumulation rates (SAR). More information about age models and calculations are explained in detail by Sanchez [20].

Results

The core shows an exponential decay of the total 210Pb (210PbTot) activity with mass depth (Figure 2a), with values ranging between 13.0 ± 1.1 Bq kg-1 and 43.7 ± 4.5 Bq kg-1. and an average 210PbTot activity of 24.78 ± 7.3Bq kg-1 However, there are clear differences mainly after 15 g cm-2 where the profile shows a peak with the lowest activity of 13.0 Bq kg-1, increasing to 25.5 Bq kg-1 at 17.7 g cm-2. The activities behavior until the end of the core is erratic. Values for 210Pbsup are very similar by the two methods of calculation, i.e. via 214Pb (226Ra) emission peaks (Table 1) and by averaging the activities of 210PbTot (Figure 2a) at the bottom of the core (20.9 ± 3.1 Bq kg-1). Due to the uncertainties associated to both methods, the average activity determined by alpha spectrometry was used for calculations of 210Pbex. The 210Pbexs activity (Figure 2b) shows values between 22.7 and 4.3 Bq kg-1 with an average value of 13.8 Bq kg-1 fitted to an exponential decay profile (r2=0.75). The 210Pbexs activities in the first 15 cm of the sediment section were used to calculate the age sediments applying the CF model (Figure 2c), allowing to date the period since 1888 until 2019. The model was validated by gamma detection of 137Cs in the core at 7.7 g cm-2 which was dated at 1983 ± 4, with this uncertainty the result could be associated with the Chernobyl accident in 1986. MAR and SAR profiles (Figure 3) present the same trends with time, a low and constant rate in the bottom increasing little by little until the top of the core. MAR increase from 0.02 g cm-2 year-1 in 1888 to 0.30 g cm-2 year-1 in 2019. By the other hand, SAR increase from 0.02 cm year-1 in 1888 to 0.45 cm year-1 in 2018 and decreasing to 0.38 cm year-1 in 2019. Due to the low sedimentation rates each analyzed section enclose several years having decadal or five-years period resolution.

Table 1: Gamma emission for 226Ra (210Pbsup) for the bottom sediment section for the core P01-BDC, Cispatá Bay Colombian Caribbean.

Core section

 214Pb295kev (Bq kg-1)

214Pb351kev (Bq kg-1)

67-68

 17.99

17.25

70-71

 18.54 18.38
71-72 17.85

20.30

Average

18.39

Std. Dev

1.04

fig 2

Figure 2: Dated core P01-BDC in Cispatá Bay Colombian Caribbean. a) total activity profile of 210Pb, b) excess activity profile of 210Pb, c) Age model.

fig 3

Figure 3: Sediment rates for core P01-BDC: a) Mass accumulation rates, b) Sediment accumulation rates.

Discussion

Activity of 210Pbtot is comparable with the reported values of 12.8 ± 0.4 to 46.6 ± 1.1 Bq kg-1 in Soledad Lagoon [21] which is part of the Cispatá swampy system. This low activity values are expected in some marine areas previously explained as the result of low atmospheric 210Pb fluxes and low production of 210Pb [22]. Sedimentation rates (MAR ad SAR) are higher in Cispatá bay compare with those calculated for Soledad Lagoon MAR 0.08 ± 0.01 g cm-2 year-1 and SAR 0.154 ± 0.018 cm year-1 [21], due to the differences in the type of system, being Cispatá bay a more dynamic system influenced directly by the Caribbean sea and the fluctuations of the Sinú river mouth relocation, that control the sediment supply.

The Sediment rates in Cispatá bay showed changes associated with the geomorphological variations during the last 100 year. The relocation of the principal mouth after 1938 is evidenced in the increase of MAR and SAR. Before this time, the system was an estuarine system with high input of fresh water [6] and with variable hydrodynamics because of the changes in the Sinú river mouth which have been occurring since 1762 according to the available registers [6,11]. The transitional events occurring between an estuarie and a marine system in which salinity changes could form a salt wedge or significant differences in density, causing the fine sediment to remain more time in the water column. Thus, the sedimentation rates are low even with high sediment supply. The gradually increase trend of the sedimentation rates are in agreement with [6] who showed bathymetrically that during the period 1762-1849 the area where the core was recollected, presented erosive processes which implies a minor sediment input, meanwhile for the period 1849-1938 occurred a siltation process. According with the MAR and SAR calculated between 1938 and 2019, the sedimentation process has increased slowly evidencing that sedimentary behavior of Cispatá Bay is driven by: the morphodynamical characteristics of the surrounding environment, the input of water and sediment from the Sinú River remaining channels, the possible income of sediments from the erosion process occurring in the previous river mouth in Punta Terraplen, and by changes in land use.

Conclusion

The age model, based on 210Pb activities, give valuable information about the sedimentary rates (MAR and SAR) in Cispatá Bay during the last ~100 year, evidencing changes in the sedimentary regime associated with geomorphological events which are important for the management of this marine protected area with high ecological potential, especially in blue Carbon sequestration. These preliminary results should be part of complementary research about flux of organic matter, pollutants as heavy metal, hydrocarbons, and other variables of environmental interest.

Acknowledgment

This research was financed by the National Hydrocarbons Agency (ANH) of Colombia, Ministry of Environment and Sustainable Development and the Institute for Marine and Coastal Research (INVEMAR). The authors thank to the Ministry of Science and Technology of Colombia, who support the post doctorate of Dr. Pedro Vallejo-Toro. The authors acknowledge the fishermen Domingo Rodríguez and Nairo Mendoza for their support to collect the sample cores, the staff of INVEMAR Marine Environmental Quality Laboratories Unit, for collect the samples and carry out the laboratory analysis, and Andrea Beltran of the INVEMAR Laboratory for Information Services, for preparing the map. Finally, the authors thank the anonymous reviewers whose suggestions improved the manuscript. Scientific Contribution of INVEMAR No. 1303.

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Seroprevalence of Cytomegalovirus Antibodies in a Group of Bangladeshi Women in Child-Bearing Age: A Pilot Study

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DOI: 10.31038/AWHC.2021433

Abstract

Background: Human Cytomegalovirus (HCMV) is the most common cause of congenital infections and can be life-threatening in immune compromised individuals. We aimed to shed light on the Seroprevalence of HCMV antibodies in women of child-bearing age in a tertiary care hospital and in a health science university of Bangladesh.

Methods: A total of 84 apparently healthy 20-40 years old women (42 pregnant and 42 non-pregnant) were screened for anti-CMV IgG and IgM antibodies using Enzyme Linked Immunosorbent Assay (ELISA). Serum levels of bilirubin, and liver enzymes (alanine aminotransferase, aspartate aminotransferase) were evaluated by biochemistry auto analyzers.

Results: All the participants were found positive for anti-CMV IgG (100%) while 1 pregnant woman revealed positivity for both IgM and IgG justifying recent infection. CMV IgG antibody was found positive in 48 (68.6%) and 14 (100%) relatively younger volunteers in married (n=70) and unmarried (n=14) group respectively, and in 22 (31.4%) elderly volunteers of married group. Significantly higher mean value of Sample Optical Density (SOD) for CMV IgM was observed in pregnant than that of non-pregnant counterpart (p=0.023; 95% CI=0.032-0.002). Again, the mean SOD of CMV IgG was significantly lower in non-pregnant women compared to that of the pregnant women in the employed group [p=0.029; 95% CI=1.176-(-0.006)].

Conclusion: The present study demonstrates that the women of child bearing age are very much exposed to CMV infection. Pregnancy and working outside (employment) are two important risk factors for repeated exposure to infection as indicated by higher measured Optical Density (OD) for CMV IgG. A comprehensive study with a long-term follow-up of offspring born to HCMV IgM-positive mothers would provide estimates of an accurate percentage of symptomatic congenital HCMV infection in Bangladesh.

Keywords

CMV IgM, CMV IgG antibody, ELISA, Child-bearing age

Introduction

Human Cytomegalovirus (CMV), a double-stranded DNA virus belonging to the Herpesviridae family, is widespread throughout the world. The seroprevalence rates of CMV vary in countries with an estimated seroprevalence of 45% to 100% in the general population [1-3]. Globally, the disease burden is highest because of congenital CMV infection. Non-primary maternal infection among seropositive women is the cause of most congenital infections in populations with high CMV seroprevalence [4] though there are potential risk factors also for pregnant seronegative women in these settings. Intrauterine transmission of this virus has been associated with both primary and non-primary maternal CMV infection resulting in birth defects and long-term developmental disabilities [4]. Permanent sequelae include Sensorineural Hearing Loss (SNHL), microcephaly, seizures, neurologic deficits, and retinitis. The virus becomes latent after primary infection and sporadic recurrence with intermittent viral shedding may last throughout the life an important source of infection [5]. Studies in high-income and middle-income countries revealed that sensorineural hearing loss and neurological damage due to CMV infection is driven by maternal infection that occurs before 14 weeks of pregnancy [6,7]. Majority of the patients are asymptomatic but can cause life-threatening complications in immunocompromised individuals like patients with AIDS and other immune disorders, transplant recipients, individuals admitted to intensive-care units, and to some extent in elderly people [8]. In these patients, high viral loads in the urine are associated with viraemia, dissemination to multiple organs, and end‐organ diseases such as pneumonitis, retinitis, hepatitis, or gastroenteritis [9]. Transmission of CMV via blood transfusion and blood component is a matter for concern among blood bank professionals and blood transfusion recipient, particularly in cases of transfusion to neonates and immunocompromised patients.

Few women are aware of this public health burden [10-12] which can be alleviated by widespread education relating CMV transmission and preventive hygiene behavior and thereby can reduce congenital CMV infections [13-17]. Active and passive immunization strategies would be necessary to prevent in utero infection. The tendency for infection with multiple different virus strains and high virus diversity pose a vital biological barrier to the progress of effective vaccines [18-22]. Though there is no licensed vaccine available so far that protects against CMV, still several vaccine candidates are being tested now in clinical trials [23-25]. To address public health issue and for primary prevention through immunization, epidemiological data on CMV susceptibility of the population are crucial so that undesirable consequences in infants could be circumvented. Since there is insufficient population-based CMV-specific IgG seroprevalence data available for adults of Bangladesh, the aims of this study were to estimate CMV seroprevalence in the women of child bearing age in Bangladesh and to identify socio-demographic factors that are potentially associated with CMV seropositivity.

Methods and Materials

Study Design, Setting, and Type of Participants/Materials Involved

This cross-sectional study spanned between July 2019 to June 2020 which included total 84 (42 pregnant, 42 non-pregnant) women. Pregnant women of child-bearing age (20-40 years) attending at the Obstetrics and Gynaecology out-patient department of Bangladesh Institute of Health Sciences General Hospital, Mirpur, Dhaka for routine antenatal checkup and non-pregnant women (faculty members, staffs and senior students) of equal age group from the Bangladesh University of Health Sciences (BUHS) were enrolled as study subjects. Pregnancy status and duration of pregnancy was confirmed by Obstetricians diagnosis and ultrasonography report (USG of lower abdomen) respectively.

Specimen Collection and Serum Preparation

Under aseptic precaution, 4 ml of blood sample was collected from each volunteer by venipuncture and transferred to a vacutainer (plain red–top tube). Prior to sample collection, a written informed consent was obtained from each participant. Sample was allowed to stand for one hour to clot and then centrifuged at 3000 rpm for 15 minutes. Separated serum was aliquoted into three microcentrifuge tubes (0.5 ml in each). One aliquot was used for biochemical liver function test, another for determination of IgM and IgG antibodies for CMV. The third aliquot was preserved at -20º C for future laboratory analyses (if any).

Liver Function Test, Anti-CMV IgM and Anti-CMV IgG Detection

Liver function tests; serum bilirubin, ALT (Alanine Transaminase) and AST (Aspartate Transaminase) levels were estimated by biochemistry auto analyzer (Dimension, Siemens, Germany). Anti-CMV IgM and anti-CMV IgG antibodies were determined by Enzyme Linked Immunosorbent Assay (ELISA) method using commercially available qualitative ELISA kits (DRG, Germany).

Statistical Analysis

Data were expressed as mean ± SD, number (percent) as appropriate. Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 20.0 was used to carry out statistical analysis. Unpaired Student’s ‘t’-test and Chi-squared test with 95% Confidence Interval (CI) were applied to calculate statistical difference and association for continuous and qualitative data respectively. Means and standard deviations were calculated for continuous variables while frequencies and percentages were calculated for categorical variables. Data were presented by tables and figures. A p value of less than 0.05 was considered as level of significance.

Ethical Aspects

The study was carried out following the international codes for ethical use of human subjects. The study was approved by the Ethical Review Committee (ERC) of Bangladesh University of Health Sciences and proper ethical guidelines were followed during sample collection.

To meet the ethical consideration an information sheet explaining the purpose of the study was provided to the subjects and a written informed consent from each of the participants was sought to recruit them in this study.

Results

Socio economic characteristics of the volunteers were shown in Table 1. The study included adult women (pregnant 42 and non-pregnant 42) of child bearing age in Dhaka city of age range from 20 to 40 years. Mean ( ± SD) age (years) of the pregnant cases was 27.62 ( ± 4.57) and non-pregnant 28.21 ( ± 5.41). Most of the participants (67%) of the pregnant women group were homemakers and rests involved in job of different type (33%). Of the non-pregnant counterpart majority (67%) were working outside which demonstrated statistically significant association (p=0.002).

Table 1: Socio-economic characteristics in respect to the pregnancy status (N=84).

Variables

 Pregnant (n=42) N (%) Non-pregnant (n=42) N (%) χ2

p value
Educational Level Upto class 12

12 (38)

20 (62)

3.23

0.072
Graduate and Higher

30 (58)

22 (42)
Occupational Status Employed

14 (33)

 28 (67) 9.33

0.002
Unemployed

28 (67)

14 (33)
Income group Below cut off

30 (52)

 28 (48) 0.223

0.637
Above cut off

12 (46)

14 (54)

Results were expressed as number and percentage. Chi square test was performed to calculate significant statistical association. p< 0.05 was considered as level of statistical significance.

Income group taking per-capita income USD 2064/- to date; Unemployed include homemakers (26 pregnant & 5 non pregnant) and students (2 pregnant & 9 non pregnant).

All the participants were found to be seropositive for CMV IgG antibody irrespective of pregnancy status, whereas only one pregnant woman of 28 years was found to be seropositive for CMV IgM antibody at her third trimester of pregnancy.

CMV IgG antibody was found positive in 48 (68.6%) and 14 (100%) relatively younger volunteers in married (n=70) and unmarried (n=14) group respectively, and in 22 (31.4%) elderly volunteers of married group (Figure 1).

fig 1

Figure 1: Percentage of positive CMV IgG antibody among different age group of married and unmarried women.

Mean ± SD of Age, Bilirubin, ALT and AST levels in pregnant and non-pregnant group did not show any statistically significant difference (Table 2). It was observed that majority of the subjects had no history of blood transfusion and jaundice (pregnant 83.3% and 95.2% respectively and non-pregnant women 90.5% and 90.5% respectively). It was also found that majority of the pregnant women (83.3%) had no history of major surgery previously. Although 69% of non-pregnant women had no history of major surgery in their previous days, almost one-third (31%) of this group had positive history of major surgery previously (Data not shown).

Table 2: Age and biochemical variables of the subjects in respect to Pregnancy status (N=84).

Variables

Pregnant (n=42) Non-pregnant (n=42) p value 95% CI
Upper

Lower
Age (yrs)

27.62 ± 4.57

 28.21 ± 5.41 0.59 1.58

-2.78
S bilirubin (mg/dl)

0.31 ± 0.13

 0.37 ± 0.17 0.07 -0.13

0.01
S ALT (U/l)

22.63 ± 8.51

 22.41 ± 6.82 0.89 3.56

-3.13
S AST (U/l)

23.78 ± 12.19

 20.67 ± 5.43 0.14 7.2

-0.99

Results were expressed as Mean ± SD. Unpaired Students’ t-test was performed to calculate statistical difference between the two groups. p<0.05 was considered significant.

When we measured Optical Density (OD) for CMV IgM, it was observed significantly higher in pregnant than that in the non-pregnant women (p=0.023). No such significant difference was seen in case of CMV IgG (Table 3).

Table 3: Mean values of optical density (OD) of CMV IgG and CMV IgM with Pregnancy status (N=84).

Optical density (OD)

 Pregnant (n=42) Non pregnant (n=42) P value 95% CI
Upper

Lower
CMV IgG

2.78 ± 1.08

 2.70 ± 0.73 0.711 0.477

0.327
CMV IgM

0.040 ± 0.044

 0.023 ± 0.17 0.023 0.032

0.002

Results were expressed as Mean ± SD. Unpaired Students’ t-test was performed to calculate statistical difference between the two groups. p<0.05 was considered significant.

Upon comparison between employed and unemployed status, the OD for measurement of CMV IgG was significantly higher in pregnant women than that of the non-pregnant women in the employed group (p=0.029). Among the unemployed group, it is quite similar (2.57 ± 1.22 in pregnant and 2.49 ± 0.75 in non-pregnant) (p=0.184). No statistically significant difference was observed in OD for measurement of CMV IgM (Table 4).

Table 4: Optical density values of CMV IgG and IgM assay among those employed and unemployed of pregnant and non-pregnant subjects (N=84).

Variable

 Pregnant (n=42) Non pregnant (n=42) P value 95% CI
Upper

Lower

CMV IgG assay Employed (14/28)

3.19 ± 0.55

 2.81 ± 0.71 0.029 1.176

-0.066
Unemployed (28/14)

2.57 ± 1.22

 2.49 ± 0.75 0.184 0.799

-0.158
CMV IgM assay Employed (14/28)

0.043 ± 0.07

 0.020 ± 0.01 0.817 0.033

-0.026
Unemployed (28/14)

0.039 ± 0.03

 0.029 ± 0.02 0.098 0.001

0.02

Results were expressed as Mean ± SD. Unpaired Students’ t-test was performed to calculate statistical difference between the two groups. p<0.05 was considered significant.

Discussion

All the subjects of childbearing age (20-40 years), pregnant and non-pregnant, recruited in the study demonstrated 100% seropositivity for anti-CMV IgG antibody. It suggests that these women had been exposed with cytomegalovirus previously at some points of their life. They were of different occupations ranging from being unemployed housewives to pursuing high careers and also students. The level of education also ranged widely up to post-graduation. This vast diversity of participants being positive for CMV IgG represents that the virus is well spread through the population of Bangladesh. The present study is supported by report carried out in a tertiary care hospital of Dhaka which also demonstrated 100% pregnant women were seropositive for anti CMV IgG antibody in their first antenatal visit, reflecting a high seroprevalence of CMV IgG in Bangladesh [26]. Another recent study in Bangladesh revealed 91% seroprevalence of CMV IgG among the blood donors [27]. Finding of this study is also consistent with a report from India where seropositivity of anti-CMV IgG was 87% in women of child bearing age [28]. Higher seroprevalence of CMV IgG in pregnant women was also found in other countries like 98.5% in Turkey [29], 89.6% in Mexico [30] and 98% in Brazil [31]. A systematic review and meta‐analysis estimated global mean seroprevalence for the general population was 83% and the maximum mean seroprevalence was found 90% in the Eastern Mediterranean region, while the lowest was 66% in the European countries [1].

Majority of the participants from both pregnant and non-pregnant group in this study had no previous history of blood transfusion and never underwent a major surgery although it is proven that CMV infection is not directly related with blood transfusion which can be justified by a study where CMV DNA was rarely identified in healthy blood donors validated by Polymerase Chain Reaction (PCR) assay [32]. Most of the subjects in our study never had jaundice.

One pregnant woman in her third trimester was found to be positive for both anti-CMV IgM and IgG antibodies. Being positive for both types of antibodies makes it impossible to determine whether it was a primary infection, a re-infection, or a super-added infection during the pregnancy. Although the low Sample Optical Density for IgM (SOD: 0.262) in comparison to that of IgG (SOD: 3.14) was indicative for convalescence stage of a primary infection earlier in her pregnancy or there may be a possibility of low level of re-infection. Our study does not correlate with findings of a hospital study in Dhaka where the researchers found 60% of the pregnant women were positive for anti-CMV IgM antibody, whereas 1.3% newborns of CMV IgM positive mothers were also found positive for CMV IgM antibody [26]. We did not perform such screening in the newborns in our study. However, the CMV IgM positive mother in our study neither showed any symptom of viral infection nor had a suggestive history during blood collection. Again, her USG of pregnancy profile revealed a normal pregnancy going on. Since this pregnant woman was moderately anemic (Hb level: 9 gm/dl, data not shown), it probably exposes her vulnerability to viral infections due to poor immune status though single finding is not enough to prove. Her serum Bilirubin, ALT and AST levels were all within normal range possibly for the mild infection. Since, anemia significantly correlated with pregnancy status, our findings did not support its relationship with CMV infection. Especially iron deficiency anemia affects humoral immunity adversely which subsequently renders increased chance of viral infection. Although high incidence of anemia in pregnancy is probably the result of inadequate intake of nutritious food and increasing demand for iron and folic acid making them more vulnerable to different viral infections [33]. CMV has an uncommon link with anemia since it is one of the features of Chronic Kidney Disease (CKD) and a complication of renal transplantation because of impaired production of erythropoietin [34].

Both married and unmarried participants who were relatively younger (20-30 years) showed increased seropositivity for CMV IgG than the older (above 30 years) age group. A longitudinal study in Germany also exhibited the maximum seroprevalence in the 16-20 years age group [35].

Significantly, higher mean SOD value of CMV IgM in pregnant women compared to non-pregnant women reflects probable reactivation of the virus since CMV IgM is highly sensitive but has poor specificity for identifying primary CMV infection. One drawback of this study was that we could not measure Avidity Index (AI) which is a suitable diagnostic tool for the detection of primary infection or reactivation/reinfection. Low CMV IgG avidity indicates primary infection whereas high avidity exhibits past infection or reactivation excluding primary infection [36-38].

Another limitation was the small sample size which was confined to only one selected hospital and health Science University at same premise. Newborns of infected mothers could not be screened for the presence of CMV antibodies due to time constraints.

In this study, we observed that the pregnant women who were employed, more likely to demonstrate significantly higher mean SOD value for CMV IgG than the employed but non-pregnant women. This higher measurement for CMV IgG assay perhaps may be caused by repeated exposure (for working outside) to the CMV infection during pregnancy or by development of cross-reactive antibodies in pregnant women. Higher prevalence of CMV IgG among working women was observed than homemakers though the difference was not significant demonstrated by Aljumaili et al., [39]. Moreover, immunocompromised state during pregnancy makes the women much more vulnerable to any kind of infection like infection by CMV.

A major strength of this study was the use of a representative population-based sample to determine CMV seroprevalence in women of reproductive age. But longitudinal analysis with large sample size and factors associated with it would be essential to figure out the true picture of CMV seroprevalence in women.

Conclusion

Data suggest that high endemicity of CMV infection is present in women of child bearing age in Bangladesh. To reduce the risk of CMV infection, measures like CMV screening during pregnancy and educating seronegative women could prevent congenital CMV infections with its serious consequences. Advanced laboratory techniques like PCR may be applied for strain detection and following up treatment outcome. Moreover, due to mutation, a strain of CMV is possible to emerge with devastating effects such as seen in case of COVID-19.

Acknowledgement

We are thankful as well as grateful to the BUHS authority for financial support to perform the study and to all the subjects who participated voluntarily in this study.

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  35. Hoehl S, Berger A, Ciesek S and Rabenau HF (2020) Thirty years of CMV seroprevalence-a longitudinal analysis in a German university hospital. European Journal of Clinical Microbiology & Infectious Diseases 39: 1095-1102.
  36. Grangeot-Keros L, Mayaux MJ, Lebon P, Freymuth F, Eugene G, et al. (1997) Value of Cytomegalovirus (CMV) IgG avidity index for the diagnosis of primary CMV infection in pregnant women. J Infect Dis 175: 944-996. [crossref]
  37. Bodeus M, Feyder S, Goubau P (1998) Avidity of IgG antibodies distinguishes primary from non-primary cytomegalovirus infection in pregnant women. Clin Diagn Virol 9: 9-16. [crossref]
  38. Lazzarotto T, Spezzacatena P, Pradelli P, Abate DA, Varani S, et al. (1997) Avidity of immunoglobulin G directed against human cytomegalovirus during primary and secondary infections in immunocompetent and immunocompromised subjects. Clin Diagn Lab Immunol 4: 469-473. [crossref]
  39. Aljumaili ZKM, Alsamarai AM, Najem WS (2014) Cytomegalovirus seroprevalence in womenwith bad obstetric history in Kirkuk, Iraq. Journal of Infection and Public Health 7: 277-288.

 

Homeopathic Viscum Album on the Treatment of Scamous Cell Carcinoma Lesion in a Dog (Canis familiaris) – Case Report

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DOI: 10.31038/IJVB.2021523

Abstract

Squamous Cell Carcinoma (SCC) is characterized by the uncontrolled growth of abnormal skin cells. The disease affects dogs and cats generally with advanced age and has a high incidence in white and/or depigmented animals. In some situations, the conventional treatments do not contemplate the cure nor the improvement of life quality of the patients affected by this disease. For this reason, the Viscum album therapy has been indicated for treating cancer patients when conventional medicine is not an option to be considered anymore, as well in Palliative Care aiming to maintain the patient’s quality of life. This study aimed to report the healing process of a difficult resolution lesion, due to a squamous cell carcinoma, in a 9-year-old dog (Canis familiaris), PitBull breed. The disease was treated by the intravenous Viscum album therapy associated with Hamamellis virginiana, which was orally administered. The patient showed excellent response to the prescribed treatment with complete healing of a lesion derived from a SCC in only four weeks. Improvement in appetite and overall disposition were also recorded.

Keywords

Squamous cell carcinoma, Hamamellis virginiana, Viscum album, Therapy

Introduction

Squamous cell carcinoma (SCC) is a malignant neoplasia relatively common in dogs and cats [1]. The disease development is directly related to skin exposition to UV rays. However, it can also be related to burnings, previous non-malignant lesions, and chronic inflammatory diseases [2]. SCC has a higher incidence in dogs with advanced age among 6-10 years. There is no sex predisposition. The breeds Collie, Basset Hound, Schnauzer, Dalmatian, Pitbull, and Beagle seem to have a higher risk for developing this disease. Dogs of white and short fur with white or spotted ventral body parts also seem to be predisposed [2]. Diagnosis occurs by histopathological analysis of the injured tissue. The treatment of choice is by surgical resection, when possible, intralesional chemotherapy, phototherapy, cryosurgery, and electrotherapy according to the localization, evolution time, and progression of the disease [2]. Nevertheless, all treatments considered by conventional medicine cause moderate to severe side effects to the patients. Also, many times, they are not efficient. Complementary therapies have gained notoriety in cancer treatment either as a single or complementary therapy. Within this context, the Viscum album therapy is the complementary treatment most indicated by the medical doctors in Germany and Switzerland for treating cancer patients. One of the main benefits of this medicine is its selective toxicity activity on tissues affected by cancer. Viscum album presents a bidirectional activity for the patients since it can also immunomodulate the host organism [3].

Therefore, this study aimed to report the healing process of a lesion of difficult resolution due to a squamous cell carcinoma in a 9-year-old dog, PitBull breed.

Material and Methods

A 9-year-old female PitBull with white fur, 29 Kg, fed with commercial dog food, was seen at NaturalPet Clinic in Brasilia, DF, Brazil. The patient was referred from another colleague with the main complaint of a difficult to heal lesion in the abdomen and the impossibility of its surgical removal (Figure 1). The previous diagnosis was squamous cell carcinoma. The lesion had already been treated by conventional chemotherapy but with no success. On physical examination, the animal was alert to stimuli, had normal mucous membranes, and CRT 2”. The cardiac auscultation and cardiac and respiratory frequencies were within the normal range considering age and species. The patient was overweight, in normal hydration conditions, and had opaque and dry fur. Blood was collected for complete blood count and biochemical measurements. The treatment was initiated on the same day using the Viscum album therapy. One ampoule of Viscum album D3 (1×10-3) (1.1 mL) (Injectcenterâ) was intravenously administered. Additionally, Hamamellis virginiana 30CH (1×10-60), three drops, SID, for 30 days; and Omega 3 2000 mg, SID, for 60 days, were orally prescribed. It was recommended for the animal to begin a low-carb diet containing 10% carbohydrate. The tutor was also advised that the animal should come back at a 7-day interval for Viscum album D3 intravenously applications for 60 days.

fig 1

Figure 1: Overall abdomen appearance of the animal with an ulcerated and difficult to heal abdominal lesion.

Results

The result of the blood tests showed: Red blood cells – 7,750,000/uL; Hemoglobin – 17.7 g/dL; Hematcrit – 53.5%; Leukocytes – 7,600/mL; Eosinophils – 152/mL; Lymphocytes – 1,444/mL; Platelets – 324,000/mL; Albumin – 3.26 g/dL; Alanine aminotransferase – 57 U/L; Aspartate aminotransferase – 87 U/L; Creatinine – 1.23 mg/dL; Alkaline phosphatase – 29 U/L; Total proteins – 7.14 g/dL; and Urea – 29 mg/dL.

Seven days after treatment initiation, the patient returned for the endovenous Viscum album administration, and the lesion already had another appearance. The edema was smaller than the observed in the first evaluation, and so was the lesion size (Figure 2A). The progressive improvement was observed every seven days throughout four weeks (Figures 2B-D).

fig 2

Figure 2: Lesion appearance seven (A), 14 (B), and 21 (C) and (D) days after treatment initiation.

The tutor reported that the animal was more cheerful than before previously, and its appetite had improved. It also restarted playing with the other dogs of the house, which has not happened for months. This patient was followed up by the total healing period of the lesion. After the lesion has healed, the owner did not want to continue the treatment. Six months after the lesion has healed, another colleague took care of the animal, within the principles of conventional medicine. The complaint was claudication in the left posterior limb. A new investigation was initiated, and osteosarcoma was diagnosed. The patient died in 30 days by euthanasia.

Discussion

Squamous Cell Carcinoma is characterized by the uncontrolled growth of abnormal cells that appear in the squamous cell layer of the epidermis [1]. The conventional treatment protocols include surgical intervention, chemotherapy, and radiation, which possess various adverse effects [4].

Many homeopathic and phytotherapeutic medicines (Complementary Medicine) with anticancer properties, similar to the conventional medicines for treating cancer, are currently available [4], such as Viscum album. The use of complementary therapies is common among patients with advanced cancer. The role of the therapies used in Palliative Care is to guarantee the best quality of life for patients to whom healing is no longer an option. On the other hand, comfort and welfare must be reached as much as possible until the moment of death.

Within this context, Kienle and Kiene [5] had already recorded in a systematic review the best quality of life of patients using the Viscum album therapy, especially in cases of advanced cancer. Similarly, Valle and Carvalho [6] reported enhanced life quality, including improved overall condition, appetite, and activity in a patient with cutaneous melanoma under Palliative Care. Our findings are corroborated by these authors and described a clear improvement in the patient’s quality of life, which was verified not only for the lesion clinical improvement but also for enhancing the animal’s disposition and appetite. The animal started to do activities that she did not use to do for a long time, such as playing and inviting other dogs to play. She also became more active, less sleepy, and less tired.

In this study, the animal was systematically treated for approximately one month until lesion healing and had another six months of survival until the osteosarcoma diagnosis in the posterior limb. Its tutor opted for euthanasia. Among the various roles of the Viscum album therapy for the cure and treatment of cancer patients, it plays a critical action within Palliative Care. Under this perspective, this therapy aims to maintain the quality of life of patients in cases when the cure of the disease is no longer possible, but only the disease control, providing welfare until the moment of the death.

Conclusion

The Viscum album therapy associated with Hamamellis virginiana proved to be efficient in its purpose of healing an ulcerated lesion derived from the SCC development. This therapy also improved the patient’s life quality and clearly showed that Integrative therapies could be intrinsic to Palliative Care. Additional studies must be developed for the confirmation of such effects.

References

  1. Ciani F, Tafuri S, Troiano A, Cimmino A, Fioretto BS, et al. (2018) Anti- proliferative and pro-apoptotic effects of Uncaria tomentosa aqueous extract in squamous carcinoma cells. J Ethnopharmacol 211: 285-294. [crossref]
  2. Daleck CR, De Nardi AB (2017) Oncology in dogs and cats. 2nd ed, Rocca, Rio de Janeiro. 343p.
  3. Valle ACV (2020) In vitro and in vivo evaluation of the ultra-diluted Viscum album efficacy and safety. Doctorate dissertation. Catholic University of Brasilia – UCB, Brasilia-DF, Brazil. 78p.
  4. Magadi VP, Ravi V, Arpitha A, Litha, Kumaraswamy K, Manjunath K (2015) Evaluation of cytotoxicity of aqueous extract of Graviola leaves on squamous cell carcinoma cell-25 cell lines by 3-(4,5-dimethylthiazol-2-Yl) -2,5-diphenyltetrazolium bromide assay and determination of percentage of cell inhibition at G2M phase of cell cycle by flow cytometry: An in vitro Contemp Clin Dent 6: 529-533. [crossref]
  5. Kienle GS, Kiene H (2010) Review article: Influence of Viscum album L (European mistletoe) extracts on quality of life in cancer patients: a systematic review of controlled clinical studies. Integr Cancer Ther 9: 142-157. [crossref]
  6. Valle ACV, Carvalho AC (2021) Ultra-diluted Viscum album in the treatment of cutaneous melanoma in a dog (Canis familiaris) – Case report. Paripex Indian J Res 10: 1-4.

Awareness of Ultrasonography, Preconception during Pregnancy and Use of Sonography by Tribal Women- Rural Community Based Study

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DOI: 10.31038/IGOJ.2021415

Abstract

Background: Ultrasonography (USG) has become part of everyday care of pregnant women in most of the countries of the globe. However like any other technology, it has potential to raise social, ethical, economic dilemmas about benefits, challenges for health providers, beneficiaries of the services. Awareness, utilization of USG by rural tribal women who live in extreme poverty with access problems is not well known.

Objective: Community based study was carried out to know awareness of USG amongst rural, tribal, preconception, pregnant women and use of USG during pregnancy.

Material Methods: Study was conducted in tribal communities of 100 villages where community based mother child care services were initiated after having developed a health facility in one of 100 villages. Total 2400 preconception, 1040 pregnant women of 15-45 years, were interviewed in villages for knowing their awareness about USG, whether pregnant women had USG during pregnancy.

Results: Of 2400 preconception women, 626 (26.08%) were not aware of Sonography. Of those who knew, 694 (39.1%) said Sonography helped in confirmation of pregnancy, 1080 (60.88%) said it helped in knowing fetal age and position. Of 1040 pregnant women also 271 (26.1%) were not aware of USG. Those who knew, sources of information, were Accredited Social Health Activists (ASHAs) in 208 (27%), nurse midwives in 170 (22.1%), family members in 311 (40.4%), doctors in 80 (10.4%). Only 258 (33.5%) of 769 women who knew about USG had got USG done. Of them 82 (31.8%) were told that something was wrong without any details.

Conclusion: Study revealed that many rural tribal women did not even know about USG. Community health workers, ASHAs did create awareness of USG in some. Only 25% pregnant women had USG done but without knowing any details of findings.

Keywords

Preconception, Pregnancy, Awareness, Ultrasonography Finding

Background

Ultrasonography is now a integrated part of pregnancy care in most of the countries around the world. Diagnostic ultrasound during pregnancy may be employed for variety of reasons to see image of the baby, placenta and amonite fluid even for the woman and her family to see in addition to sonologist. Actually some clinicians are replacing clinical examination of pregnant women by USG, may be for confirmation of pregnancy, duration of pregnancy, number of foetuses, fetal growth and development, abnormalities of fetus, placenta and liquor by direct visualization, amniocentesis and/or cordocentesis. It can be used for foetal therapy too and even foetal foeticide and also for prediction of maternal disorders which affect mother as well as the baby [1]. However if abnormalities are detected during pregnancy it might lead to stress for the woman and the family, sometimes problems may be detected in women who do not have any risk factors, creating a lot of stress which has sequlae. Unfortunately there is likelihood of false alarm too specially when USG is performed by a person who lacks desired skill and knowledge or lack of time or desired attitude too. Assumptions are made that routine USG will prove beneficial by enabling earlier detection and improved management of pregnancy complications [2]. Routine screening may be done in early or late pregnancy, or both. Use of USG early in pregnancy is increasing, but there is limited information about linkage decision-making and impact on expectant women/couples. It is essential to know because globally there has been increasing medicalization of pregnancy [3]. However the awareness and utilization of USG by rural tribal women especially those with extreme poverty are not well known.

Material and Methods

After approval of ethics committee, which works on the principle of Helsinki Declaration, the study was conducted in tribal communities of 100 villages of rural, hilly and forestry, Melghat of Amravati, Maharashtra, India. In these villages community based mother and child care services were initiated after having created a health facility in one of the villages. Information was collected visiting every 5th house randomly, minimum 20 preconception women from each village total 2400 and 1040 pregnant women of 15-45 years. Interviews were conducted taking consent using a pretested tool in the language understood by women. Some questions needed yes or no answers and others short open answers.

Results

Of total 2400 preconception study subjects, 27% did not know anything and 1774 (73.9%) women were aware about sonography. Overall 694 (39.1%) of those who were aware said sonography helped in knowing about pregnancy, 1080 (60.88%) of those who knew about USG said it helped to know the fetal age and position. Overall 336 (14%) of 2400 women were of 15-19 years age, 271 (80.65%) of them were aware of sonography during pregnancy and 245 (90.41%) of them said USG helped in knowing fetal age with position and only 26 (9.59%) said it can confirm pregnancy. Of 74 women of 40-45 years age, 59 (79.3) were aware of USG similar to young women and 50 (84.75%) of them said it helped in knowing fetal age and position and only 9 (15.25%) said for confirmation of pregnancy. Of 953 (39.70%) of 2400 women were illiterate, 726 (76.18%) of them were aware of sonography and 539 (74.24%) said it helped to know fetal age and position and 187 (25.76%) said it confirmed pregnancy. Of 60 (65.93%) of 91 women with higher secondary education, 54 (90%) said USG helped in knowing fetal age and position and only 6 (10%) said confirmation pregnancy. Of 275 housewives 211 (76.72%) were aware of USG, 182 (86.26%) women said sonography helped in estimation of fetal age and position and 29 (13.74%) said for confirmation of pregnancy. Of 958 labourer 681 (71.86%), knew about sonography and 444 (65.2%) of those who knew about USG, said it helped to know the fetal age and position and 237 (34.8%) for confirmation pregnancy. Of 2400 preconception women, 662 (27.58%) belonged to upper lower economic class, [economic status was divided in five], 553 (83.53%) of them were aware of sonography, 340 (61.48%) said it helped in knowing fetal age and position and 213 (38.52%) confirmation of pregnancy. Seventy-four (50.34%) of 147 women who belonged to upper economic class, knew about sonography, significantly less (P Value 0.0127) and 39 (52.7%) said it helped in confirmation of pregnancy and 35 (47.3%) said to know about fetal age and position. Overall 85 (81%) of 105 who had no child were aware of sonography, 75 (88.24%) said it helped in estimation of fetal age, position and only 10 (11.8%) said confirmation pregnancy. Overall 421 (82.7%) of 509 who had five or more births were aware of sonography, similar to those with no child, 250 (59.4%) said it helped in confirmation of pregnancy and 171 (40.62%) estimation of fetal age and position. Total 626 (26.08%) 2400 preconception women did not know that there was something like sonography (Tables 1-3).

Table 1: Awareness of Ultrasonography in Preconception Women.

Variables

 Total

Awareness

Age
No % Yes

%
15 to 19

336

 65 19.35 271

80.65
20 to 24

828

 181 21.86 647

78.14
25 to 29

736

 243 33.02 493

66.98
30 to 34

333

 75 22.52 258

77.48
35 to 39

93

 47 50.54 46

49.46
TOTAL

74

 15 20.27 59

79.73

Education

2400

 626 26.08 1774

73.92
Illiterate
Primary

953

 227 23.8 726

76.18
Secondary

850

 282 33.2 568

66.82
Higher secondary

506

 86 17.0 420

83
Graduate

91

 31 34.1 60

65.93
Post graduate

0

 0 0.0 0

0
Total

2400

 626 26.08 1774

73.92
Economic status
Upper

275

 64 23.27 211

76.73
Upper middle

958

 277 28.91 681

71.09
Upper lower

468

 121 25.85 347

74.15
Lower middle

699

 154 22.03 545

77.97
Lower

2400

 626 26.08 1774

73.92
Total
Profession

147

 73 49.66 74

50.34
Housewife

183

 59 32.24 124

67.76
Own farm labour

544

 170 31.25 374

68.75
Labourer

662

 109 16.47 553

83.53
Other work

864

 215 24.88 649

75.12
Total

2400

 626 26.08 1774

73.92
Parity
P. 0

105

 20 19.05 85

81
P. 1

411

 131 31.87 280

68.1
P. 2

672

 218 32.44 454

67.6
P. 3

453

 123 27.15 330

72.8
P. 4

250

 46 18.4 204

81.6
P. 5 Above

509

 88 17.29 421

82.7
Total

2400

 626 26.08 1774

73.9

Table 2: Awareness of Ultrasonography Pregnant Women and Source of Information.

Variables

 Total Awareness

Source of information

Age

NO

% YES % ASHA % ANM % Doctor % Family Member

%
15 to 19

323

 107 33.1 216 66.9 129 59.7 49 22.7 21 9.7 17

7.9
20 to 24

536

 130 24.3 406 75.7 166 40.9 152 37.4 66 16.3 22

5.4
25 to 29

109

 22 20.2 87 79.8 19 21.8 41 47.1 3 3.4 24

27.6
30 to 34

68

 12 17.6 56 82.4 21 37.5 19 33.9 4 7.1 12

21.4
35 to 39

4

 0 0.0 4 100.0 1 25.0 0 0.0 0 0.0 3 75.0

TOTAL

 1040 271 26.1 769 73.9 336 43.7 261 33.9 94 12.2 78

10.1
Education
Illiterate

56

 19 33.9 37 66.1 21 56.8 13 35.1 3 8.1 0 0.0

Primary

 321 42 13.1 279 86.9 134 48.0 97 34.8 33 11.8 15

5.4
Secondary

358

 58 16.2 300 83.8 102 34.0 186 62.0 6 2.0 6 2.0

Higher secondary

 196 58 29.6 138 70.4 41 29.7 29 21.0 13 9.4 55

39.9
Graduate

66

 54 81.8 12 18.2 2 16.7 3 25.0 2 16.7 5 41.7
Post graduate

43

 40 93.0 3 6.97 1 33.3 0 0.0 0 0.0 2 66.7

Total

 1040 271 26.1 769 73.9 301 39.1 328 42.7 57 7.4 83

10.8
Economic status
Upper

43

 42 97.7 1 2.3 1 100.0 0 0.0 0 0.0 0 0.0

Upper middle

 51 49 96.1 2 3.9 2 100.0 0 0.0 0 0.0 0

0.0
Upper lower

142

 42 29.6 100 70.4 56 56.0 20 20.0 11 11.0 13 13.0

Lower middle

 186 61 32.8 125 67.2 67 53.6 30 24.0 12 9.6 16

12.8
Lower

618

 77 12.5 541 87.5 294 54.3 166 30.7 52 9.6 29 5.4

Total

 1040 271 26.1 769 73.9 420 54.6 216 28.1 75 9.8 58

7.5
Profession
Housewife

943

 227 24.1 716 75.9 322 45.0 109 15.2 103 14.4 182 25.4

Own farm labour

 53 24 45.3 29 54.7 19 65.5 6 20.7 1 3.4 3

10.3
Labourer

40

 19 47.5 21 52.5 17 81.0 2 9.5 0 0.0 2 9.5

Other work

 4 1 25.0 3 75.0 2 66.7 1 33.3 0 0.0 0

0.0
Total

1040

 271 26.1 769 73.9 360 46.8 118 15.3 104 13.5 187

24.3
Parity
P.1

117

 6 5.1 111 94.9 11 9.9 52 46.8 21 18.9 27

24.3
P.2

103

 4 3.9 99 96.1 66 66.7 21 21.2 8 8.1 4

4.0
P.3

155

 6 3.9 149 96.1 41 27.5 64 43.0 11 7.4 33 22.1

P.4

 204 15 7.4 189 92.6 49 25.9 21 11.1 29 15.3 90

47.6
P.5 Above

461

 240 52.1 221 47.9 41 18.6 12 5.4 11 5.0 157 71.0
Total

1040

 271 26.1 769 73.9 208 27.0 170 22.1 80 10.4 311

40.4

ASHA: Accredited Social Health Activist.
ANM: Auxiliary nurse midwife.

Table 3: Ultrasonography during Pregnancy by Rural Tribal Women.

Variables

 Total Ultrasound done

If YES Abnormality Informed
Age

NO

% YES % Yes % No

%
15 to 19

323

 220 68.1 103 31.9 25 24.3 78 75.7

20 to 24

 536 413 77.1 123 22.9 42 34.1 81

65.9
25 to 29

109

 91 83.5 18 16.5 7 38.9 11 61.1

30 to 34

 68 57 83.8 11 16.2 6 54.5 5

45.5
35 to 39

4

 1 25.0 3 75.0 2 66.7 1 33.3

Total

 1040 782 75.2 258 24.8 82 31.8 176

68.2
Education
Illiterate

56

 40 71.4 16 28.6 4 25.0 12 75.0

Primary

 321 282 87.9 39 12.1 19 48.7 20

51.3
Secondary

358

 307 85.8 51 14.2 15 29.4 36 70.6

Higher secondary

 196 136 69.4 60 30.6 16 26.7 44

73.3
Graduate

66

 11 16.7 55 83.3 14 25.5 41 74.5

Post graduate

 43 6 14.0 37 86.0 14 37.8 23

62.2
Total

1040

 782 75.2 258 24.8 82 31.8 176

68.2
Economic status
Upper

43

 1 2.3 42 97.7 11 26.2 31 73.8

Upper middle

 51 10 19.6 41 80.4 6 14.6 35

85.4
Upper lower

142

 82 57.7 60 42.3 12 20.0 48 80.0

Lower middle

 186 130 69.9 56 30.1 27 48.2 29

51.8
Lower

618

 559 90.5 59 9.5 26 44.1 33 55.9

Total

 1040 782 75.2 258 24.8 82 31.8 176

68.2
Profession
Housewife

943

 718 76.1 225 23.9 66 29.3 159 70.7

Own farm labour

 53 34 64.2 19 35.8 16 84.2 3

15.8
Labourer

40

 29 72.5 11 27.5 0 0.0 11 100

Other work

 4 1 25.0 3 75.0 0 0.0 3

100
Total

1040

 782 75.2 258 24.8 82 31.8 176

68.2
Parity
P.1

117

 88 75.2 29 24.8 7 24.1 22 75.9

P.2

 103 62 60.2 41 39.8 11 26.8 30

73.2
P.3

155

 87 56.1 68 43.9 24 35.3 44 64.7

P.4

 204 135 66.2 69 33.8 22 31.9 47

68.1
P.5 Above

461

 410 88.9 51 11.1 18 35.3 33 64.7

Total

 1040 782 75.2 258 24.8 82 31.8 176

68.2

Total 769 (73.9%) of 1040 rural tribal pregnant women, knew about USG in pregnant women but 271 (26.1%) did not know. The sources of information were Accredited Social Health activists (ASHA) 208 (27%), nurse midwives 170 (22.1%), family members 311 (40.4%) and in 80 (10.4%) doctors. Of 1040 study subjects, 406 (75.7%) of 536 of 20-24 years were aware of USG, Sources of information were ASHAs in 166 (40.9%), Nurse Midwives in 152 (34.4%), 66 (16.3%) Doctors and 22 (5.4%) family members. As age increased more women were found to be knowing about USG, 216 (66.9%) of 323 of 15 to 19 year, 60 (83.33%) of 72 of 30-39 years old. (P Value 0.3776) It seemed to be related to increased parity too. Out of 1040 pregnant women, 43 (4.13%) were postgraduate studied still only 3 (6.97%) were aware, one (33.3%) was toldby ASHA and 2 (66.7%) by family members. Overall 56 (5.38%) illiterate women, 34 (66.1%) were aware of USG, by ASHAs 21 (56.8%), Nurse midwives 13 (35.1%) and Doctors 3 (8.1%). Only 2 (3.9%) of 51who belonged to middle economic class were aware of USG, ASHAs, being the source of information in both. Of 1040 pregnant women, 618 belonged to lower economic class and 541 (87.5%) of them were aware of USG, ASHAs were the source in 294 (54.3%), nurse midwives in 166 (30.7%), doctors in 52 (9.6%) and family members in 29 (5.4%). Among 1040 pregnant women, 943 were housewives and of them 716 (75.9%) were aware of USG. ASHAs were the source in 322 (45.0%) and family members in 182 (25.4%). Overall 21 (52.5%) of 40 labourers were aware of USG and 17 (81%) were told by ASHAs.

As the parity increased number of women with awareness increased, 27 (24.3%) of 111 primigravida and 157 (71%) of 221 fifth gravida said they were told by family members. Only 258 (24.8%) of 1040 pregnant women themselves had USG and 782 (75.2%) did not. 258 (33.5%) of 769 women who knew about USG had USG done. Of them 82 (31.8%) were told of possibilities of some abnormalities but they did not know any details. There seemed to be no communication in most of the cases in whom USGs was done, probably because USG were done in camps at Primary Health Centers or Sub District Hospital with crowds around. Of 1040 study subjects, 536 (51.53%) were of 20-24 year, 123 (22.9%) got USG done, 42 (34.1%) said some abnormalities were told but did not know any details. 14 (19.44%) of 72 of 30-39 year had USG, of which 8 (57.14%) were told of abnormalities without details. Of 66 graduates, 55 (83.3%) had USG and 29 (52.7%) were told of some abnormalities. Only 16 (28.6%) of 56 illiterate had USG and 4 (25%) were told of some abnormalities. Of 43 (4.13%) who belonged to middle economic class, 41 (80.4%) had USG and 9 (22%) of them were told of some abnormalities. Only 59 (9.5%) of 618 women who belonged to lower economic class had USG. Twenty (33.9%) said some abnormalities were told without any details. Of 943 (90.67%) of 1040 pregnant housewives, 225 (23.9%) had USG and 66 (29.3%) were told about abnormalities, but they did not know any details. Only 11 (27.5%) of 40 labourers had USG and no one said they were told of any abnormalities. Total 117 (11.25%) were primipara, only 29 (24.8%) of them had USG and 7 (24.1%) said some abnormalities were told without any details. Overall 188 (29.74%) of 632 women who had 3 or more births in 64 (34.04%) were told of some abnormalities with no details.

Discussion

In the present day clinical practice the discussion is on evidence-based guidelines disseminated to physicians, obstetrician, nurses and sonologists for antenatal ultrasound scans with advocacy of guidance about the appropriate use of ultrasound scans to be shared with women in order to discourage unreasonable expectations, demands and apprehensions. On one side USG is done many times during pregnancy by urban women for various reasons, many rural women do not even know about USG, do not even think of diagnostic antenatal checkup. Bashour et al. reported that private doctors, who looked after 80% of pregnant women, offered ultrasound primarily to attract women to their clinics and increase their income [4]. Kozuki et al. reported that the utilization of obstetric USG in rural women of Nepal was very limited. Researchers reported that more research was necessary to assess the potential of health impact of obstetric USG in low-resource settings, while addressing limitations such as cost and misuse [5]. Cherniak et al. reported that women could be motivated to attend antenatal clinics when offered the incentive of seeing their baby through USG [6]. Huang et al. reported high use of antenatal ultrasound in rural Eastern China, influenced by socio-demographic and clinical factors [7]. Torloni et al. reported that USG in pregnancy was not associated with adverse maternal effects, impaired physical or neurological development or increased risk to children [8]. However with over diagnosis some stress is always likely. With under diagnosis there are many problems and it is essential that there is awareness and understanding of use and misuse.

Whitworth et al. also reported that early USG helped in the detection of multiple pregnancies with improved gestational dating which resulted in fewer inductions for post maturity [2]. This can only happen if women know and can use the technology. It does not seem to be happening for rural women. Abramowicz et al. reported that USG carried some risks of misdiagnosis on the one hand and possible undesired effects on the other [9]. The general belief existed that diagnostic USG did not pose any risk, neither to the pregnant women nor to the fetus. But risk-benefit analysis may also be important, as well as education of the end users to assure safety. Fact remains false diagnosis might give mental stress even dilemmas when not knowing anything as happened in the present study. USG were done during camps at PHCs and Sub-District Hospital (SDH) and women did not know details of abnormalities. Phutke et al. reported it is essential to re-examine and update the use of diagnostic, USG widely available even the most peripheral health facilities [10]. Studies showed that pregnant women generally value routine ultrasounds in the first two trimesters because they get reassurance and chances to see their unborn baby.

Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited, questions around the purpose and the intended benefits as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric USG in Low-and Middle-Income Countries (LMICs). Whitworth et al. reported that some (but not all) benefits described in the literature have been validated by evidence-based analysis [2]. Unlike other modes for prenatal screening and diagnosis, USG offers parents direct access to images of the fetus. This makes obstetric ultrasound popular and attractive among expectant mothers so they want to use it often [11,12]. Women see prenatal USG as means for reassurance about the health and well-being of their fetuses. However, sometimes USG may yield unexpected findings which may have adverse effects on the mental health of mother and may provoke emotional crisis [13,14]. Significant psychological harm from antenatal ultrasound as well as positive psychological effects have been reported [15]. Counselling is needed to further enhance the USG experience and to reduce anxiety and dispel any misconceptions and irrational expectations regarding the antenatal USG. In the present study quite a few preconception as well as pregnant women did not know anything about USG. Those pregnant women who knew also did not get USG done during pregnancy due to various reasons. Those who had USG did not know details of abnormalities as any discussion or communication took place.

Of 2400 preconception study subjects, 1774 (73.9%) women were aware about sonography, 694 (39.1%) said sonography helped knowing about pregnancy, 1080 (60.88%) of those who knew said it helped in knowing fetal age and position. Overall 1774 of 2400 preconception women, 626 (26.08%) were not aware of USG, of 953 (39.70%) illiterate, 726 (76.18%) were aware of sonography, 539 (74.24%) said sonography helped to know fetal age and position and 187 (25.76%) said for confirmation pregnancy. So it was word of mouth which more often made women aware.

Of 1040 pregnant women, 271 (26.1%) were not even aware about USG during pregnancy, women with more than one birth too did not know. Most women got information from ASHAs 208 (27.0%), 170 (22.1%) NM of Sub center. Of 1040 study subjects, 258 of 769 (33.5%) of those who knew had USG, 82 (10.7%) of them were told about some abnormalities, but without any details. Rest did not know anything about what was found. Communication and counseling are essential.

Halle et al. reported that USG in the first half of pregnancy were in high use in Iceland and apparently became part of a broader pregnancy culture, encompassing both high- and low-risk pregnancies [16]. Whether this is a favourable development or to some extent represents unwarranted medicalization needs further discussion. More balanced information might be provided prior to early screening for foetal anomalies. In rural community women start care by mid pregnancy.

Yadav et al. reported that in their study 72.41% pregnant women felt USG was done for knowing fetal anomalies and 27.93% for sex detection, majority (93.1%) had USG more (43.45 %) in second trimester mainly on advice of doctors (91.03%) [17]. Nearly half of them (50.69%) considered it as expensive procedure and 50.69%% of them opined it should be done twice in pregnancy. Almost 94.83% considered USG as safe and beneficial. Awareness regarding the uses of USG during pregnancy and attitude towards USG was neither negative possible. Westerneng et al. reported that pregnant women seemed to appreciate a third trimester routine ultrasound, but it did not seem to reduce anxiety or improve bonding with their baby [18]. Women’s appreciation of a third trimester routine ultrasound might arise from getting used to routine ultrasounds throughout pregnancy. Results of such findings should be taken into consideration when balancing the gains, which are as yet not clear, of introducing a third trimester routine ultrasound against unwanted side effects and costs.

Ikeako et al. did a study and reported that the number of respondents who had USG in their previous pregnancies was 58.7% [19]. Although many reasons were given for personal USG requests, 19.7% women who had obstetric scan in their previous pregnancies thought it was a normal booking test done for every pregnant woman. When compared with other booking investigations, 60.1%, mainly civil servants said that USG in pregnancy was costly, 24.4% felt it was cheap, 9.1% said it was very costly and remaining 2.4% thought it was not affordable. Apart from visualizing the images of their babies, 17.8% of the cases wanted to know the gender and 15.4% said it was for knowing of fetal position.

Total 52.9% were of the opinion that women could decide when to request for sonography. Majority of Nigerian women requested ultrasound for looking at fetus and gender determination. Gururaj et al. reported that care providers and government officials perceived ultrasound diagnosis as critical to deciding whether to refer women who might need high-risk support from higher-level centres that are often geographically remote [20]. Findings suggested a strong need to re-evaluate the evidence base for routine obstetric ultrasound in rural LMIC settings and include more stakeholders in participatory, co-design approaches to innovation. Firtha et al. opined that ultrasound would increase Antenatal Care (ANC) attendance [21]. Kim et al. opined that as cost of obstetric ultrasound became more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation [22]. Additionally, there was a need to more clearly identify the capabilities and the limitations of ultrasound, particularly in the context of limited training of providers, to ensure that the purpose, for which an ultrasound was intended, was actually feasible. Researchers also reported that there was evidence that ultrasound was not associated with reducing maternal, perinatal or neonatal mortality, also reported various studies revealed both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex raised a concern. Saleh et al. reported that most of the participants were aware of ultrasound scan and also believed that the procedure was safe, and the main purpose was for fetal wellbeing and viability [23].

Ugwu et al. did a study and reported that 73% women got their information from antenatal centres. Over 20% were interested in the lies and presentation of their foetus [24].

Conclusion

The role of prenatal sonography in obstetric care should be real with preconception awareness in antenatal centres, and initiating mother/sonographers interaction is necessary.

References

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  17. Yadav JU, Yadav DJ (2017) Ultrasonography awareness among pregnant women attending medical college hospital in Kolhapur District of Maharashtra, India. International Journal of Research in Medical Sciences 5: 2612.
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  19. Ikeako LC, Ezegwui HU, Onwudiwe E, Enwereji JO (2014) Attitude of expectant mothers on the use of ultrasound in pregnancy in a tertiary institution in South East of Nigeria. Annals of Medical and Health Sciences Research 4: 949-953. [crossref]
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DQRF™ (Dynamic Quadripolar Radiofrequency) and UPR™ (Ultra-Pulsed Radioporation) 12-Month Synergy in Postmenopausal Vulvovaginal Atrophy

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DOI: 10.31038/IGOJ.2021414

Abstract

Introduction: The low-energy Dynamic Quadripolar Radiofrequency or DQRF™ vaginal technology overcomes several problems of manageability and safety experienced with other energy-based vulvovaginal energy-providing technologies by postmenopausal women with symptoms of vulvovaginal atrophy. The proprietary Ultra-Pulsed Radioporation or UPR™ technology has already shown to accrue the benefits of the new radiofrequency technology by facilitating penetration of active principles into the deep layers of vulvar skin and vaginal mucosa and enhancing hydration and trophism. Evaluating the impact on vulvovaginal atrophy symptoms, with vaginal dryness expected to benefit the most from the DQRF/UPR™ synergy, is the goal of this interim study.

Methods: Prospective real-life cohort study on 106 ambulatory women (mean age, 56.8 ± 8.61 years old) with vaginal atrophy and dryness. VVA treatment: four to five 25-min sessions every 14-16 days (coupling gel with hyaluronic acid); one more DQRF/UPR™ maintenance session after six months and a final visit (only assessment, no treatment) after 12 months. Operative temperatures in target tissues during the procedure: 42°C (range 40-43°C). Assessments (baseline and at the end of the treatment cycle): vaginal dryness (primary efficacy parameter, 10-cm impromptu Visual Analogue Scale); dyspareunia, burning and itching (4-score impromptu Likert-like scale) and photographic documentation at baseline at the end of the DQRF/UPR™ treatment cycle.

Results: Vaginal dryness rapidly improved vs baseline (T0), with a highly significant reduction (−83.1%) at the end of the treatment cycle (T1) that steadily persisted after 6 and 12 months (T2 and T3; −79.2% and −64.9%, respectively). All other symptoms similarly improved vs baseline over the year of follow-up: dyspareunia −81.5% (T1) and −70.4% (T3); burning −87.0% (T1) and −65.2% (T3); itching −89.5% (T1) and −68.4% (T3). All treatments were well tolerated, with no troubling pain or other side effects during or after the procedures.

Conclusion: The study confirms, over a one-year follow-up, the previously demonstrated benefits of the Dynamic Quadripolar Radiofrequency (DQRF™) in synergy with Ultra-Pulsed Radioporation (UPR™) as an innovative treatment option of vulvovaginal atrophy/genitourinary syndrome of the menopause symptoms. The novel UPR™ technology facilitates the deep penetration of active topical principles favourably acting on postmenopausal atrophic tissues. The DQRF/UPR™ concept aims to enhance the effects of the DQRF™ technology exploiting the synergy between the double biological effects-by the energy-based DQRF™ and the UPR™ active principle. Long-term studies will confi.

Keywords

Electroporation, Genitourinary syndrome of menopause, Dynamic quadripolar radiofrequency, DQRF™, Ultra-Pulsed Radioporation, UPR™, Vulvovaginal atrophy

Abbreviations

DQRF™: Dynamic Quadripolar Radiofrequency

GSM: Genitourinary Syndrome of Menopause

HA: Hyaluronic Acid

MDa: x106 Dalton

MHz: Megahertz or x106 Hertz

RSS™: Radiofrequency Safety System

SEM: Standard Error of the Mean

UPR™: Ultra-Pulsed Radioporation

VAS: Visual Analogue Scale

VDR™: Vaginal Dynamic Radiofrequency

VVA: Vulvovaginal Atrophy

W: Watt

Introduction

Energy-based vulvovaginal treatment technologies often show manageability and safety difficulties in postmenopausal women with life-disrupting Vulvovaginal Atrophy (VVA) and Genitourinary Syndrome of Menopause (GSM). The low-energy DQRF™ (Dynamic Quadripolar Radiofrequency) technology candidates to overcome such problems in VVA women [1,2]. The four algorithmically controlled radiofrequency electrodes, continuously cycling between receiver and transmitter states (VDR™ or Vaginal Dynamic Radiofrequency™ technology), generate repelling electric fields within the closed electrode system and concentrate their low-energy thermal effects with high topographical precision in precise subepithelial areas without the need for grounding pads.

In addition, the treated area – usually a 4-inch area centred on the hymenal ring -need no systemic analgesia or local anaesthesia thanks to the integrated RSS™ (Radiofrequency Safety System) proprietary technology that steadily tracks the tip movements and local tissue temperature [1,2]. The Novavision Group S.p.A. (Misinto, Monza-Brianza, Italy) holds worldwide rights for the patented DQRF™, VDR™, and RSS™ technologies.

Since 2018, integrating the DQRF™ concept with the proprietary UPR™ (Ultra-Pulsed Radioporation) radiofrequency electroporation technology has been a second technological jump forward. UPR™ modulates the DQRF™ radiofrequency effects and facilitates the transfer of biologically active principles through aqueous channels in vulvar skin and vaginal mucosa cell membranes [3]. The DQRF™ effects on vulvovaginal hypotrophy thus synergise with those of the UPR™-mobilised active principles-for instance, highly hydrating and pro-trophic Hyaluronic Acid (HA) [4]. Counteracting the postmenopausal loss of elasticity and volume with topical HA formulations and HA dermal fillers in women with labia majora hypotrophy has long been a common cosmetic gynaecology practice [5,6]. A double-blind pilot study compared VVA/GSM symptoms and women’s satisfaction with their sexual and couple lives in two random samples of postmenopausal women randomised to either DQRF™ and DQRF/ UPR™ vulvovaginal treatment [3]. The low-molecular-weight HA was interspersed in the coupling gel in the DQRF/ UPR™ treatment group; the study established the DQRF/ UPR™ superior benefits [3].

The interim 12-month DQRF/ UPR™ outcomes on VVA symptoms herein illustrated aim to confirm the previous favourable outcomes over a more extended follow-up period and a more ample postmenopausal women cohort. Vaginal dryness, expected to benefit the most from the UPR™ synergy with DQRF™, was the primary efficacy parameter. The interim DQRF/ UPR™ cohort study herein described is currently being expanded to identify the characteristics of VVA women who will most likely benefit from the advanced DQRF/UPR™ technology.

Methods

Real-life Study Design, Cohort Selection Criteria and Interim Cohort Demographics

All VVA/GSM women enrolled in the prospective DQRF/UPR™ cohort attended specialist departments for postmenopausal disorders in the authors’ private health facilities. Candidate participants in the 45 to 66 years old age range with moderate to severe VVA symptoms (vaginal dryness, itching, burning and dyspareunia) and negative recent Papanicolau and mammography tests should not have reported menstruations for at least 12 months. In addition, they should not have participated in other clinical studies for the last six months. After giving informed consent to the anonymous collection of their data and photographic evidence before the first treatment session, the 106 women underwent their planned DQRF/UPR™ treatment cycle between January 2020 and March 2021. All women had objective evidence of moderate to severe mucosal atrophy with thinning or loss of vaginal rugae and mucosal pallor; an explicit wish for a still-active sexual life was also a must.

Hormonal replacement therapy, pelvic organ prolapses beyond the hymenal ring, vulvodynia or chronic vulvar pain, vulvar dermatitis or dystrophy, viral lesions, including a high risk for human Papillomavirus infections, vaginal infections in the last two months, a Sjögren syndrome diagnosis, and inadequate thickness of the recto-vaginal septum at the pelvic examination-all were exclusion criteria from the study.

All study materials, including informed consent forms and study protocol and case report forms, were peer-reviewed for ethical problems, and the authors always safeguarded the full respect of the ethical standards laid down in the Declaration of Helsinki as revised in Brazil 2013. Participant women also agreed to the publication of the study outcomes.

Operative Procedures

The DQRF™-based EVA™ device (Novavision Group S.p.A., Misinto, Monza-Brianza, Italy) and the proprietary UPR™ technology were previously described [1-3]. The protocol foresaw 4 to 5 treatment sessions spaced 14-16 days as a treatment cycle. First, power was applied for 15 minutes to the vaginal mucosa with hyaluronic acid (1.5 to 2.0 MDa, 0, 2% concentration) mixed with the coupling gel, starting behind the hymenal ring with circular back-and-forth continuous movements and always keeping contact between the tip probe and the mucosa. Then followed another 10 minutes of DQRF™ application for vulvar treatment: in both steps with the power of the EVA™ device set at 20% to 27% of the 55-W maximum emitting power. Previous preparation was limited to an alcohol-free cleanse; all procedures were performed with the woman on the examining table in the dorsal lithotomy position.

With particular attention to pain and discomfort, safety was investigated in all women at each study visit and by telephone over the following days. The treatment protocol foresaw a further DQRF/UPR™ maintenance session after six months and a final visit (only assessment, no treatment) after 12 months. Figure 1 illustrates the sterilisable vaginal and vulvar DQRF™ tips with their medically certified AISI 316 stainless steel dynamic quadripolar electrodes. The electrodes continuously cycle between receiver and transmitter states; the generated active electric fields in subepithelial tissues minimise the delivered energy (only 11 to 15 W), tissue Ohm’s resistances and untoward thermal side effects with the help of the RSS™ safety technology.

inline matter fig

fig 1

Figure 1: On the left: the EVA™ vaginal tip with the four emitters/receivers DQRF™ electrodes distributed longitudinally to adapt to the vaginal anatomy. On the right: the EVA™ vulvar tip with the four DQRF™ electrodes distributed on the terminal tip plane to adapt ergonomically to the vulvar areas.

Assessments

Vaginal dryness was assessed before the first treatment session (baseline, T0) and at the end of the treatment cycle (T1), together with baseline and end-of-treatment photographs, with the help of a 10-cm impromptu Visual Analogue Scale (VAS). Assessments of itching, burning, and dyspareunia made use of impromptu 4-score Likert-like scales (0=none; 1=mild; 2=moderate; 3= severe), with semi-quantitative score assessments repeated at the two follow-up visits: after 6 and 12 months (T2 and T3, respectively). In addition, all participant women received a Pap-test and a transvaginal echography as further safety control at all visits up to T3.

Statistics

Descriptive data were tabulated as means ± standard errors of the mean. The non-continuous nature of the VAS (vaginal dryness) and Likert-like (other VVA symptoms) semi-quantitative scores and the lack of assumptions about the normal distribution of baseline and final data justified a conservative approach. The general linear model for repeated measures or Kruskal-Wallis test for independent samples (nonparametric one-way ANOVA test) was applied to scores, after correction of means for age and Body Mass Index, to assess for any DQRF/UPR™ effect, with two-sided 95% confidence levels and p <0.05 as a cut-off for significance. Using the nonparametric one-way ANOVA test was justified because the score variances were homogeneous at the Levene’s test. After detecting a significant DQRF/UPR™ effect, pairwise post-hoc Sidak multiple comparisons identified the exact time points of score trend divergence vs baseline during the T1 to T3 period.

Results

Table 1 illustrates the cohort demographics before the first treatment session. The clinical severity of the mail efficacy parameter, vaginal dryness, was alarming for most of the cohort VVA women (56.8 ± 8.61 years old), as highlighted by the high baseline VAS score and the low dispersion of baseline VAS scores (mean ± SEM, 7.7 ± 0.49). All other VVA symptoms were also quite troubling, as shown by the concentration of baseline scores for dyspareunia, but also burning and itching, in the “Moderate” (score 2) and “Severe” (score 3) groups. The baseline scores for dyspareunia and vaginal burning and itching were 2.7 ± 0.56, 2.3 ± 0.475 and 1.9 ± 0.88, respectively, in an impromptu 0-3 Likert-like scale. All women reported dyspareunia at baseline, and almost all intimate burning and itching.

Table 1: DQRF/UPR™ cohort demographics and baseline symptom profile. SEM, standard error of the mean.

Baseline Prospective Cohort Data
Postmenopausal women (N)

106
Age (years, mean ± SEM)

56.8 ± 8.61
Vaginal dryness (VAS scale ± SEM)

7.7 ± 1.35

Other VVA symptoms

Absent

 Mild Moderate

Severe
Dyspareunia (cohort per cent)

0

 5 22

74
Burning (cohort per cent)

1

 14 39

46
Itching (cohort per cent)

4

 32 34

30

Sixty-three women underwent four DQRF/UPR™ sessions, 43 women five treatment sessions. All participant women completed their DQRF/UPR™ treatment program as planned without missing visits and described their experience as always comfortable. All treatments were well tolerated, with no troubling pain, burns or blisters or other fastidious side effects or complications during or after the procedures. All women also resumed their everyday activities and sexual life immediately after the end of their treatment program.

The primary efficacy parameter, vaginal dryness, markedly improved at the end of the DQRF/UPR™ treatment cycle with the relevant VAS score already diverging from the null hypothesis of no-effect trend (mean ± SEM, 1.3 ± 1.35, −83.1% and p <0.001 vs baseline), with 41 women reporting total subjective relief with a zero score for dryness. Furthermore, the benefits for vaginal dryness steadily persisted six months after the end of the treatment cycle (median VAS score 1.0; mean 1.6 ± 1.41, −79.2% and p <0.001 vs baseline) and only slightly deteriorated after 12 months of no DQRF/UPR™ sessions (median 3.0; mean 2.7 ± 1.44, −64.9% and p <0.001 vs baseline) (Figure 2). However, after 12 months, five women still reported no vaginal dryness and 15 only a mild dryness (Figures 3 and 4).

fig 2

•• p <0.001 vs baseline.

Figure 2: Vaginal dryness VAS scores at T0 (baseline), T1 (after the end of the DQRF/UPR™ treatment cycle), T2 (maintenance and assessment visit after six months), T3 (assessment visit after 12 months); means ± standard errors of the mean.

fig 3

Figure 3: Per cent distribution of the symptom severity scores at baseline (T0), end of the DQRF/UPR™ treatment cycle (T1), and follow-up visits after 6 and 12 months (T2 and T3, respectively).

fig 4

Figure 4: Vestibular atrophy at the end of the DQRF/UPR™ cycle, with the evidence of new vestibular rugae as morphological markers of the treatment benefits.

The benefits at T1 were similar for other VVA symptoms (Table 2): dyspareunia −81.5%, burning −87.0%, itching −89.5% vs baseline, all of them already diverging at T1 with high significance from the null hypothesis of no-effect trend.

Table 2: Dyspareunia, burning and itching scores (0-3 Likert-like scales) after the 4-5 DQRF/UPR™ treatment sessions. ••p<0.001 vs. baseline; means ± standard errors of the mean.

VVA Symptom

End of the DQRF/UPR™ treatment cycle (T1)
Dyspareunia

0.5 ± 0.52•• (median 0)

 56 women reporting no dyspareunia
Burning

0.3 ± 0.52•• (median 0)

 70 women reporting no vulvovaginal burning
Itching

0.2 ± 0.41•• (median 0)

 84 women reporting no vulvovaginal itching

The dyspareunia, burning and itching scores also remained steady at the maintenance visit after six months and only marginally deteriorated after 12 months (Table 3). However, the vaginal dryness VAS score was still 64.9% lower than baseline after one year, whilst the dyspareunia and vaginal burning and itching subjective scores were 70.4%, 65.2% and 68.4% lower.

Table 3: VVA severity scores (0-3 Likert-like scales) at the maintenance/assessment visit six months after the end of the DQRF/UPT™ treatment cycle (T2) and the final assessment follow-up after 12 months. ••p<0.001 vs. baseline; means ± standard errors of the mean.

VVA symptom

 T2

T3
Dyspareunia

0.5 ± 0.62•• (median 0)

0.8 ± 0.73•• (median 1)
Burning

0.5 ± 0.62•• (median 0)

0.8 ± 0.70•• (median 1)
Itching

0.4 ± 0.57•• (median 0)

0.6 ± 0.68•• (median 0)

Discussion

The DQRF™-induced variable electrical currents continuously re-orient dipole moments like water molecules in target vulvovaginal tissues. Other biomolecules, facing variable electric impedance and mechanical attrition due to the water viscosity, dissipate their Brownian kinetic energy into heat [7].

Over the years, more and more evidence has highlighted how thermal energy conveyed to vulvovaginal tissue may help reverse the natural ageing processes by stimulating the proliferation of glycogen-enriched epithelium new vessels and collagen formation in the lamina propria and by improving natural lubrication and urination control [7]. The 40°C to 43°C temperature range is critical to activate neocollagenesis by tissue fibroblasts [8].

The burden of bleeding, pain and burning problems may be severe for laser devices [9]. The digitally controlled DQRF™ technology helps to reduce the related discomfort, while the synergy with the UPR™ technology helps the in-depth penetration of hydrating and pro-trophic agents in treated vulvovaginal areas [3].

The study confirms the short-term outcomes of the first DQRF/UPR™ double-blind study over a longer one-year follow-up. The double-blind study already established the UPR™ contribution acting in synergy with the DQRF™ technology [3].

Although the baseline vaginal dryness and overall cohort VVA symptom profile appeared quite severe, most cohort women reported T1 reductions of baseline symptom scores between -81.5% and -89.5%-quite impressive after the relatively short DQRF/UPR™ treatment cycle, at most no more than about 80 days. Indeed, some caution is justified: together with the uncontrolled design, assessing symptom relief from VVA symptoms only through impromptu, non-validated VAS and Likert-like subjective scales is a weak point that deserves consideration before hasty conclusions.

Besides physical discomfort, VVA symptoms may severely affect the postmenopausal woman’s self-perception [10-12]. In clinical situations where even minor clinical improvements may translate into significant perceived relief, benefits may appear magnified due to the placebo effect. Psychological and self-rated measures, mainly if assessed via subjective semi-quantitative scores, are primarily liable to placebo effects-as in this study.

However, the study intended only to confirm the benefits of the DQRF/UPR™ VVA treatment option, which the double-blind trial demonstrated [3], over a one-year follow-up, and its value is unaffected. On the contrary, the study provides new clinically significant information-the subjective VVA benefits persist for one year after a relatively short, four-to-five session treatment cycle, with VVA symptom severity scores still -64.9% and -70.4% vs baseline after twelve months. Interestingly, dyspareunia showed the most remarkable long-term improvement, indirectly highlighting the importance of a gratifying sexual life for the cohort’s postmenopausal women. The open-label nature of the study cannot contribute to defining the contributing role of in-depth radioporation of the lenitive and possibly pro-trophic glucose-hyaluronic acid gel. However, the previous double-blind investigation already demonstrated the DQRF™ and UPR™ synergy [3].

Of course, further long-term studies will confirm these preliminary encouraging results.

Conclusion

The study confirms, over a one-year follow-up, the benefits, previously demonstrated in a double-blind trial, of the Dynamic Quadripolar Radiofrequency (DQRF™) in synergy with Ultra-Pulsed Radioporation (UPR™) of hydrating and pro-trophic hyaluronic acid as an innovative treatment option of the vulvovaginal atrophy, and in the general genitourinary syndrome of the menopause symptoms.

Acknowledgement

The authors declare they have no financial or any other conflict of interest related to the study or the issues discussed in the paper.

References

  1. Vicariotto F, De Seta F, Faoro V, Raichi M (2017) Dynamic quadripolar radiofrequency treatment of vaginal laxity/menopausal vulvo-vaginal atrophy: 12-month efficacy and safety. Minerva Ginecol 69: 342-349. [crossref]
  2. Vicariotto F, Raichi M (2016) Technological evolution in the radiofrequency treatment of vaginal laxity and menopausal vulvo-vaginal atrophy and other genitourinary symptoms: first experiences with a novel dynamic quadripolar device. Minerva Ginecol 68: 225-236. [crossref]
  3. Tranchini R, Raichi M (2018) Ultra-Pulsed Radioporation further enhances the efficacy of Dynamic Quadripolar Radiofrequency in women with post-menopausal vulvo-vaginal atrophy. Clin Obstet Gynecol Reprod Med 4: 1-5.
  4. Landau M, Fagien S (2015) Science of hyaluronic acid beyond filling: fibroblasts and their response to the extracellular matrix. Plast Reconstr Surg 136: 188S-195S. [crossref]
  5. Fasola E, Gazzola R (2016) Labia majora augmentation with hyaluronic acid filler: technique and results. Aesthet Surg J 36: 1155-1163. [crossref]
  6. Tadir Y, Gaspar A, Lev-Sagie A, Alexiades M, Alinsod R, et al. (2017) Light and energy-based therapeutics for genitourinary syndrome of menopause: Consensus and controversies. Lasers Surg Med 49: 137-159. [crossref]
  7. Dunbar SW, Goldberg DJ (2015) Radiofrequency in cosmetic dermatology: an update. J Drugs Dermatol 14: 1229-1238. [crossref]
  8. Gaspar A, Addamo G, Brandi H (2011) Vaginal fractional CO2 laser: a minimally invasive option for vaginal rejuvenation. Am J Cosmetic Surg 28: 156-162.
  9. Beasley KL, Weiss RA (2014) Radiofrequency in cosmetic dermatology. Dermatol Clin 32: 79-90. [crossref]
  10. Alexiades M, Berube D (2015) Randomized, blinded, 3-arm clinical trial assessing optimal temperature and duration for treatment with minimally invasive fractional radiofrequency. Dermatol Surg 41: 623-632. [crossref]
  11. Nappi RE, Martini E, Cucinella L, Martella S, Tiranini L, et al. (2019) Addressing vulvovaginal atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for healthy aging in women. Front Endocrinol (Lausanne) 10: 561. [crossref]
  12. Oken BS (2008) Placebo effects: clinical aspects and neurobiology. Brain 131: 2812-2823. [crossref]

Caddisflies as an Underwater Architectures and Indicator for Water Quality and Classification of Water Habits

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DOI: 10.31038/GEMS.2021321

 

Trichoptera (Caddisflies) insects has long, silky hairs that cover most of the body and wings. This order of insect is included: 21 families, 145 Genera and 1200 species. This order is closely related to Lepidoptera. The Immature stage is aquatic and respiration at the larval stage by respiratory gills. Adults are active and winged insects and they have broad diversity of habitats. Larvae are worm-like, soft bodies, head contains a hard covering, color vary from yellow or brown, but usually green, larvae are known for their construction of hollow cases that they either carry with them or attach to rock, cases are built from sand, twigs, small stones, crushed shells, rolled leaves, and bark pieces, cases used for protection and pupation, length up to 1 inch. Larvae are Eruciform (caterpillar-like) body, abdomen usually enclosed in a case made of stones, leaves, twigs, or other natural materials.Head capsule well-developed with chewing mouthparts . Thread-like abdominal gills usually present in case-makers . They have one pair of hooked prolegs often present at tip of abdomen (Figure 1). larvae feed on algae,small bits of plant material . Some species build nets where they catch drifting food, fed upon by several species of fish. They are sensitive to water pollution and are used as important indicators in studies of water quality. The larval habitats are; lotic, lentic, erosional,warm rivers, headwater stream, cool streams, rock face streams, seeps, large rivers, small spring, marshland, small rapid stream, pond, pool, lake, temporary streams, depositional habitats, moss. The main habits of this insects are; clingers, burrowers, sprawlers, collectors, filterer, gatherer, scraper, predator (engulfers), shredder, herbivores, piercers, climbers, chewer (detritivore), scavenger, swimmer.

fig 1

Figure 1: Larvae of Caddisfly

Caddisfly larvae best known for the construction of: nets, retreats and cases. Different types of larval cases are: smooth mineral, case flat, mineral tube with long plant pieces, tapered, flat tube of bark, sand construction case, case with stone, very slender case, case with wood fragments, snail shell shaped, flask shaped case, a tube of fine mineral, cylinder case, curved cylinder shape with wood pieces, tapered shape, irregular strands of vegetation, Christmas tree shape, curved cylinder of leaf pieces, square in cross-section, cylindrical of sand, rough mineral (Figure 2).

fig 2 a

fig 2b

fig 2c

fig 2d

fig 2e

fig 2f

Figure 2: Different types of cases of caddisflies larvae

Larvae change to pupae (Figure 3).

fig 3

Figure 3: Pupae of Caddisflies

Adults are moth-like, brownish and usually nocturnal, wings thickly covered with hairs (Figure 4).

fig 4

Figure 4: Adult of Caddisfly

Water Quality Indicators are: dissolved oxygen (do), phosphorus, coliform bacteria, turbidity, pH and macro-invertebrates. The presence, condition, and numbers of the types of Insects, can provide accurate information about the health of a specific river, stream, lake, wetland, or estuary. Cadissflies are being used as biological indicators for assessing water quality and good tools of physico-chemical properties of the water for classification. The most diverse group of freshwater benthic macroinvertebrates is the aquatic insects. Around 70% of known species of major groups of aquatic macro invertebrates were identified in North America. Around 4000 species of aquatic insects and water mites have been reported from Canada. Thus, as a highly diverse group, benthic macroinvertebrates are excellent candidates for studies of changes in biodiversity.

Psychological Responses of Patients Receiving a Diagnosis of Adenocarcinoma

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DOI: 10.31038/CST.2021622

 

Mr. X is a 62-year-old man who just had a needle biopsy of the pancreas showing adenocarcinoma. The nurse and his doctor want to tell the patient about this result?

Question One

How can you deliver this news to Mr. X (Refer to 2 articles, references?)

Answer

In some health organizations, the patients kept ignored in relation to the true nature of their disease, the risks involved, and their prognosis. While in some cases a doctor and a nurse may still withhold information concerning certain details that might threaten the recovery of a patient who is unstable, nervous, or seriously depressed. Nowadays, the sharing of information is governed by the principle of autonomy that is, patients themselves take decisions on everything concerning their disease and must confirm their knowledge and acceptance of any tests or treatments that carry risks by signing an informed consent form Guerra-Tapia [1]. Therefore, before starting to discuss the case of Mr. X and how to inform him with his new diagnosis, more emphasis should be done to understand the definition of what we call it as “bad news”. Buckman (1984) [2], was the first person to define the bad news as “any information likely to alter drastically a patient’s view of his or her future” [3]. Although those information are as it was mentioned in the definition will altered Mr. X expectations for his future, he should be informed about his condition. Delivering unfavorable information is important for many reasons. Giving him the truthful and correct information about his condition can help him make informed choices about his treatment and take responsibility for his care, rise his understanding and awareness of his condition and support him to make appropriate plans for his future. Additionally, this practice will prevent him from undertaking heavy treatment and facilitate end-of-life care planning [4]. Mr. X should know everything he needs in order to participate in diagnostic and therapeutic decisions concerning his own disease. As a long term outcome, Mr. X will perceive the healthcare team as honest; he will experience an increase in his satisfaction, compliance, and coping mechanisms. Moreover, and in general, after a person’s death, memories of care at the end of life will remain with those who grieve the loss and can affect their perception of the facility, healthcare professionals, or memories about their role in easing suffering or death. For these reasons, bad news must be delivered sympathetically and empathetically [4].

The Barriers to Break the Bad News

On the other hand, and in order to decrease the barriers of breaking the bad news, we as a health team members should establish Mr. X’s trust and rapport, reduce his anxiety and uncertainty, educate him, provide him with the sufficient support, and help him to establish a treatment plan. All of those points will be enhanced and supported by the usage of proper communication skills which can be the most important tool we have to support Mr. X and his family on their cancer journey. Yet, oncology nurses may find communicating bad news difficult for several reasons. One of those reasons is that the nurses may fear that sharing critical medical information can cause harm, such as hopelessness, depression, or a sense of disappointment to the patient. Other reason is that, delivering bad news can be painful because of nurses’ lack of practice or skill; embarrassment with emotional reactions, such as denial or anger that can be focused toward care providers; or fear of removing hope. Further reasons are related to the staff overload, not finding the right time to talk to the patient and the increase in hospital unit demanding. Even during the pressured time, the nurses should be aware of their tone of voice, facial expressions, hand gestures, posture of being unhurried, and attention to space and touch. In addition to all of those reasons, lack of special training in breaking the bad news and how to deal with cancer patients is another crucial issue. Extra barriers encountered by both physicians and nurses include concerns about lack of privacy, language and cultural barriers and inconsistencies between relatives’ and patients’ wishes as to whether information is withheld or shared [5].

The Role of the Nurse in Breaking the Bad News

Communicating the bad news for the patient is not conserved only by the physician; in contrast, it is a multidisciplinary activity which necessitates the active participation of a wide range of healthcare professionals working as a team. The nurse actually became actively involved in the process of breaking bad news by assuming the role of educator, supporter, and advocate for patients. They were also involved in the bad news process as they helped patients understand the implications of their illnesses. The supportive activities that nurses have been found to engage in around bad news include assessing needs for information, identifying and clarifying misunderstandings, initiating discussion, obtaining and explaining complex medical information and helping patients and relatives cope with their emotional reactions [6]. Once news has been given, nurses often are asked additional questions about bad news after the physician leaves the room and may be needed to help restore equilibrium with patients or family members. Warnock et al. [4] did a study about “breaking bad news in in-patient clinical settings: role of the nurse”. They concluded that guidance for breaking bad news should encompass the whole process of doing this and acknowledge the challenges nurses face in the inpatient clinical area. Developments in education and support are required that reflect the challenges that nurses encounter in the inpatient care setting. From this study we can conclude that, nurses should have a vital role in breaking the bad news but after appropriate and high quality training sessions on the steps or strategies for delivering the bad news. Moreover, nurses can deliver hope and serve as advocates for patients and families by sharing patients’ information needs or concerns with the healthcare team and physician, providing support for the physician who may feel guilt or unwillingness to approach unfavorable issues, meeting with patients and families afterward to comfort them and clarify issues, and presenting information in the context of patients’ hopes and expectations [5].

The Steps for Delivering the Bad News to Mr. X

Delivering the bad news can be perceived as a process, which includes the communications that take place before, during and after the moment that bad news is delivered. Therefore, the preparation of Mr. X and /or his family for receiving the bad news, clarification and explanation for the information they have been given during all the disease stages become part of the process. Radziewicz [5], describe the skills for breaking the bad news by using the SPIKES—Six Step Protocol which was developed in 2000 by Baile [7] and colleagues. This model includes six steps: Setting, Perception, Invitation, Knowledge, Emotion, and Summary. But according to Guerra (2013) [1], they used what they called it as five practical steps that actually have the same concepts or way of approach to the SPIKES but without labeling the steps. They also add four pre-conditions criteria which should be met before breaking the bad news. Thus, and in the situation of Mr. X who was newly diagnosed with adenocarcinoma, we as a physician and a nurse (health team members) start to break the bad news in such a way: First we have to meet the four pre-conditions. Me and the physician should set first together and evaluate the seriousness of Mr. X disease and its prognosis, so we will understand the case from all the angles. Also, we should remember that each patient is a unique individual, and Mr. X is having a different personality, work situation, and Religious beliefs, economic status than the other patients. Then, we should know which type o family Mr. X is belonging to? If he likes to involve his family in the discussion of the bad news? And whom he wants to include in the meetings? The last consideration that, we as a group should foster the trust relationship between us and Mr. X. choosing the right members in our team who dealt previously with Mr. X and know him well will facilitate the delivery of his bad news. As a first practical step in delivering the bad news is to analyze the context. In this step, we should prepare ourselves by considering the questions of when, how, with whom, and how long to take with Mr. X. The context or the environment where the interview will be held in should be chosen precisely (e.g., free from distractions and interruptions, has a comfortable chairs, closed enough to maintain Mr. X privacy, and free enough for a reasonable length of time). The second step is to consider the starting point. This will include questions like: what does Mr. X know? What does he want to know? We should provide the answers and must accept possible silences, evasive answers, or a refusal to be informed, but always offer another possibility. Sharing the information is the third step in breaking the bad news. For this, we must do the following three points: firstly, pay attention to nonverbal communication (gestures, postures, looks). We should look to Mr. X directly in his eyes, but we must be careful not to stare, as that might frighten him. Our facial expression should express seriousness, but not severity. Gestures should be kind, but not overly cheerful. We should speak in a neutral tone, with a firm voice that is neither authoritarian nor tremulous. Our manner should express confidence and be unhurried. We also need to be prepared for the possibility when Mr. X taking his anger out on us, following the impulse to “kill the messenger”. The best response will be a serene and understanding one. Secondly, pay attention to verbal communication (the words). The most important elements here are our opening words, in which we formulate our main statements, questions, and answers. We must present the facts as objectively and concretely as possible. Difficult expressions and technical terminologies should be avoided, unless we are going to clarify their meaning immediately. During the interview, comprehension should be checked regularly: “Do you understand what I mean?”. Lastly, listen attentively to Mr. X feelings even if he interrupts our explanations. Listen with an attitude that is not judgmental or moralizing. Listening in this way, even to the silences, is known as “active listening” and is a very effective tool in human communication Guerra [1]. The fourth step in bad news breaking is to empathize, don’t sympathize. We as a breaking the bad news team must try to imagine how the other person might feel without letting it affect us personally. It is good to be well practiced in giving support and to learn to empathize with our patients’ emotions without identifying with their anguish. Repeated failure in adapting to individual situations can lead to physician and nurse burnout. The fifth and last step is that propose care and follow-up for Mr. X. We cannot change bad news, but we can offer positive advice and constant emotional support both to Mr. X and to his family. There is always something that can be done (e.g., “We can start eliminating the affected areas”). We should try to manage uncertainty without setting specific time limits. Additionally, we can reinforce the role of the family as a resource of support and provide information about the social support available from support groups, patients’ associations Guerra [1].

Question Two

Mr. X is crying uncontrollably. The nurse helps the client to calm down and then asks what made him cry. Mr. X says (I’m feeling very guilty). When the nurse ask why, Mr. X suddenly stops crying and replies angrily (why do you think I‘ve been keeping quiet? I know you will tell everybody here about what a failure I am. Please leave me alone. I‘m not saying anything. How will the nurse earn Mr. X trust to help build a therapeutic relationship? Refer to 2 articles.

Answer

Trust is described as a belief that our good will be taken care of, or as an attitude bound to time and space in which one relies with confidence on someone or something, and as a willingness to engage oneself in a relationship with an acceptance that vulnerability may arise [8]. Also it defines as “rely on “or “confidence in truth [9]. Although concept of trust is used in everyday nursing language, but it’s still vague, complex and not fully understood among nurses [10] conducted a systematic review to identify empirical studies on trust within the nurse–patient relationship and to analyze and synthesize the results, a total of thirty four studies were included, twenty-two studies used a qualitative design, and twelve studies used quantitative research methods. The context of most quantitative studies was nurse caring behaviors, whereas most qualitative studies focused on trust in the nurse–patient relationship, the result revealed that building trust was characterized as a process that includes various stages during which trust could be established, damaged and repaired, the first characteristic, trust is a dynamic process which means that it is ongoing process from feeling comfortable to building a rapport, that cannot be hastened. The trust-building process between nurse and patients involved trying to understand each other, individualizing and sharing of self, and for patients with chronic illness, the process developed from general naïve trust into specific reconstructed trust. The second characteristic trust as a relational phenomenon, which means trust was regarded as the foundation of any therapeutic relationship, and an essential element of nurse–patient relationships, It is considered inherent in the relationship between a nurse and children and between a nurse and parents, establishing a trusting relationship with patients was identified as an important facet of the nurse’s role and as a basis for continued care and treatment. Also trust is not something that nurses possess or are given; instead, it is something that they earn and have to work hard to achieve. It requires a two-way relationship between the person who makes themselves trustworthy and the person who puts their trust in them. Third characteristic trust as a fragile and ambiguous phenomenon, trust and distrust are often viewed as two ends of a continuum, and exposed as “fragile “ phenomena that can easily “ tip over” towards their opposites. Also the findings of included studies indicated that various factors may facilitate or impede the development of a trusting relationship, some of which were related to personal and professional characteristics of nurses or vulnerability of patients. Factors that facilitate the trust such as accepting patient’s culture and life style, and decisions without prejudgment, providing good advice, convey respect, show warmth and caring, use active listening, give sufficient time to answer patient’s questions, maintain confidentiality, show congruence between verbal and nonverbal behaviors, use appropriate eye contact, give complete information, provide consistency, be honest and open. Factors that hinder trust such as is lack of the necessary knowledge and skill to undertake nursing procedures, using medical terminology or jargon which the patient does not fully understand creates a language barrier that hinders effective communication and the building of a trusting relationship. Additionally, failure to anticipate or understand the information needs of patients, depersonalizing the patient by referring to him or her by medical diagnosis or bed number, neglecting responsibilities and remaining distant undermined patients’ trust of nurses, also work-related factors and emotionally challenging nursing procedures such as busy workload, inadequate time, lack of parental understanding. Similarly Hillen [11-16] designed a systematic review to describe the current knowledge of the conceptualization, assessment, correlates, and consequences of cancer patients’ trust in their physician, a total of eleven studies were included, and the result revealed that trust in physicians was strong overall, patients’ trust appeared to be enhanced by the physician’s perceived technical competence, honesty, and patient-centered behavior. A trusting relationship between patient and physician resulted in facilitated communication and medical decision making, a decrease of patient fear, and better treatment adherence. So after discussing these articles we can answer this question as: the nurse can earn Mr. X trust by firstly, telling him the truth and use honest disclosure related his condition and treatment option with full honesty and clarity, upon clarifying Mr. X diagnosis and prognosis and the treatment option, secondly, speaking with good purposes and calm approaches with honest, clear and respectful ways of communication that will contribute to building our relationship with Mr. X. thirdly, telling him about his diagnosis and prognosis and that all the issues related to his condition will be confidential; by stating that “Mr. X keep in mind that all information related to your health condition will be confidential”, fourthly, providing alternatives regarding his condition and his diagnosis with adenocarcinoma, then allow for decision making, in this stage we empower the patient by providing alternatives and allow him to choose, acknowledge Mr. X skills and abilities and demonstrates respect for his decisions and choice in the previous stage of communication. Fifthly, manage expectation and make it realistic and explicit, also to clarify the limits and boundaries of what can be done to treat his cancer, establishing therapeutics and professional boundaries, clear boundaries allow for safe and a therapeutic connection between the nurses and Mr. X. sixthly, using therapeutic ways of communication such as showing empathy, giving information, and exploring to answer and to build therapeutic relationship with Mr. X. Finally, building trust is an ongoing and progressive process during all phases of working with Mr. X.

Question Three

The nurse can provide Mr. X with the names and details of other clients in the unit who have been through similar experiences to make him realize that he is not the only one who have such diagnosis?

A: True

B: False

Select true or false and rationalize your answer?

Answer

False; the nurse at Mr. X situation breaches the principle of confidentiality when she shares information for other patient without the patient approval. The nurse should protect health information; including: Names, Geographic data, All elements of dates, Telephone numbers, and any information that can be used to identify the individual. Also Mr. X may feel insecure about his information and privacy, when the information of other patient shared to him.

Question Four

Connection with its corresponding:

Answer in the table below (Table 1):

Table 1: Answers to Question 4.

Num Element Description
1 Trust Involve talking the risk of sharing oneself with  another
2 Professionalism Involve applying a specific background of  knowledge and skills
3 Genuineness Allows the nurse to relax and resist trying to impress others
4 Empathy Having insight into the meaning of the other persons thoughts, feeling and behaviors
5 Unconditional positive regard Respecting and being attentive regardless of the other persons behavior
6 Caring Meeting a client needs and providing comfort measure when required

References

  1. Guerra Tapia A, González Guerrab E (2013) Communicating Bad News During an Office Visit: Transmisión de malas noticias en la consulta. Actas Dermosifiliogr 104: 1-3.
  2. Buckman R (1984) Breaking bad news: why is it still so difficult? BMJ 288: 1597-1599. [crossref]
  3. Martins RG, Carvalho IP (2013) Breaking bad news: Patients’ preferences and health locus of control. Patient Education and Counseling 92: 67-73. [crossref]
  4. Warnock C, Tod A, Foster J, Soreny C (2010) Breaking bad news in inpatient clinical settings: role of the nurse. Journal of Advanced Nursing, 66: 1543–1555. [crossref]
  5. Radziewicz R, Baile FW (2001) Communication Skills: Breaking Bad News inthe Clinical Setting. Leadership and Professional Development 28: 951-953. [crossref]
  6. McSteen K, Peden-McAlpine C (2006) The role of the nurse as advocate in ethically difficult care situations with dying patients. Journal of Hospice and Palliative Nursing 8: 259–269.
  7. Back AL, Arnold RM, Baile WF, Tulsky J A, Fryer‐Edwards K (2005) Approaching Difficult Communication Tasks in Oncology1. CA: A Cancer Journal for Clinicians 55: 164-177. [crossref]
  8. Dinç L, Gastmans C (2012) Trust and trustworthiness in nursing: an argument‐based literature review. Nursing inquiry 19: 223-237. [crossref]
  9. Bell L, Duffy A (2009) A concept analysis of nurse–patient trust. British journal of Nursing 18: 46-51. [crossref]
  10. Dinç L, Gastmans C (2013) Trust in nurse-patient relationships: a literature review. Nursing ethics 20: 501-516. [crossref]
  11. Hillen MA, de Haes HC, Smets EM (2010) Cancer patients’ trust in their physician—a review. Psycho-Oncology 20: 227-241. [crossref]
  12. Dean E (2011) It’s not all bad news: how the care campaign challenges are being met. Nursing Standard 26: 12-13.
  13. Kaplan M (2010) SPIKES: a framework for breaking bad news to patients with cancer. Clinical Journal of Oncology Nursing 14: 514-516. [crossref]
  14. Konstantis A, Exiara, T. (2015) Breaking bad news in cancer patients. Indian Journal of Palliative Care 21: 35-38. [crossref]
  15. McGowan C (2012. Patients’ confidentiality. Critical Care Nurse 32: 61-64.
  16. Salem A, Salem AF (2013) Breaking Bad News: Current Prospective and Practical Guideline for Muslim Countries. Journal of Cancer Education 28: 790-794. [crossref]

Assessment of Knowledge, Attitude and Practice Towards Female Genital cutting (FGC) among Women of Reproductive Age Group in Jigjiga City, Somali Region; Ethiopia: Community Based Cross-Sectional Study

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DOI: 10.31038/IGOJ.2021413

Abstract

Background: Female Genital Cutting (FGC) is dangerous and humiliating traditional practice that violates the right of girls and women and it is serous public health problems as it affects the health of poor Ethiopian girls and woman. Moreover, it is proved that all forms of FGC entail an immediate and long-term life treating damage to the physical, mental and social well-being of girls and women.

Objective: The objective of the study was to assess knowledge, attitude & practice towards FGC among women of reproductive age group in Jigjiga town.

Methodology: A community-based cross-sectional study design was used from January to March 2016. Structure questionnaires were used to collect data from-311study participants. Descriptive statistics was used to calculate frequency/percentage, mean and medium & the results were presented using tables, graphs and charts.

Results: A total of 311 women were included in the study. One hundred and thirty (43%) of the respondents were within the age of 15-30years. Majority 264 (84.9%)] were from Somali ethnic group and 272 (87.5%) were Muslims. 140(45%) were house wife and about 201 (64.6%) were found to be illiterate. All of the respondents have heard about FGC and 32.5% of them got information regarding FGC from Media. A total of 226 study participants practiced one or more type of the different forms of FGM/C on their daughters making the prevalence of FGC 72.7%. Of these, 158 (70.1%) were circumcised during the age < 8years. Most of the respondents 280(90.1%) knew that FGC has negative health effect. Common reasons for the practice of FGC they mentioned was to preserve virginity (49.8%) Most of those respondents (75.7%) reported that FGM/C was performed at their own home. The decision to have FGM/C was made by respondents’ mothers (42.5%), followed by father (25%]).

Conclusion: There is high practice of FGC among the community (72.7% prevalence) though they know the health impact of the FGC. As majority agrees to stop the practice efforts towards FGC prevision should focus on supporting the community on the factors that favour the practice. In addition, interventions focusing on behavioral change towards harmful traditional practices including FGC should be strengthened.

Keywords

KAP, FGC, Jigjiga, Somali region, Ethiopia

Introduction

Female Genital Cutting (FGC), sometimes called female circumcision or female genital mutilation, means piercing, cutting removing, or sewing closed all part of a girl’s or women’s external genitals for no medical reason. The operation, which lasts around 15-20 minutes, is carried out by traditional birth attendants and other untrained personnel living in the community with unsterile settings. According to its severity WHO/UNICEF/UNFPA, jointly adopted in April 1997 four type of FGC. Among the four types, Type II is commonest while the most extreme type is III [1].

There have been no comprehensive global surreys of prevalence of FGC. However, WHO estimated that 140 million of girls and women have under gone the operation and three million girls are at risk each year in 28 African countries including Ethiopia with estimated prevalence of 90% [2].

In Ethiopian FGC is practiced by Muslims and Christians as well with 90% prevalence. Study undertaken by National Committee on Traditional Practice in Ethiopia (NCTPE) about national base line survey to determine the prevalence of this practice 1997/1998 revealed regional statistics of prevalence; Afar 94.5%, Addis Ababa 70.2%, Somali 69.7%, Benishangul 52.9%, Tigray 48% and Southern region 46.3%. Other two studies conducted at Serbo and Seko Woredas, Jimma zone, Western Ethiopia revealed a prevalence of 96% & 78% respectively [3,4]. Similar study conducted on FGC in Somali on 1998 by Mohamed Omer, reported elimination of this practice would result in more than 40% and 50% reduction of Neonatal mortality and female child mortality, respectively [5].

Study done by Egyptian Care Society, showed that 39% of study women perpetuate FGC due to custom. Eighty percent believed that practice should continue. 15%-20% refused to give opinion on FGC. Sixty percent believed FGC was religious practice [6].

A study done by United Nations Population Fund (UNFPA) indicated that reproduction and sexual health are affected over the entire life course of FGC- despite the seriousness of the issues, there are major gaps in knowledge about extent of the problem and the nature of successful intervention. On a report of qualitative research on KAP related to FGC in Serra Leone, all 300 interviewees (adult and young men) were strongly; opposed to FGC because of it is determinant impact on Female (women’s) health and the drain of family financial resources [1]. Another study done in Sudan mentioned that 45 people of women interviewed believed that FGC is a good practice because of it is promote cleanliness, and keep virginity [7].

According to study in entitled female genital mutilation a new challenge for health service; most Children or women are circumcised by local women and traditional midwives. Often the practice is part of cultural rituals that make the transition to womanhood and preparation for marriage. There are four forms of FGM, most of community in Somali region practice at least one of it [8-10].

All types of female genital mutilation involve removal or damage to the normal functioning of the external female genitalia and can give rise to a range of well documented physical complications. They are irreversible and their effects last a lifetime. Studies on health effects of FGC shown this practice has negative consequences for delivery, first sexual intercourse, and during menstruation. Studies on the psychological effects of FGC are scarce and need to be given due emphasis, given that FGC is one of the reported risk factors for posttraumatic stress disorder in women [11-16].

It is important to bear in mind that FGC is a serious public health problem, as it affects the health of poor girls and women, particularly places where the most aggressive type (infibulations) is highly practiced. Despite recognition of this sensitive issue and realization of its extent that it should be addressed, if the health, social and economic development of girls are to be met for there is still major gap in knowledge about the extent and nature of the problem and the kinds of intervention that can be successful in eliminating reducing the FGC practice.

It is thus important to assess knowledge, attitude and practice of FGC to ensure existing health priorities of the women’s reproductive age group, in order to tackle the problems with community (teachers, student/Family) participation and other partnership or stakeholders.

Therefore, the objective of this study was to assess the knowledge, attitude, and practice towards FGC among women of reproductive age group in Jigjiga town Somali regional state, Eastern Ethiopia in 2016.

Methods and Materials

Study Area and Study Period

The study was conducted in Jigjiga town, Capital of Somali region from January to May 2016. Jigjiga is located in Eastern part of Ethiopia 635km from the capital city, Addis Ababa. The town’s climate is sub tropic climate and receives 300-500mm annual rain fall a year, the mean annual temperature of the town is 24-26 degree Celsius (Figures 1 and 2).

fig 1

Figure 1: Source of information on Knowledge on Female Genital Cutting (FGC) of the respondents in Jigjiga town, Somali regional state, Ethiopia, April 2016.

fig 2

Figure 2: Decision maker for Practice towards FGC of the respondents in Jigjiga town, Somali regional state, Ethiopia, April 2016.

Study Design

A community based cross-sectional study was conducted to assess the knowledge, attitude and practice to Female Genital Cutting (FGC) of females of reproductive age group in Jigjiga town of Somali regional state, Eastern Ethiopia.

Source Population

The source populations of the study were all women of reproductive age group of Jigjiga town, Somali regional state, Eastern Ethiopia.

Study Population

The study population was randomly selected women of reproductive age group in the selected kebeles who fulfilled inclusion criteria.

Sample Size

Sample size determination was done using the sample size formula using single population proportion formula with P=proportion of women’s reproductive age group, 74% (0.74) in 2005 EDHS and adding 5% (15) to it the final sample size was 311.

Data Collection Procedure

Face to face interview method was applied by using structured questionnaires to collect the data on knowledge, attitude and practice and other socioeconomic and demographic variables from the women of reproductive age group.

Data Quality Control and Analysis

Pre-test was done on to 5% women of reproductive age who did not participate in actual study. All collected questionnaires were checked for completeness and correctness on daily basis. The data was analyzed using descriptive statistics using mean, frequency/percentages and was presented by tables, graphs and charts,

Ethical Consideration

Ethical approval was obtained from Jigjiga University College of medicine and Health Science College and letter of permission was obtained from Jigjiga counsel to undergo the study. In addition participants were informed about the voluntary nature of participation and that they can exit the interview any time they decided. All data of the respondents were kept confidential.

Result

Three hundred eleven (311) women in the reproductive age group of Jigjiga town were interviewed. Majority of the respondents were Somalis (84.9%) & Muslims (90.67%) in religion. Nearly half (45%) of the study participants were house wives. Regarding their educational status, most of them were not able to read and write (67.85%). More than half of the respondents (62.4%) were single (Tables 1-4).

Table 1: Socio demographic and economic characteristics of the respondents in Jigjiga town, Somali regional state, Ethiopia, April, 2016 (N=311).

Feature

 Variables Number

%
Age of women in years

15-29

  154  49.5%

30-49

  157

 50.5%

Total

  311

 100%
Ethnicity

Somali

  264  84.9%

Oromo

  18  5.8%

Amhara

  14

 4.5%

Others

  15

 4.8%

Total

  311

 100%
Religion

Muslim

  282  90.67

Orthodox

  11

 3.5%

Catholic

 7 2.3%

Others

  11

 3.5 %

Total

  311

 100%
 Occupational status

Government worker

  70  22.5%

Private worker

  85

 27.6%

House wife

 140 45%

Others

  16

 5.14%

Total

  311

 100%
Educational Status

Not able to read and write

  211  67.85%

Elementary school (1-8)

 50

 16.1%

High school (9-12)

  36  11.6%

College & above

  14

4.5 %

Total

  311

 100%
Marital Status

Single

  194 62.4%

Married

 70

22.5%

Divorced

  39  12.5%

Separated

  8

 2.6%
Total

 311

 100%

Table 2: knowledge about the health effects of FGC on health & Common reasons why the community practice FGM Jigjiga city, Ethiopian Somali in April 2016.

Effects of FGC

 Frequency

Percentage

 Ill-effect

179

57.56%
Bleeding during delivery

39

12.54%
Urinary infections

54

17.4%
No effect

31

9.97%
Others

8

2.57%
Total

311

100%
Reason for FGC practice
Religious approval

 47

 15.1%
Preserve virginity

 155

 49.8%
Avoid sexual problems

 70

 22.5%
To keep hygiene and aesthetics

 23

 7.4%
Others

 16

 5.14%
Total

 311

 100%

Table 3: Distribution of woman’s attitude towards the practice of FGC Jigjiga city, Ethiopian Somali in April 2016.

 Response towards FGC

 Variables Frequency % Remark
NO

%
 FGC should be stopped Strongly agree

 162

 52.1%
Agree

 78

 25..1%
Neutral

 16

 5.14%
Disagree

 39

 12.5%
Strongly disagree

 16

 5.14
Total

311

100%
Female should actively participate in FGC eradication Strongly agree

 147

 47%
Agree

78

 25%
Neutral

 78

 25%
Disagree

8

 3%
Strongly disagree

0

0%
Total

311

100%

Table 4: FGC practice in Jigjig city, Somali region, Ethiopia, April 2016.

S/N

 performed FGC practice Number

Percent (%)
1 Yes

 226

 72.7%
2 No

 85

 27.3%
  Total

 311

 100%
Age at which circumcised
  1-8

 158

 70.1%
  8-16

 56

 24.76%
  >16

 12

 5.14%
  Total

 226

 100%
Place of FGC occurrence
  Home

 171

75.7%
  Do not know

 29

 12.8%
  Others (TBA, traditional healer etc home)

 26

 11.5%
  Total

 226

 100%

Knowledge on Female Genital Cutting (FGC)

All of the respondents have heard about FGC and 32.5% of them got information regarding FGC from Media followed by professionals (31.5%).

Most of the respondents 280(90.1%) knew that FGC has negative health effect. As to why FGC conducted in the community, Common reasons for the practice of FGC (nearly half of the respondents (49.8%)) mentioned to preserve virginity. In addition they reported religious approval (15.1%) as the next reason of the practice.

Attitude towards Female Genital Cutting (FGC)

Majority of the respondents 240(77.2%) agree that FGC should be stopped More than half 201(64.9%) of the respondents also believe FGC results poor sexual pleasure. In addition, majority 225(72%) of the respondents agree that female should actively participate on FGC eradication.

Practice towards FGC

A total of 226 study participants reported that one or more type of the different forms of FGM/C practice making the prevalence of FGC 72.7%. Of these, 158 (70.1%) were circumcised during the age < 8years. Most of those respondents (75.7%) reported that FGM/C was performed at their own home. The decision to have FGM/C was made by respondents’ mothers (42.5%), followed by father (25%]).

Discussion

Female genital cutting/mutilation (FGC/M) is a procedure that involves physically altering a woman’s/girl’s genitals for no health benefits. This is a practice that is deeply rooted in culture, religion, and social tradition primarily in some African and Middle East countries. It is performed by a midwife, barber, traditional healer with no surgical training, or a physician. The practice of FGC/M has been gaining increased attention as women from those countries have been migrating to the United States and Western Europe [9]. This community based cross-sectional study has attempted to assess the knowledge, attitude & practice towards FGC among women of reproductive age in Jigjiga town.

In this study, all of the respondents have heard about FGC and 32.5% of them got information regarding FGC from Media followed by professionals (31.5%). Most of the respondents 280 (90.1%) knew that FGC has negative health effect. a study done in Somalia revealed that, about 66.9% of women had good knowledge on the effects of FGC. In that Somalia study, respondents mentioned, infection 60%, bleeding 20%, and 68% difficult of labor to be the main ill effect of FGC [10-15]. This is consistency with our study finding, in contrast to our current findings, a study done in northwest Ethiopia shows that only 46.2% of women had good knowledge about the ill health effect of FGC and 53.8% of the mothers had poor knowledge about the ill health effect of FGC. This discrepancy might be due difference in study setting (facility Vs community) [9].

As to why FGC conducted in the community, Common reasons for the practice of FGC (nearly half of the respondents (49.8%)) mentioned to preserve virginity our study. In addition, they reported religious approval (15.1%) as the next reason of the practice similarly; more than half of Egyptian women believed that FGM would prevent adultery and that it is proof of a girl’s virginity and perceived that it improves marriage prospects for unmarried girls in Nigeria. This shows that traditional and religious reasons for practicing FGM are also widely accepted by females in the societies in different regions [10].

In this study, majority of the respondents 240 (77.2%) agree that FGC should be stopped More than half 201 (64.9%) of the respondents also believe FGC results poor sexual pleasure. In addition, majority 225 (72%) of the respondents agree that female should actively participate on FGC eradication. Similarly, in study conducted at Harari & Somali regions, the finding of the study reveals that 86% of study participants condemn the practice of FGC [12]. But in Similar study conducted in eastern Ethiopia showed, 47.9% of women have positive attitude, while 52.1% of women have favorable attitude against FGC practice [10]. This discrepancy might be due to combination efforts from different stake holders against FGC in the region & community awareness difference.

A total of 226 study participants reported that one or more type of the different forms of FGM/C practiced in their area making the prevalence of FGC 72.7%. As they reported 158 (70.1%) were circumcised during the age < 8years. Most of those respondents (75.7%) reported that FGM/C was performed at their own home. The decision to have FGM/C was made by respondents’ mothers (42.5%), followed by father (25%]). In Study conducted at Hadiya zone of southern Ethiopia, about 60% of the circumcisions were performed by traditional circumcisers while health professionals had performed 30% of them [14]. Similar study in Jigjiga on 2014 depicted that the prevalence of FGC among the respondents was found to be 82.6%. The dominant form of FGC in this study was type I FGC, 265 (49.3%). Four hundred and seven (62.7%) study participants had positive attitude toward FGC discontinuation. Religion, residence, respondents’ educational level, maternal education, attitude, and belief in religious requirement were the most significant predictors of FGC. The possible reasons for FGC practice were to keep virginity, improve social acceptance, have better marriage prospects, religious approval, and have hygiene [15].

On the other hand, in some countries, medical personnel, including doctors, nurses, and certified midwives perform FGM under anesthesia in health care facilities, even though it is forbidden and subject to prosecution in the west. The highest rate of use of medical personnel to perform FGM can be found in Egypt (61%), Kenya (34%), and Sudan (36%), with rates of 9% and 13%, respectively. These findings were inconsistency with our present study findings [12,16].

Limitation

Bias related to social desirability; since the study is self-reporting there is more likelihood of the participants to give culturally acceptable answer. There may be also information or recall bias as mothers were asked to recall events occurred long time.

Conclusion & Recommendation

There is high practice of FGC among the community (72.7% prevalence) though they know the health impact of the FGC. As majority agrees to stop the practice efforts towards FGC prevision should focus on supporting the community on the factors that favor the practice. In addition, interventions focusing on behavioral change towards harmful traditional practices including FGC should be strengthened.

Acknowledgment

I would like to pass my gratitude for Jigjiga town community specially the study groups who keenly supported by accepting the consent for the data collection. I would also like to pass my thanks to data collectors for their continuous effort during the data collection.

References

  1. World Health Organization (1997) “Female genital mutilation: a joint WHO/UNICEF/UNFPA statement,” WHO, Geneva.
  2. WHO (1998) “Female genital mutilation overview,” Geneva, Switzerland press.
  3. National committee on traditional practices in Ethiopia (NCTPE) (1997) “FGM,” Ethiopia, Addis Abeba.
  4. Abate A, Kifle M (2002) “Prevalence of female genital mutilation and attitude of mothers towards it” 12.
  5. Mahamed OA (1999) “Female circumcision and child mortality in urban Somali region”.
  6. “Egyptian Fertility care society, population council, Asia and East operation research and technical assistance final report,” Egypt, Cairo, November, 1996.
  7. Herieka E, Dhar J (2003) “Female genital mutilation in the Sudan: survey of the attitude of the Khartoum University students towards this practice” Sexually Transmitted Infect 79: 220-230. [crossref]
  8. UNICEF, “Female genital mutilation/cutting among Iraqi Kurdistan,” 2013.
  9. CM Little (2015) “Caring for Women Who Have Experienced Female Genital Cutting” MCN Am J Matern Child Nurs 40: 291-297. [crossref]
  10. M. e. Nurilign A, (2015) “Knowledge, Attitude and Practice of Women Towards FGM in Lejet Kebele, Dembecha Woreda, Amhara Regional state” Journal of Gynecology and Obstetrics 3: 21-25.
  11. Tag-Eldin MA, Gadallah MA, Al-Tayeb MN, Abdel-Aty M, Mansour E, et al. (2008) “Prevalence of female genital cutting among Egyptian girls” Bull World Health Organ 86: 269-274. [crossref]
  12. Abathun AD, Gele AA, Sundby J (2017) “Attitude Towards the Practice of Female Genital Cutting Among School Boys and Girls in Somali and Harari Regions, Eastern Ethiopia” Obstet Gynecol Int. [crossref]
  13. Muktar A (2013) “Knowledge, Attitude and Practice of FGM among women in Jigjiga town, Eastern Ethiopia; Cross sectional study” Gaziantep med J 19: 164-168.
  14. Tamire M, Molla M (2013) “Prevalence and Belief in the Continuation of Female Genital Cutting Among High School Girls: A Cross – Sectional Study in Hadiya Zone, Southern Ethiopia” BMC Public Health 5: 1120. [crossref]
  15. Gebremariam K, Assefa D, Weldegebreal F (2016) “Prevalence and associated factors of female genital cutting among young adult females in Jigjiga district, eastern Ethiopia: a cross-sectional mixed study”, International Journal of Women’s Health 8: 357-365. [crossref]
  16. Banks E, Meirik O, Farley T, Akande O, Bathija H, et al. (2006) “Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries” Lancet 367: 1835-1841. [crossref]
  17. Nurilign A, Getechew M, et’al. (2015) Knowledge, Attitude and Practice of Women
    towards Female Genital Mutilation in Lejet Kebele, Dembecha Woreda, Amhara
    Regional State. Journal of Gynecology and Obstetrics 3: 21-25.

Biennial (2007/8) Crisis of Sarotherodon galilaeus Fishery in Lake Kinneret (Israel): A Synopsis

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DOI: 10.31038/AFS.2021325

Background

There are 19 native fish species in Lake Kinneret [1,2] of which 6 are endemic, 2 are extinct, 5 are intentional and non-intentional introductions, and 10 under commercial exploitation and of the commercial species, Sarotherodon galilaeus (Arabic: Musht Abiad; Hebrew: Amnoon HaGalil; Common: Galilee St. Peter Fish) [1-6] and the stocked mugilids [2,3,7] have the highest market value. The silver carp (introduced), bleaks (native), the common carp (non-intentionally invasion), Barbus spp, and 3 other tilapia species have lower market values (Tables 1 and 2) [8].

Table 1: Scientific names and features (endemism, commercial fishery) of the Kinneret native fish species (Ben-Tuvia 1978; Gophen 1992;2018; 2019).

Scientific Name Features
Mirogrex terrae sanctae Commercial, endemic
Acanthobrama lissneri Commercial, endemic
Carasobarbus canis Commercial
Luciobarbus longiceps Commercial
Capoeta damascina Commercial
Garra jordanica
Hemmigramocapoeta nana
Pseudophoxinus kervilei
Coptodon zillii Commercial
Oreochromis aureus Commercial
Sarotherodon galilaeus Commercial
Tristramella simonis simonis Commercial, endemic
Tristramella sacra Endemic, no recent recording
Haplochromis flaviijosephi Endemic
Clarias gariepinus Commercial
Aphanius mento
Oxynoemacheilus jordanicus
Salaria fluviatilis

Table 2: Scientific names and features (commercial fishery, introduction, invasion) of the Kinneret non-native fish species (Ben-Tuvia 1978).

Scientific Name Features
Mugil cephalus Commercial, introduced
Mugil capito Commercial, introduced
Hypophthalmichthys molitrix Commercial, Introduced
Cyprinus carpio Commercial, invasion
Anguilla Anguilla Commercial, invasion
Salmo gairdneri irideus Commercial, invasion
Gambusia affinis Invasion

Sarotherodon galilaeus (SG) is a common native fish species in Lake Kinneret. The fish is a nest-builder and bi-parental mouth-breeder with tropical-Ethiopian origin. The adult stages are planktivorous filter-feeders specified on utilization of the phyrrhophyte Peridinium gatunenze [7,9]. The juveniles and fingerlings with a total length (TL) below 5 cm are visual particulate attack-feeders which selectively prey on zooplankton. Displays are carried out in the shallows (0.5-3-m depth) and nests are constructed on sand-silt-clay bottom in the shallows uncovered by vegetation. The nests are flat depressions (20-40-cm diameter) which are easily devastated by wave action immediately after spawning. The number of eggs in one clutch varies between 1000 and 3000, and fertilization takes place externally. Immediately after fertilization, collected by both parents’ mouths. Each couple may repeat 3-4 reproductive cycles in one season. Reproductive activity is initiated not before daily temperature in the shallows is above 21°C. Moreover, the reproductive process is very sensitive and the activity of swimmers or boat shading might cause an interruption. Newborn juveniles are sheltered 3-4 weeks inside the parents’ mouths and later on in shoals between submerged vegetation. Due to its flavored taste, SG is in high market demand. In the North-Eastern region of Lake Kinneret, there are open shallow lagoons which are highly favored by SG during the spawning season due to their ecological suitability for reproductive activity. Local fishermen are aware of that and used to intensify fishing pressure there from spring to early summer seasons. Therefore, a legislation imposing a two-month fishing ban in that area every spawning was passed. Moreover, due to climate change, severe river discharge was documented, accompanied by water scarcity and lake water level decline, which led to the disappearance of the lagoons. Nevertheless, it was documented that SG successfully used spawning grounds in other parts of the lake shallows. As part of SG population maintenance, a long-term program of fingerling production for stocking (2-5 × 106 fingerlings, each of weight 5 g, per year) was implemented.

Landings (1959-2017)

A summary of landings (ton/year) of total fishery, SG, barbels (BAL), bleaks, and Oreochromis aureus (OA) is given in Table 3.

Table 3: Annual landings (ton/year) of total fishery, Sarotherodon galilaeus, bleaks, and barbels (and their percentage of the total) during two periods 1959–2002 and 2003–2016 (Sarid and Shapiro 1959-2017).

  1959-2002 2003-2016
Total Fishery 1969 670
Bleaks 970 (57%) 234 (35%)
S. galilaeus 243 (14%) 144 (21%)
O. aureus 129 (8%) 9 (1%)
Barbels 98 (6%) 40 (6%)

through 2010

Two principle parameters strongly influence total catch: fishing effort and the crisis of SG population. Moreover, fishing effort is the result of marketing potential. Marketing of bleaks was abolished in the late 1990s. Because barbel fishery is not affected by marketing and probably was not damaged by ecological factors, it is suggested that its landing decline is due to decrease in fishing effort. The market capabilities of SG are unlimited, therefore, its fishery decline is mostly related to ecological conditions. The fishery decline of O. aureus is probably indicative of the elimination of its stocking.

In the period 1987-2015, routine bi-monthly night acoustic surveys were carried out along 14 trans-sections directed perpendicularly to the shoreline towards the open water area, in order to document fish targets within a depth range of between 2 m from surface to bottom. Annual averages are presented in Figure 1, which shows a prominent elevation of population size since the 2000s. Because the majority of the recorded target signals are due to bleaks, the increase in their population during the period 2000-2016 was prominent. Results given in Figure 2 indicate a quasi-cycled population size of Sarotherodon galilaeus in Lake Kinneret [6,10]: a 10-12 periodical years of landing onset and offset cycling. Nevertheless, the exceptional decline in the early 2000s was followed by a consequent increase in landing of Sarotherodon galilaeus, which is clearly shown in Figure 2. Moreover, a clear indication of the positive relations between bleak and SG landings is presented in Figure 3. The more the bleak biomass removed by fishery, the higher the catch of S. galilaeus. Consequently, fish population size [11] has an inverse relation with the landing (Figure 4) of the most common fish, namely bleaks. Intensification of bleak landing is accompanied by a decrease in their population size.

fig 1

Figure 1: Temporal (1987-2015) changes of Fish Number (millions/lake)) As measured by acoustic surveys in Lake Kinneret, Left-Linear regression with confidence interval Right-LOWESS Smoother, band width-0.8.

fig 2

Figure 2: Temporal (1970-2017) changes of annual landings of Sarotherodon galilaeus: Left Upper: Line scatter; Right Upper: Trend of Changes by LOWESS (0.8); Left Lower: Lowess Smoother (Bandwidth 0.8);

fig 3

Figure 3: Annual Landing (tons) of Bleaks in relation to Sarotherodon galilaeus:Bleaks landing Vs S. galilaeus landings (1959-2016). Left – Linear Regression with Confidence interval (95%). Right – LOWESS Smoother, band-width – 0.8.

fig 4

Figure 4: Linear Regression between Bleak annual landings (ton) and fish population size (acoustic documentation in millions) in Lake Kinneret (1987-2015).

Simultaneous implementation of natural and anthropogenic parameters created optimal ecological combination for the initiation of the S. galilaeus crisis. This crisis was demonstrated by the following: 1: stocking reduction [9]; 2: fish size (TL) reduction caused by the use of illegal fishing nets with smaller mesh sizes (unpublished data); 3: dominant replacement of Peridinium by Cyanobacteria [4]; 4: significant reduction in bleak fishing due to market depletion: 5: outbreak of a mysterious viral disease that affects mainly tilapia (NODA virus blind eye disease) [12]; 6: intensified cormorant predation [13,14]; 7: natural cycled fluctuations in tilapia stock [6,10].

The number of great cormorants (Phalcocorax carbo) wintering (from the end of October through March) in the Lake Kinneret region is approximated as 6000 (5000-7000). The predation rate of cormorants indicates a daily range of 300-1000 (most commonly 500) grams per bird. The cormorants are winter migratory birds, arriving towards the end of October and leaving in March (they stay for 100-120 days). It has been documented that their diet comprises mostly of bleaks in October and November and of sub-commercial-sized S. galilaeus from January to March (100 days). Six thousand cormorants prey daily on 500 g of fish per bird during the 100 days from January to March, removing 300 tons of sub-commercial-sized S. galilaeus from the lake. It has to be considered that a fish the same size as one preyed on in January might have grown by 30-70 % when fished in summer (legal size >200 g/fish). Individually preyed tilapia of weight 50-70 g might grow up to a commercial size within 5-6 months. Consequently, the commercial value of such losses was approximated as US$1.5-3.0 million. Such a damage to fishermen income and to the ecological system can be reduced by aggressive deportation of the cormorants from Lake Kinneret and their night station site. The contribution of tilapia to the ecosystem, which is aimed at water quality protection, is the selective consumption of gradually reappearing Peridinium biomass [5,7].

Conclusive Remarks

The sharp decline in S. galilaeus landing in the 2000s is an extremity of the natural appearance of quasi-cyclic fluctuations in the S. galilaeus population size. High landing in the years 1970-2000 was correlated to heavy blooms of Peridinium which was dominated later by Cyanobacteria. Peridinium is a favored food by S. galilaeus, therefore the predation pressure of S. galilaeus on zooplankton was enhanced. The landing record confirms an increase in S. galilaeus accompanied by enhancement of bleak removal. The predictability of fishing ban indicates competition between proliferated bleaks and suppressed S. galilaeus. Such conditions are mostly predicted during drought seasons with nitrogen deficiency and Cyanobacteria takeover. Among parameters of climate change, temperature elevation is also included. Higher temperature enhances metabolic activity and increases food consumption. Therefore, fishing ban accompanied by bleak competition strength justifies objection of this recommendation. Lake Kinneret is not a completely open natural ecosystem. The hydrological management of Lake Kinneret is partly anthropogenic, i.e. human-controlled. The anthropogenic involvement is mostly emphasized during drought conditions. As part of climate change, droughts are predicted to be enhanced. Human management is accompanied by fishery regulations. Nevertheless, fishery regulations are based on the natural trait and regulation of fishing efforts and introductions should not exceeding the natural structure. This kind of management policy has continued for many years. Of course, fishery rates fluctuate but within acceptable ranges or extremes. The crisis of S. galilaeus fishery presented in this paper has never been recorded before. The recommendation suggested here is the following: the long history of successful management policy implementations must go on. A change in long-term management methods is risky due to the natural reclamation capabilities of the ecosystem, accompanied by the validity of previous policies of which the principles are: introduction of a limited number of fingerlings of S. galilaeus, mugilids and silver carp; commercial and sport fishing maintenance under fishery regulations (technologies, net mesh-size); fishing ban enforcement in the breeding grounds (North-East part of the lake) during the spawning season of S. galilaeus; and tight inspection of the fish market (fish size and health). The rational behind fishery management is dual: lake water quality protection and sustenance of fishers’ income. Total fishing ban for three years, which was wrongly suggested as part of reclamation, has the potential to damage both water quality and, obviously, fishers’ source of income. The national constrained commitments do not leave a free space for ecological trials, and previous management designs are recommended. Conclusively, the cancelation of the fishing ban was justified. Forwarded recovery of S. galilaeus landings recoinciled the recommendation to reject the fishing-ban suggestion.

Acknowledgement

Warm thanks to J. Shapiro, M. Lev, Z. Snovsky, O. Sonin, Y. Fdida. A. Eldar and G. Rubinstein for their technical assistance and providing with Kinneret fishery information.

References

  1. Ben-Tuvia A (1978) Chapter: Fishes, in: Lake Kinneret, Monographiae Biologicae 32 (C. Serruya ed.) Dr. Junk bv Publishers The Hague-Boston-London 1978, 407-430.
  2. Gophen M (1992) Book: The Kinneret Book, Part a: The Lake, Ministry of Defence -Israel. 160. (in Hebrew).
  3. Gophen M (2018) Part C, in: Ecoloical Research in the Lake Kinneret and Hula Valley (Israel) Ecosystems, Scientific Research Publishing, Inc. USA, 187-281.
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  10. Pisanti SM, Ben-Yami, H Talpaz (1987) Quasi-Fluctuation in St. Peter`s Fish in Lake Kinneret and theie manage,ment implications,. A: The cyclic and the effect of effort. Fisheries and Fish Breeding in Israel 20: 26-38.
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  12. Eyngor MR, Zamostiano JE, Krmbou TA, Berkovitz H, Brcovier S Tinman et al. (2014) Identification of Novel RNA Virus Lethal to Tilapia. Journal of Clinical Microbiology 52: 4137-4146.
  13. Gophen M (2017) Tilapia Stock Suppression by the Great Cormorant (Falacrocorax carbo) in Lake Kinneret, Israel. Open Journal of Modern Hydrology 7: 153-164.
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