Introduction

Fast growing technological developments have significant effects in the educational context. In cases of providing students with opportunities that enable them to use information technologies efficiently and effectively, it is seen that their perceptions of information literacy and self-sufficiency regarding the fields that they study have improved [1]. Recently thanks to these technological applications used commonly for educational purposes, students can communicate with whomever they want to, share/receive files and correspond within a short span of time. These technologies include social networks and other electronic communication tools. All these technologies can be categorized under Web 2.0[2]. Web 2.0. technologies are determined to be used efficiently by especially university students [3, 4, 5].

Informal learning is defined as the learning formed according to self-performances of an individual by interacting with other individuals on a social platform [6]. With the help of Web 2.0 technologies utilized frequently in educational environments in the recent period, students have been integrating into such environments and taking individual responsibility for learning [7]. However Web 2.0 platforms are used efficiently and effectively in the formal education environment as well as in the informal education environment. But if studies are conducted with the participation of students in terms of how to benefit from these technologies in both of these educational environments, opportunities can be created in efficient learning with a more realistic point of view [8, 9].

There are several studies [10, 11, 12, 13, 14] indicating the positive impact on students when technological applications and tools are used to assist face-to-face education. In a study a wiki was used as part of a blended learning approach to promote collaborative learning among students in a first year university statistics class [11]. The findings of this research suggest that student engagement was enhanced when a wiki is used to support learning in higher education. The important thing is to create awareness of these technologies’ positive effects on students in the educational context. In this study the aim is to determine which technological applications are used by physician and nurse candidates; where, why and how they are used, based upon the technologic and educational context. In accordance with this primary aim, the answers to the three questions below are required.

1. Which technological applications do the physician and nurse candidates use in their daily lives and why?

2. Which technological applications do the physician and nurse candidates use in the educational context and why?

3. Out of the technological applications that the physician and nurse candidates use in their daily lives, which ones do they prefer to use in the educational context and why?

Method and Material

Research Design

The study was carried out pursuant to the design of case study method that is one of the qualitative research methods. Case studies are survey arrangements aiming to make judgments related to a specific section in population after analyzing it in detail [15]. There are no generalization purposes in these kinds of studies. The main purpose is to discover typical situations of each case [16]. As in the case studied in the scope of this research, not only physician and nurse candidates’ use of technology both in their daily lives and academic purposes (in the educational context) and their reason for that but also their views in terms of their expectation in using technological application for their classes were analyzed individually and approached as a whole; multiple case design was used [17].

Participants

The study group was determined by “easily accessible case sampling” and consisted of 78 freshman, sophomore and junior physician candidates from the Faculty of Medicine of Hacettepe University; 50 freshman, sophomore, junior and senior nurse candidates from the Nursing Program of the Faculty of Medical Sciences in Başkent University.

Instruments and Data Collection

A questionnaire and a semi-structured interview form created by the researchers were used in this study. In the creation process of both the questionnaire and the form, expert opinions were requested and necessary corrections were made. In the final form of the questionnaire, open-ended questions regarding the students’ circumstances and purposes for using technology in daily life and in classes were included. In addition, the semi-structured interview form was prepared in accordance with the questionnaire questions, and interviews with the participants were held to get more detailed information. The data collected after the interviews with students were coded by two scientists and then the credibility of data was calculated with the formula “Credibility=Consensus/Divergence+Consensus x 100” [18]. The coefficient of credibility is determined to be over acceptable limits. (> %80).

Data Analysis

The content analysis method was used in the data solution. In this study, the researchers applied the coding using the “coding according to concepts in the data” method. The researchers and the two other scientists coded separately. Then themes were created; frequency and percentages were calculated.

Findings

In this part of the research findings were included under separate topics in accordance with the research questions.

Which technologies do the physician and nurse candidates use in daily life? Why?

When the results obtained in accordance with this sub-question of the research were examined, it was determined that the physician and nurse candidates used the social networks the most (%79,6) in daily life. When other applications were examined in order, it is seen that they used office programs (% 69,8), e-mail applications (%57,1), search engines (%55,1) and educational software (%16,0). Purposes for using these applications were introduced below:

Social Networks

The students’ answers to the question about the purpose of their social media use in daily life were placed under four categories. It was determined that students use social networks to communicate (%69,5), to make friends (%52,3), to satisfy their curiosity (%34,8) and to play games (%24). It was assessed in the focus group meetings that students use social networks to relieve the stress of life and to have a good time (A.P.: Classes are intense and I follow social networks when I can spare myself some time from this intensity. I always stay in touch with my friends via constant notifications thanks to my smart phone. H.T.: I communicate with long-distance friends about classes and socially via social networks. Of course, if I can find some time outside of classes.)

Office Programs

The students’ answers to the question about the purpose of their office programs use in daily life were placed under three categories. It was determined that students use office programs to create class reports (%83,8), to keep the electronic records of hospital visits (%52,6) and to create academic study plans (%29,7). It was ascertained in the focus group meetings that students use office programs because they have to use them when writing class reports and they are unable to do any homework without a computer. (S.A.: We almost forgot how to write with a pen. Everything is performed with a keyboard. In the near future we will have electronic tests. It would not be wrong to say I can’t manage anything without office programs. Y.T.: I use my computer just for writing in Word. Courses are so intense that office programs constitute a part of life.)

E-mail Applications

The students’ answers to the question about the purpose of their e-mail applications use in daily life were placed under two categories. It was determined that students use e-mail applications to communicate with friends and family (%88,3) and share files (%74,5). It was assessed in the focus group meetings that students use e-mail applications to communicate with friends and to send/receive files. (U.R.: I check my mail at least 10 times a day to see if there are any notifications from my family and friends. I don’t use social media so I get the news via e-mail. But I can’t be informed of lots of things just because I don’t use social media. Y.T.: I use e-mail applications to video chat with my family. Other than that I’m not too involved in it.)

Which technologies do students use for classes? Why?

When the results obtained in accordance with this sub-question of the research were examined, it was determined that the physician and nurse candidates used search engines the most (%83,9). When other applications were examined in order, it is indicated that they use office programs (%79,6), e-mail applications (%67,1) and social networks (%23,8). Purposes for using these applications were introduced below:

Search Engines

When responses of the students when asked why they used search engines were analyzed, it is seen that the students use search engines to do research for projects and classes (%84,5) and to get additional professional information (%47,2). It was assessed in the focus group meetings that students use search engines to frequently research about project subjects that they are given, and as assistance to class materials. (Y.R.: We are very busy with projects and homework. Now I can access everything thanks to the search engines considered as virtual libraries. Y.T.: I benefit from Internet for my professional development. Google opens every door.)

Office Programs

It is ascertained that students use office programs to write assignments (%69,2) and summarize the book chapters before exams (%36,4). It was assessed in the focus group meetings that students use office programs to prepare assignments needed to be handed in and summarize foreign books electronically. (S.R.: Now as we have to prepare everything on computer, office programs are indispensable for me. Y.T.: We translate thick medical course books on computer by sharing among each friend, then we collect and use them in classes.)

E-mail Applications

The students’ answers to the question about the purpose of their e-mail application use in daily life were placed under three categories. It is determined that the students use e-mail applications to share files (%92,3), to exchange opinions with friends (%67,9) and to communicate with instructors (%44,5). It was assessed in the focus group meetings that students use e-mail applications to share various documents with friends and to exchange information before exams. (S.R. My friends and I share and archive the academic files we come across on the Internet via e-mail. Y.T. We send potential exam questions to each other.)

Social Networks

The students’ answers to the question about the purpose of their social network use in daily life were placed under two categories. It was determined that students use social network to share files (%79,2) and exchange opinions with friends (%62,0). It was assessed in the focus group meetings that students do not use social networks a lot. However the ones who do use them for exchanging files and chatting with friends especially about classes (especially before exams). (U.R.: I do not generally use social media for educational purposes. But when I do it is to discuss questions before exams. Y.T. Social media is the best way to share files because all my friends have an account.)

Which Technological Applications Do Students Use for Classes? Why?

It is established that students use distance learning programs (%88,5) and social networks (%76,6) for classes. The reasons for their use of these two applications are stated below:

Distance Learning Programs

When responses of the students when asked why they used distance learning programs were analyzed, it is indicated that they use these for watching lectures later (%86,2), participating in some classes without going to school (%58,3) and following other instructors’ lectures in another university (%23,4).

Social Networks

Students state that they need to use social networks at least to communicate for classes. This is especially true for physician candidates because there are so many students; they explain that they often get disconnected with each other and instructors. When their opinions were analyzed, it is seen that they use social networks for sharing information about class cancellation/class hour changes (%88,3) and for sharing files (%66,7).

It was assessed in the focus group meetings that students stated that they use distance learning programs for making up for classes, accessing course materials later and following some classes without going to school. They said they used social networks for file exchanges and to get information on cancelled classes and class hour changes.(U.R. It makes great sense that some of the classes are provided with distance learning. We squeeze into lecture halls. Sometimes we can’t find seats. It would be nice if there were a distance learning option for courses without going through that and then everyone would follow the lectures at home. Y.T.: They put up announcements on a board. But it would be nice to give up these kinds of traditional procedures in this electronic era. After all everyone has an e-mail or a social network account.)

Discussion

Research participants stated that technological applications they used in daily life and for classes were different. This situation can be considered as an indication that we could not yet integrate technology into education. This case, which is described as digital inconsistency, unveils the need for recreation of teaching approaches in faculties [19, 20]. Thus, the fact that almost every student has a social network or an e-mail account cannot be counted as a benefit in terms of education. The clearest indication for this is that according to the research results, even if all the students have a social network account they do not turn it into an academic advantage. It is no doubt that faculty administrations should consider this situation as a contributing factor for creating a positive learning platform with some arrangements.

It was determined in the research that students used search engines and office programs the most. When the related domain was examined, it was found that social networks could easily be used in educational context [9, 19, 21] and this would contribute to teaching, improving and sharing of class materials, and extracurricular group studies [22, 5, 23]. Similarly, it is [23] stated that classes where undergraduate students are present have positive contributions on academic success, motivation and self-monitoring. According to a study [5] supporting social networks in the educational processes has a positive impact on students’ learning and facilitates and improves the learning processes.

In an another study [24] with the participation of university students, students’ willingness to use electronic learning was analyzed. As a result of the research, it is ascertained that students were willing to support their formal training with electronic learning. In the research carried out with the participation of undergraduate students, attitudes towards distance learning and academic success were examined [25]. As a result of the research, results of the students who take distance learning courses was higher than those who formal learning. Moreover students presented positive attitudes towards distance learning.

In conclusion, the finding regarding students’ willingness to take distance learning courses and use of social networks should be carefully dealt with. Especially considering the high numbers of students attending faculties that school health professionals, alternative teaching methods and procedures should be conceived. Student participation should be encouraged along with mixed learning platforms, and students who are crammed into the lecture halls should be supported in terms of education.

Competing interests

The authors declare that they have no competing interests.

References

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Introduction

A giant cell tumor of the tendon sheath (GCTTS) is a benign proliferative disorder of the synovium that may affect the tendon sheaths, joints, and bursae [1]. It is the second most common benign soft tissue tumor of the hand after the ganglion cyst [2]. The tumor affects digits more often than large joints (53.33%) [3]. It can also be seen in other parts of the body including the ankle, wrist, elbow, toes, knees, hips, and spine [4]. It is more frequently seen in women, especially those between the ages of 30 to 40 years. The etiology is still unknown, but it is thought to be associated with trauma [1]. These lesions are characteristically slow- growing, smooth, painless, and usually asymptomatic. However, secondary nerve compression, joint degeneration, and bone involvement can occur.

Magnetic Resonance (MR) imaging is useful for the diagnosis because it demonstrates the characteristic features of the tumor. These include low signal intensity equal to or slightly higher than the signal intensity of skeletal muscle on T1 and T2 weighted images (WI) [3,5]. In this study, we evaluated 25 cases of histologically proven GCTTS in the finger with MR imaging findings and also reviewed its epidemiological features. In addition, we assessed the literature regarding GCTTS and performed an analysis of the available information.

Material and Method

This study was approved by the Institutional Review Board of the Samsun Education and Research hospital. We retrospectively reviewed the MR images of 25 histolopathologically proven cases of GCTTS of the finger during the period from 2012-2014. A retrospective analysis of the patients’ records was carried out with respect to age, gender, location, dimension of lesion, and recurrence. MR imaging findings were evaluated by the same radiologist (ATS). Also, neurovascular and flexor tendon involvement were evaluated with MR and compared with pathology reports.

MR imaging was performed on the 25 cases of GCTTS with a 1.5-T system (Signa HDX 1.5 T; GE Medical Systems, Milwaukee, WI, USA). The fields of view varied from 7.5 to 20 cm. The slice thickness varied from 2 to 4 mm and the slice gap varied from 0 to 2.7 cm. Matrices of 256×128-256 were used. Axial and either sagittal or coronal images, or both, were obtained for all lesions. In each patient, T1-weighted spin-echo images [pulse sequences: 300-600/11-30 (TR/TE)], T2-weighted spin-echo images (puls sequences: 2000-2700/80-90 (TR/TE) ) or fast spin-echo images [pulse sequences: 2000-4000/80-120 (TR/TE)] were obtained. Gadolinium-enhanced images and the fat suppression technique were applied for all patients. Each lesion was assessed with regard to its location, size, extension, signal-intensity characteristics, and pattern of contrast enhancement. Also, the signal intensity of the lesions was compared with that of normal skeletal muscle and subcutaneous tissue on T1 and T2-weighted sequences. Contrast enhancement patterns of the lesions were evaluated by comparison with the pre-contrast images. Finally, bony erosion, calcification, and cystic changes were evaluated by the same radiologist using plain film x-rays.

Surgical management was performed with complete resection of all lesions and there were no complications. The resected specimens were examined by a staff pathologist. All of the lesions were confirmed to be localized GCTTS.

Statistical Analyses

Data were summarized as mean ± standard deviation and median (minimum-maximum) for continuous variables and frequencies (percentiles) for categorical variables. The Mann Whitney U test was used for independent group comparisons, depending on the distributional properties of the data. The Chi-square test was used when the data were sparse. A p value <0.05 was considered to be statistically significant.

Results

All of the 25 cases were new patients presenting with primary tumors. The age of the patients ranged from 28 to 75 years, with a mean age of 49.5±13.2 years. GCTTS was found most often in the fourth and fifth decades of life (24%). By gender, 16 patients were female and 9 were male, yielding a female to male ratio of 1.7/1. The mean age was 51.9±12.8 years for females and 45.1±13.4 years for males. The size of the tumors ranged from 6 mm to 30 mm, with a mean size of 15.3±6.8 mm. The volume of the tumors ranged from 0.15 cm3 to 15 cm3, with a mean volume of 2.6±3.69 cm3. All of the lesions were solitary and located adjacent to the flexor tendon sheath. Most of the patients presented with a slow growing, painless mass in the hand.

The following is a description of the location of the GCTTS:

Tumors were present on the right hand in 15 patients and on the left hand in 10 patients. In women, 11 tumors were located on the right hand while 5 were on the left hand. In men, 4 of the tumors were located on the right hand and 5 were on the left hand. The digits involved were the thumb (n=5), index (n=10), middle (n=3), ring (n=5), and little fingers (n=2) (Table 1). In women, the affected digits were the thumb (n=3), index (n=6), middle (n=2), ring (n=3), and little fingers (n=2). In men, the affected digits were the thumb (n= 2), index (n=4), middle (n=1), and ring fingers (n=2). None of the tumors in men were located on the little finger. Overall, the most frequent location of the tumors was the index finger in 40% of patients (n=10). The most frequent location of the tumor was the index finger (n=6) in women and men (n=4).

There were no statistically significant differences between male and female patients in terms of age, tumor side, involved digit, and tumor size. The tumor volume was slightly larger in female patients compared with male patients (2.97± 3.94 cm3 versus 1.96 ± 3.31 cm3; p= 0.083) (Table 1).

All of the patients presented with slow growing, painless, palpable masses in the volar aspect of the fingers. In all cases, physical examination revealed a hard, painless, well-circumscribed, fixed, subcutaneous mass lesion. The overlying skin and neurological examination of the extremity was normal in all cases.

All of the lesions were described as well-circumscribed, encapsulated, lobulated, or multilobulated solitary masses with MR imaging. Signal intensity on T1WIs was equal to that of skeletal muscle in 23 cases (Figure 1a,b,c). In two cases, signal intensity was slightly higher (Figure 2). On T2WIs, the signal intensities tended to be between those of skeletal muscle and fat in all of the cases. Most of the lesions showed non-homogeneous signal intensities, including foci of low-signal intensities, that might be associated with hemosiderin deposits on T2WIs. All of the lesions showed high signal intensity on fat-saturated T2WI and short tau inversion recovery (STIR) sequences (Figure 3a,b). All of the lesions showed mild to moderate contrast enhancement when compared with precontrast images (Figure 4a,b). All of the lesions were not obviously in contact with the tendon sheath and the joint on MR imaging.

All patients underwent conventional radiological examinations of the affected finger. There were no abnormalities such as bone erosion, impression, calcification, or cystic changes on the X-rays. Similarly, involvement of the bone adjacent to the lesion was not detected by MR imaging.

All of the lesions were managed by surgical excision of the tumor under local anesthesia. Macroscopically, each of the lesions was described as a well-circumscribed, encapsulated, yellow-brownish, lobulated, or multilobulated mass. Only one particularly large lesion was found to be attached to the flexor tendon sheath during the surgery. Its size was 30x15x15 mm.

Synovial cell hyperplasia, histiocytes, multinucleated giant cell accumulation, hemosiderin-laden macrophages, and collagen strands were observed during microscopic examination of all lesions (Figure 5). There was no evidence of necrosis or mitotic activity in any of the tumors. There was no recurrence in any of the patients. In three cases, however, the boundaries of the lesion were found to be positive during microscopic examination. One of them was located at the middle phalanx of the left index finger near the flexor tendon sheath. Its size was 2.5x2x2 mm. Microscopic examination revealed that the mitotic activity varied from 10-15. Another lesion was seen in the subcutaneous tissue near the proximal phalanx of the right thumb in a 32 year-old woman. The lesion was located near the flexor tendon sheath and there was no invasion. In addition, there was no increased mitotic activity or loss of capsule integrity in the lesion. The third patient was a 59 year-old man with a GCTTS in the distal phalanx of the ring finger in the right hand. There was no increased mitotic activity or loss of capsule integrity in the lesion in this case as well.

 Discussion

There are different forms of GCTTS, including the localized form (also known as tenosynovitis), the intra-articular form (also known as localized nodular synovitis), and the diffuse form (also known as extra-articular pigmented villonodular synovitis). The localized form is the most common and is mostly seen in the hand and wrist, especially on the volar aspect. More specifically, the volar aspect of the first three fingers is the most common site in the hand. Most patients present with a painless, palpable, slow-growing soft tissue mass in the third through fifth decades of life. In rare cases, distal numbness and mild disability can be seen in some patients [2, 6]. GCTTS most commonly involves a single joint with multiple joint involvement seen in less than 1% of cases [7]. In the literature, GCTTS is more common in women than men, with a range from 1.5:1 to 2:1. In our study, the female to male ratio was 1.7:1. Consistent with our study, Darwish et al observe a slight predominance of the right hand [4]. Some authors report that the most frequent tumor location is the index finger [6, 8, 9]. Darwish et al, however, report that the most common location of the tumor is the thumb [4]. In our study, the most common digit was the index finger and the second most common was the thumb and ring finger. Most lesions were on the right hand in women but on the left hand in men. In women and men, lesions were seen most often on the index finger, followed by the thumb and ring finger. Also, none of the tumors in men were on the little finger.

In the literature, some studies show that lesions are most common on the dorsal aspect of the hand, while other studies identify the volar aspect as most common [10-13]. In our study, all lesions were located on the volar aspect of the hand and were located adjacent to the flexor tendon sheath. There was no marked invasion of the flexor tendon sheath or extension into the joint space based on MR imaging.

Half of all cases were shown to consist only of a soft tissue mass and 15-20% were seen to consist of a soft tissue mass with bone erosion in the radiographs. Cystic changes in the adjacent bone tissue, degenerative changes in adjacent joints, periosteal reaction, and calcification were seen in radiographs in about 17% of cases. Darwish et al detected cortical compression by GCTTS in 5 patients with diameters ranging from 0.5 cm to 2 cm based on radiography [1]. Hamdi et al reported 3 of 27 patients having cortical bone impression of the phalanx by radiography [6]. Grazia et al detected 3 of 64 (4.7%) cases with bone erosion associated with GCTTS by radiography [2]. In our study, none of the patients were shown to have bone changes based on radiographs or abnormal signal intensity on MR imaging.

Localized GCTTS were usually described as well-defined, encapsulated, eccentric mass lesions. They were mostly close to the tendon sheath or partially/fully surrounding the tendon sheath. MR imaging can reflect the histological characterization of the GCTTS. Hemosiderin-laden tissue is shortened in the T1 and T2 relaxation times by paramagnetic effect, and results in low to intermediate signal intensity in T1- and T2 -weighted spin-echo sequences. This effect is exaggerated due to increased magnetic susceptibilities on gradient echo sequences and results in areas of very low signal intensity and blooming artifact [1]. Abundant collagen proliferation typically leads to low signal intensity as well. After the administration of intravenous gadolinium, lesions typically show moderate enhancement. Hemosiderin deposits are seen as tiny areas with low signal intensity on all sequences and post-contrast images [1]. In our cases, most of the lesions were described as isointense to muscle on T1WI and isointense or slightly hyperintense to muscle on T2WI, with higher signal intensity on fat-suppressed T2WI and STIR images. MR imaging is the most important modality for detecting tumor size, extent, neighboring tenosynovial area of insertion, and extension prior to surgical management [1].

Soft tissue tumors and tumor-like lesions should be considered in the differential diagnosis of GCTTS. Among them, particular consideration should be given to ganglion cysts, hemangiomas, nerve sheath tumors, synovial sarcomas, and foreign body granuloma. These are easily distinguished from GCTTS because they demonstrate high signal intensity in T2WI. However, sarcomas and desmoid tumors demonstrate intermediate signal intensity, depending on high collagen content, and are prone to cause confusion in the differential diagnosis [1].

Although surgery is most often curative, recurrence rates of 7-44% are reported in the literature [1]. The most important approach to prevent the recurrence of GCTTS is to perform complete surgical excision. But, sometimes it is very difficult, because GCTTS often extends into the surrounding structures, particularly neurovascular structures. As a result, a high recurrence rate has been observed in some studies [4]. The tumor must be dissected gently to avoid unwanted complications such as numbness, joint stiffness, painful scars, and skin necrosis. Also, the entire lesion must be removed without allowing any remaining abnormal tissue that could lead to a recurrence. High recurrence rates may result from incomplete excision of the lesion, proximity of the arthritic joint, proximity to the interphalangeal joint of the finger, and bony invasion by the tumor [4]. But, Lowyck et al did not support this theory, asserting that there is no significant correlation between recurrence and pressure erosion or degenerative joint disease with respect to the location at the distal interphalangeal joint [14]. Intraosseous invasion of GCTTS is uncommon in the hand, but it may be associated with high recurrence rates [15]. Therefore, intraosseous invasion is not to be confused with bony erosion. This is despite claims by some authors who suggest that recurrence is consistent with cellularity and mitotic activity, capsular involvement, and incomplete excision of the lesion [4, 16].

In our study, recurrence after complete excision was not observed in any of the 25 cases. However, we note that positive surgical margins were found in 3 cases. Follow-up with imaging and clinical findings was recommended to these patients. Abnormal bony signal intensity or intraosseous invasion was not observed in the three patients who had microscopically positive margins. However, mitotic activity varying from 10-15 was found in one of the patients during microscopic examination.

Complete primary tumor resection is the standard of care. Postoperative adjuvant radiation therapy has been recommended to prevent recurrences for high risk lesions. Using magnifying glasses or microscopy during the operation has the potential to reduce the recurrence rate. Ikeda et al reported only one recurrence in 18 patients after microscopic excision [17].

Microscopically, GCTTS consist of fibroblasts, macrophages, foam cells, and hemosiderin pigment [9]. Macroscopically, GCTTS are observed as well-circumscribed, encapsulated, yellow-brownish, lobulated, or multilobulated masses ranging in size from 0.5 to 5 cm in diameter, with an average size of 1.1 cm [1]. Capsule formation is typical around the mature, localized tumor. A diffuse form of the tumor does not include the capsule formation and extends along the tendon sheath [6]. There is no reported mitotic activity in the literature. The basic question the pathologist first attempts to answer is whether the lesion is neoplastic or non-neoplastic. A large number of immunohistochemical studies are carried out for the purpose of making this distinction.

In conclusion, GCTTS are slow-growing, benign masses of the tendon sheath that are frequently seen in the hand. The accepted treatment modality is complete surgical resection. MR imaging of the extremity is the best method for evaluating the surrounding structures before planning the definitive resection. Axial and sagittal MR images are very useful for evaluating these structures. The exact dimensions of the lesion, the degree of extension around the phalanx, the involvement of the joint, and the tenosynovial space should be evaluated carefully to provide the surgeon with additional information that can assist in planning the surgical approach.

Competing interests

The authors declare that they have no competing interests.

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Introduction

Mucociliary clearance of respiratory mucosa is the primary defense mechanism in the human airways. Mucociliary activity of the nose helps to remove foreign particles, pathogens, and

toxins by transporting the mucus layer that covers the nasal epithelium towards the nasopharynx and it also helps to keep the mucosal surfaces moist by mucous gland secretions to obtain normal nasal physiology[1]. Nasal mucociliary clearance time (NMC) can be affected from some rhinological pathologies (allergic rhinitis, sinusitis, nasal polyposis), trauma, sinonasal surgery[2,3]. It has also been shown that NMC can be affected from toxins, drugs, environmental heat, smoking, pressure, pH, and so on.

The association of smoking and NMC has been studied; however, the correlation of passive smoking and NMC has not been clearly documented yet. Although many studies

have investigated the association of smoking and NMC[4-6], there is only one study investigating the relationship between passive smoking and NMC[7].

Because of insufficient data about the relationship between passive smoking and NMC, we aimed to investigate the effect of passive and active smoking on NMC by comparing the results of age and sex matched healthy individuals, passive and active smokers.

Material and Method

Study Design

This study was conducted between January 2014 and April 2014 in the otorhinolaryngology Department of Mustafa Kemal University. Ethics committee approval was obtained and the study was conducted adhering to the Declaration of Helsinki. Informed consent was obtained from all subjects.

Study Population

One hundred ten voluntary subjects who referred to our clinic for symptoms other than rhinological diseases were enrolled in the study. The evaluation of subjects revealed detailed history, ear, nose and throat examinations and nasal endoscopic evaluations in every patient. At least 3 years of smoking history or passive smoke exposure time was required in order to be included to our study. Subjects those having a history of allergy or asthma; upper respiratory tract infection during the previous 2 months; a nasal pathology causing nasal obstruction such as sinusitis, septum deviation, nasal polyposis or bullous concha; having a history of nasal or paranasal operation; history of any medication; history of any systemic disease were excluded from the study. A total of 75 subjects met the criteria and were divided into three groups: control group (nonsmokers, Group 1, n =25), passive smokers group(Group 2, n =25), active smokers group (Group 3, n =25). NMC of these subjects were measured and compared. Moreover the amounts of cigarette consumption of active smokers group were calculated as package to year and the correlation between NMC and the amount of cigarette consumption in active smokers group were evaluated.

Measurement of NMC

Nasal mucociliary clearance times were evaluated with the saccharin tests performed by the same clinician at otorhinolaryngology clinic who was unaware of state of the subjects. Patients were asked to blow their nose and not to consume any food or drink 1 hour before the test. Patients were allowed to rest for 30 min before the measurement. While the patient was sitting in an upright position, a saccharin tablet having a diameter of approximately 1.5mm (1/4 saccharin tablet) was placed into the medial aspect of the lower concha using a bayonet forceps. Patients were asked not to sneeze, sniff or wipe their noses during the test. Until the time of saccharin taste after placement of the tablet, patients were instructed to swallow at 30-second intervals and to inform about the time when they taste saccharin. The time taken by the subjects from placement of particle to the perception of the sweet taste was measured by a chronometer and recorded as NMC.

Statistical analysis

Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences) 13.0 Evaluation for Windows. One-way ANOVA test was used to compare the data between group in quantitative parameters showing normal distribution, and the Turkey HSD test was used for the determination of the group responsible for the difference. The Kruskal-Wallis test was used in the assessment of parameters according to groups. The Mann-Whitney U test was used for the evaluation of differences. The statistically significant level was accepted as a p value<0.05.

Results

Demographic data

The control group consisted of 9 women and 16 men, with a mean age of 41.32±7.26 years ; the passive smoking group consisted of 10 women and 15 men, with a mean age of 42.96±8.07 years; the active smoking group consisted of 8 women and 17 men, with a mean age of 38.92±7.16 years. The groups were similar in terms of sex and age (p=0.069, p=0.046).

Nasal Mucociliary Clearance Time

The mean NMC value in the control group was 11,68 ±2.80; in the passive smoking group, it was 15,08± 3,41; and in the active smoking control group, it was 15,3± 2,34. The mean MMC in passive smoking group and active smoking group were significantly longer than the control group (p=0,0001) (Figure 1). The comparison of NMC values between the passive smoking group and the active smoking group revealed no statistically significant differences (p≥0,05). There was positive correlation between the increase in NMC and amount of cigarette consumption ( p=0,0001, r=0.433).

Discussion

Mucociliary clearance is the first defense mechanism of the respiratory tract. Particles that may be harmful are trapped by the mucus blanket and removed from the nasal cavity to the nasopharynx by the movements of cilia[8]. Then, they are either swallowed or coughed up.

While techniques to measure clearance time in trachea and bronchi are time consuming, and expensive, the measurement of NMC using saccharin test is a good alternative to represent the clearance in trachea and bronchi[9]. Various studies state that the saccharin test is a simple, inexpensive technique to measure NMC with a chance of repeatability[10].

Normal mucociliary transit time in humans has been reported to be 12 to 15 min. Prolonged transit times are considered to be impaired mucociliary clearance that may lead up to long-term respiratory tract diseases, sinonasal and middle ear infections[11].

There are various factors effecting mucociliary clearance time such as temperature, moisture, partial oxygen pressure , pH, cigarette and various inhalation agents; anatomic barriers as septum deviation, adenoid hypertrophy and systemic diseases such as viral infections,

chronic sinusitis, chronic and allergic rhinitis, cystic fibrosis, bronchiectasis, chronic bronchitis and diabetes mellitus[2,3,12].

Smoking is also a well-known factor that could have an effect on NMC. It has been shown that cigarette smoke inhibits ciliary beat frequency[13,14]. Also NMC has been shown to be slower in regular smokers up to the ciliostatic effect of tobacco smoke, decrease in cilia number and changes in the viscoelastic properties of mucus[4,15,16]. However, Quinlan et al. did not observe any such difference in NMC in smokers[17].

However, in the literature, the relationship between nasal MCC and exposure to passive smoking has been neglected. In an animal study by Zayas et al, tissue disruption was shown by scanning electron microscope and mucus transport was significantly reduced, even after exposure to the smoke of one cigarette[18]. There is only one study about the relationship between passive smoking and NMC in the literature. In this study conducted by Habesoğlu et al., they found that both active and passive smoking increased nasal MCC time when compared with healthy controls[7].

In our study, we found that MMC in passive smoking group and active smoking group were significantly longer than the healthy controls. The comparison of NMC values between the passive smoking group and the active smoking group revealed no statistically significant differences. In addition, there was positive correlation between the increase in NMC and amount of cigarette consumption.

Limitations of our study were the small sample size and that we did not measure the amount of tobacco exposure in passive smoking group. Finally, further studies with a larger group of participants will be beneficial.

Conclusion

Both active and passive smoking prolonged NMC when they were compared with healthy controls. According to the literature, tobacco exposure is associated with diseases such as asthma, chronic rhinosinusitis, and lower airway infections[19]. 9 It may be hypothesized that it could be related to the direct effect of prolonged NMC.

Competing interests

The authors declare that they have no competing interests.

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