Effect of COVID-19 anxiety on perceived risks and avoidance behaviors
Fadime Çınar, Haşim Çapar, Gülay Ekinci
Department of Health Management, Faculty of Health Sciences, Istanbul Sabahattin Zaim University, Istanbul, Turkey
DOI: 10.4328/ACAM.20463 Received: 2021-01-04 Accepted: 2021-02-15 Published Online: 2021-02-26 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):835-839
Corresponding Author: Fadime Çinar, Department of Health Management, Istanbul Sabahattin Zaim University, Halkalı street, No: 2 Halkalı 34303, Kucukcekmece, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 212 692 89 66 F: +90 212 693 82 29 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9017-4105
Aim: The aim of this study was to determine the perceptions of individuals concerning the COVID-19 pandemic in Turkey and to try to slip out of this perception of the relationship between anxiety and avoidance behavior.
Material and Methods: A snowball sampling method was used in this study. Data were collected through an online questionnaire between March 26 and April 1, 2020. A total of 834 persons were surveyed from 81 cities in Turkey. The demographic questions created by the researchers and a perception scale about COVID-19 were used. The data were analyzed with SPSS 25.0 statistical program.
Results: Risk perception and anxiety levels of the participants during the COVID-19 pandemic were found to be statistically associated with gender, employ- ment status, income level, general health insurance and the presence of chronic disease (p <0.05). The majority of the participants (83.3%) considered the disease fatal and 59.1% were anxious. The anxiety levels of the participants played a mediator role between perceived risks and avoidance behaviors. Partici- pants’ risk perception for the COVID-19 pandemic was 4.22 ± 0.63, and their anxiety levels were above the average of 3.92 ± 0.71.
Discussion: The perceptions, beliefs, attitudes and psychological responses of communities with increased uncertainty and epidemic effects can act as a “vec- tor” in the transmission of the disease.
Keywords: COVID-19; Anxiety; Perceived risk; Avoidance behavior; Health psychology
The World Health Organization (WHO) reported in the early days of 2020 that the world was facing a new coronavirus, a potential pandemic agent. Its etiological agent is the SARS-CoV-2 from the Coronaviridae family, located in the same subfamily as the SARS-CoV, which also appeared in China in November 2002 [1,2]. As the epidemic spreads rapidly, economic life might come to a halt, along with many uncertainties. This can cause anxiety and constant worry in individuals. It is known that there is a relationship between the way the disease is represented in the minds of individuals and the responses to the disease and adaptation to the disease [3,4]. Researches conducted in the past show that the anxiety of the public and health professionals has increased during epidemics [5,6]. In a study during the SARS pandemic, it was found that psychological reactions such as high levels of stress, helplessness, and post- traumatic symptoms were common in the sample . The results of a longitudinal study conducted by Leung et al. (2005) also showed that the anxiety scores of the participants who perceived the possibility of contracting SARS disease or death due to this reason were high. Jones and Salathé (2009) showed that participants’ anxiety levels related to H1N1 increased at the beginning of the epidemic and decreased, as expected, over time. One of the important findings of this research is that anxiety level plays an intermediary role in individuals’ preventive behaviors . There are many studies in the literature showing that the avoidance behaviors of threatened individuals increase in anxiety-triggering situations such as different types of flu pandemics [9,10].
The COVID-19 Pandemic is an internationally concerned public health emergency and poses a challenge to psychological resilience. Research data are needed to develop evidence- based strategies to reduce negative psychological effects and psychiatric symptoms during the pandemic. The aim of this research is to determine the public’s perceptions about the nature of the COVID-19 pandemic, possible causes, control methods and attitudes towards vaccination, and to examine the effect of public anxiety on the perceived risk and individuals’ avoidance behaviors during the first 14-day period, which early as seen from March 2020 in Turkey.
Material and Methods
Type of the Research
This study is a descriptive and cross-sectional study. The aim of this study was to determine the perceptions of the public about COVID-19 during the first 14 days of the quarantine process for the COVID-19 pandemic in Turkey and to determine the relationship between anxiety and avoidance behaviors. Ethics committee approval was taken for this study from XXX Etic Comitte (2020/07).
A demographic information form and a perception and attitude scale were used for data collection.
Demographic Information Form: This form included age, gender, educational levels, income levels, health insurance, working status and general questions about COVID-19. The general questions in this section are: “How deadly is COVID-19 disease?”, “How many months do you think the epidemic will continue from now on?”, “How much are you worried about getting COVID-19?” The predictions of the participants about epidemic disease were studied
Perception and Attitude Scale: The scale was prepared using the scale questions that Cırakoglu (2011) used in his research and whose reliability was valid . The scale consists of four parts: (1) COVID-19 Risk Perception, (2) Perception about COVID-19 Causes, (3) Perception about COVID-19 Control, and (4) Vaccine Attitudes. The scale was designed as a 5-point Likert type (1=Strongly disagree to 5=Strongly agree). The higher scores on the scale indicate that the participant’s belief in the relevant item has increased. Some items in the scale were written negatively and reversed before analysis. For each scale, the total variance and internal consistency coefficient were 52.62% and 0.69 for the perception subscale, 51.93% and 0.80 for the reasons subscale, 56.46% and 0.76 for the control subscale, and 55.93% and 0.82 for the vaccine attitude subscale, respectively.
Avoidance Behaviors Scale (ABS): It was prepared as a 5-point Likert-type 14-item scale developed by Cırakoglu (2011) to determine the behavioral and cognitive avoidance of the participants . The scale has three sub-dimensions: “Avoiding Common Areas”, “Cognitive Avoidance”, “Avoiding Individual Contact”. Participants were asked to mark how often they showed the behaviors defined in the scale items between 1 (I have never done this behavior) and 5 (I have done this behavior very often). An increase in the scores in this scale shows that avoidance behaviors are more frequent. Cronbach Alpha (α) value, which is the general reliability coefficient of the scale, was found to be 0.85. In this study, Cronbach Alpha (α) value was found to be 0.79.
State Trait Anxiety Inventory (STAI): The trait anxiety levels of the participants were developed by Spielberger et al. (1970) and adapted to Turkish by Öner and Le Compte (1975). The scale was developed to measure the anxiety experienced by individuals within the last seven days (Öner N, Le Compte A. State-Trait Anxiety Inventory handbook. Istanbul: Boğaziçi Üniversitesi; 1985 (in Turkish)). It consists of 20 items. Each item is scored from 1 (almost never) to 4 (almost always). Seven items are reversed from the analysis. The lowest possible score is 20, the highest score is 80, and the breakpoint is evaluated as 45 points. The increase in the scores obtained from the scale shows that anxiety is constantly increasing.
Data Collection Method
The data were collected online using Google forms via the Internet, taking into account the presence of quarantine due to the epidemic. Therefore, the geographical boundaries do not constitute an obstacle and the random error in the size of the population-sample is reduced.
Population and study sample
The universe of this study is individuals living in Turkey between March 26 and April 1, 2020, using a snowball sampling method. A total of 834 persons were surveyed from 81 cities.
SPSS 25.0 was used. The Demographic Information Form was evaluated as frequency, percentage, and scale scores as mean, standard deviation. The Kolmogorov-Smirnov test was used for normality. The t-test, Oneway Anova test, Bonferroni test, Hierarchical logistic regression were used with a 95% confidence interval and a significance level of p<0.05. Limitations of the study
Collecting data cross-sectionally with Google forms due to the epidemic is the limitation of the research.
The average age of 834 participants in the study was 39.68 ± 10.57 years, 27.8% were in the 31-40 age group and 59.1% were women; 41.4% (n=345) of the participants were civil servants, 62.8% were university graduates (n=524), 37.8% had a monthly income between 4001-6000 TL (n=315), 82% had a general health insurance (n=684); 37.9% (n=316) reported a chronic disease; 60.1% (n=501) reported that the the COVID-19 pandemic was very fatal; 59.1% (n=493) were very concerned about the pandemic, while 48.4% (n=404) evaluated their current health status as normal (Table 1).
The mean COVID-19 Perception and Attitude Scale score was 3.48 ± 0.9. The means of sub-dimensions were “Contagiousness” 4.15 ± 0.7, “Conspiracy / COVID-19 Reasons” 2.95 ± 0.7, “Environment / COVID-19 Reasons” 3.05 ± 0.7, “Faith / COVID-19 Reasons” 2.27 ± 1.16, “Control / COVID-19” 2.46 ± 0.7, “Personal Control / COVID-19 Reasons” 3.03 ± 0.6, “Attitude Against Vaccine” 2.96 ± 0.6. According to these findings, it was determined that the Covid-19 Perception and Attitude scale scores of the participants were high and the scores of belief, conspiracy and control sub-dimensions were low.The Cronbach- alpha coefficients of the scale for all dimensions ranged between 0.72 and 0.84 with a mean of 0.78 .
The mean Avoidance Behavior Scale score was 4.48±0.9, and the mean State-Trait Anxiety Inventory Scale score was 48.22±8.5. The means Avoidance Behavior Scale sub-dimensions were “Avoiding Common Areas” 4.29 ± 0.8, “Cognitive Avoidance” 2.28 ± 0.6, “Avoiding Individual Contact” 4.37 ± 0.6. Individual Contact Avoidance Scale scores were high, and cognitive avoidance subscales scores were low. The mean internal consistency coefficient was 0.82 (range 0.76 – 0.82) . According to these findings, Avoidance Behavior Scale score, State-Trait Anxiety Inventory Scale score, Avoiding Individual Contact sub- dimensions scores were high, and Cognitive Avoidance sub- dimensions scores were low.
Perceptions and attitudes, avoidance behaviors and trait anxiety behaviors of the participants did not differ in terms of gender (p>0.05); however, age (31-40 years), education level (university degree), monthly income (<2000 TL and 4001-6000 TL), current employment status (unemployed), social security and the presence of chronic disease had significant impacts (p<0.05), (Table 2).The effects of demographic variables such as monthly income, education level, social security and current status on perception and attitude towards the COVID -19 pandemic, avoidance behavior, and trait anxiety were found to be statistically significant with regression analysis (p <0.05). In addition, it was found that the perceived risk and attitude towards the COVID -19 pandemic (β =0.266 p<0.05) and the trait anxiety level (β =0.223 p<0.05) had a statistically significant effect on avoidance behavior. In addition, it was found that the effect of perception and attitude level on avoidance behavior decreased with the addition of trait anxiety level to the model
(β =0.113 p<0.05), and trait anxiety (β =0.234 p<0.05) had an effect as a partial moderator (Table 3).
This study was conducted with a Turkish sample to examine the effect of COVID-19 anxiety, which first appeared in Wuhan, China in December 2019, on perceived risk and avoidance behavior. As a result of the evaluation of the research data, it was determined that the total score average, avoidance of common areas, cognitive avoidance, personal contact avoidance, and trait anxiety levels were high. These findings are thought that participants are sensitive to this pandemic, they take into account the warnings made by state authorities, but uncertainty about this pandemic increases their anxiety. In the literature, it was found that similar outcomes have been found in epidemic diseases, especially in countries with uncertainties, such as COVID-19, where the treatment algorithm has not yet been clarified . Various factors, including socio-demographic characteristics, social context and individual values can be effective in the perception of pandemics [9,13].
Various factors, including socio-demographic characteristics, social context and individual values, can be effective in the perception of pandemics [9,14]. When the perceptions and attitudes, avoidance behaviors and trait anxiety behaviors of COVID-19 according to demographic variables were analyzed, there was a statistically significant difference in terms of age, education status, monthly income, employment status, social security, presence of chronic disease (P<0.05). This difference is for age, among those between the ages of 31 and 40, and those who are university graduates in terms of education status. It is also among the average points of those whose income is 2000 TL and below and 4001-6000 TL, and those who are unemployed and have no social security. The perceptions, beliefs, attitudes and psychological reactions of the communities in which uncertainties and the epidemic effect increase, may differ from society to society and demographic characteristics. For this reason, according to the results obtained from this study, perception and avoidance behaviors of the COVID-19 epidemic were found higher in individuals whose average age was not in the older age group and who had a high education level. It is thought that being educated in this age group is important in raising awareness of taking necessary precautions against the epidemic. However, the quarantine environment created by the pandemic indicates that production will stop, and economic crises will occur and unemployment will increase. Therefore, in this study, anxiety levels of low and middle income unemployed people without social security were higher. The results were determined to be compatible with similar studies in the literature [6,12,15].
Regression analyzes were performed to determine the effect of the demographic characteristics of the participants on avoidance behavior against the COVID-19 pandemic and the mediating role of anxiety between perceived risk and avoidance behavior against the COVID-19 pandemic. With this analysis, the effects of the participants’ monthly income status, education level, social security, and current status on demographic variables on perception and attitude, avoidance behavior and trait anxiety were found to be statistically significant (p<0.05). In addition, the perceived risk and attitude towards the COVID-19 pandemic (β=0.266 p<0.05), and the level of trait anxiety (β=0.223 p<0.05) were found to have a statistically significant effect on avoidance behavior. In order to have a variable effect, the Perception and Attitude level for the independent variable COVID-19 must have a significant effect (4th regression) on Avoidance Behavior for the dependent variable, COVID-19. This significant effect should disappear or decrease with the inclusion of Trait Anxiety as an independent variable in the regression (6th regression). In the 6th regression model made for this purpose, the effect of perception and attitude level on avoidance behavior decreases by adding the level of trait anxiety to the model (β=0.113 p<0.05) and a partial intermediate variable of trait anxiety (β=0.234 p<0.05) found to be effective. According to our findings, participants in the first psychological response of the general public, perceived the pandemic just one week after the WHO declared an emergency state of international concern and the COVID-19 pandemic in the country, their attitudes and anxiety levels were high. It was determined that the risk perceived by the participants affected their avoidance behaviors against this disease through their high level of anxiety. These results were found to be similar to the literature [2,14,16]. The anxiety levels of the participants were determined to have an intermediary role between risk and avoidance behaviors. Therefore, health authorities should identify high-risk groups based on socio-demographic information for early psychological interventions. It can be suggested that government and health authorities provide transparent and accurate health information during the pandemic to reduce the impact of rumors, so that higher satisfaction with the health information received may be associated with lower psychological effects of the pandemic and lower levels of stress, anxiety and depression.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Fadime Çınar, Haşim Çapar, Gülay Ekinci . Effect of COVID-19 anxiety on perceived risks and avoidance behaviors. Ann Clin Anal Med 2021;12(8):835-839
Investigation of the relationship between menopausal symptoms and physical activity level in the postmenopausal period of women
Bilge Basakcı Calık 1, Elif Gur Kabul 1, Fatma Taskın 2, Güldane Dınc 3, Ummuhan Bas Aslan 1
1 School of Physical Therapy and Rehabilitation, Pamukkale University, Kinikli, Denizli, 2 Department of Physical Therapy and Rehabilitation, Aydin State Hospital, Aydin, 3 Department of Therapy and Rehabilitation, Tonya Vocational School, Trabzon University, Trabzon, Turkey
DOI: 10.4328/ACAM.20464 Received: 2021-01-06 Accepted: 2021-02-17 Published Online: 2021-03-01 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):840-844
Corresponding Author: Fatma Taskin, Aydin State Hospital, Department of Physical Therapy and Rehabilitation, Aydin, 09100, Turkey. E-mail: email@example.com P: +90 2582964278 F: +90 2582964494 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2333-7207
Aim: The aim of this study was to investigate the relationship between menopausal symptoms and physical activity levels in postmenopausal women.
Material and Methods: One hundred seventeen women in the postmenopausal period with a mean age of 55.26 ± 6.24 years were included in the study. Physical activity level was evaluated with the International Physical Activity Questionnaire Short Form (IPAQ-SF), while menopausal symptoms were evaluated using the Menopausal Symptom Assessment Scale (MRS). MRS consists of three subtests: somato-vegetative, psychological and urogenital symptoms. Pearson’s correlation was used to analyze the data. The significance level was accepted as p≤0.05.
Results: The relationship between IPAQ-SF scores and MRS somato-vegetative, psychological and urogenital symptoms subtests and total score of women was as follows: r = 0.561, p = 0.054, r = 0.668, p = 0.040; r = 0.936, p = 0.008; r = 0.937, p = 0.007, respectively.
Discussion: As a result of our study, it was determined that there was a moderate and high negative correlation between physical activity level and menopausal symptoms in postmenopausal women. This result showed us that physical activity had an effective role on the menopausal symptoms of postmenopausal women.
Keywords: Menopause; Physical activity; Climacterium
The World Health Organization defines menopause as the absence of menstruation for one year in a woman as a result of a decrease in estrogen hormone levels due to the cessation of ovarian functions (available at: http://whqlibdoc.who.int/trs/ WHO_TRS_866.pdf). Menopause age varies from society to society. While menopause age is accepted as 51 in the world, in Turkey, it is accepted as 47 (available at : https://www.jcog.com. tr/article/en-editorials-66894.html). Therefore, women spend one-third of their life span with the effects and problems of menopause .
The menopausal period consists of premenopause, menopause and postmenopause. During the premenopausal period, the first symptoms appear; the menopause period is when the last menstrual bleeding occurs, and the postmenopausal period is the period starting one year after menopause and lasting until the beginning of old age .
Menopausal symptoms are influenced by age, occupation, education level, economic independence, income level, marital adjustment, marital status, orientation to other fields, the size of the family, the status of obtaining information specific to this period, role change and the value that society attaches to women .
Menopause is a period of hormonal changes in a woman, as well as changes in the family, in business life and in self-perception. Physiological and psychosocial changes, depending on estrogen deficiency, occurring in this period, manifest themselves with different intensity and duration and negatively affect physical and mental health. In addition to early health problems such as hot flashes, sweating, fatigue, insomnia and tension, late-term health problems such as osteoporosis, osteoporotic fractures, urogenital symptoms and cardiovascular diseases can also be seen. In this process, women are worried about aging, loss of fertility, changes in physical image, health problems combined with social and symbolic meanings negatively affect their lives .
Physical activity is defined as any movement that is performed using skeletal muscles in daily life and requires energy expenditure. Regular physical activity and exercise are low- cost and low-risk, as well as preserving and controlling health- related parameters such as cardiovascular endurance, body composition, muscle strength and endurance, flexibility is an effective healthy lifestyle behavior in the treatment of many diseases and symptoms .
While studies in the literature examine the effects of exercise on menopausal symptoms, quality of life and activities of daily living in women in the menopausal period, it has been observed that studies on physical activity often belong to the perimenopausal period [1,11,12,23].
The protective effect of physical activity in reducing menopausal symptoms has been emphasized, but certain conclusions have not been reached. Therefore, our study aims to examine the relationship between the physical activity level and menopausal symptoms of postmenopausal women. The study is expected to guide physiotherapists in the planning of the physical activity level for postmenopausal women to reduce menopausal symptoms.
Material and Methods
Ethical approval was obtained for this study, which was planned as a cross-sectional analytical study, with the committee meeting of Pamukkale University Non-Invasive Clinical Research Ethics Committee dated 31.01.2017 and numbered 60116787-020 / 8896, and then an application was made to Denizli Province Public Health Directorate. After the application, evaluations were made in Kinikli and Camlik Primary care clinic in Denizli. For the evaluation, people enrolled in the family health center were provided with oral information over the phone, which indicated the inclusion criteria. Beginning with 133 women, 6 women were deemed ineligible for this study, and 10 women declined to participate. As a result, 117 women were analyzed for this study (Figure 1). Informed consent forms were signed by women who agreed to participate in this study, and they were assessed using face-to-face interviews. Inclusion criteria:
The study included women aged 35 to 65 years who had at least one year after their last menstrual bleeding, whose menopausal status was defined as postmenopausal according to the STRAW classification, and who volunteered to participate in the study. The STRAW evaluation was carried out by physicians in the primary care clinic.
The exclusion criteria were the presence of a physical illness or mental disability that prevented understanding and responding to the scales applied, hysterectomy and any gynecological surgery, chronic menstrual irregularity, having received hormone therapy for any reason in the last 3 months and not speaking Turkish. Verbal information about the study was given to the participants again before the registration process. Then, anthropometric measurements (height and weight) of the participants were made by the same researcher, and sociodemographic (age, education, employment and marital status) and health information forms were filled with face- to-face interview technique. Later, the Menopausal Symptom Assessment Scale (MRS) and the International Physical Activity Questionnaire-short form (IPAQ-SF) were used for evaluation. Data Collection Tools:
1. Menopause Rating Scale (MRS)
Menopausal symptoms were evaluated according to internationally accepted Menopausal Symptoms Assessment Scale (MRS) and developed by Schneider et al. (2000). MRS consists of 11 items and 3 subtests including menopausal complaints. Subtests are somato-vegetative complaints, psychological complaints, and urogenital complaints. The validity and reliability of the scale was made by Gurkan in 2005 .
Likert-type scale has 5 options for each item. They are 0: none, 1: mild, 2: moderate, 3: severe and 4: very severe options. While the minimum score obtained from the total of MRS is “0”, the maximum score is “44”. An increase of the total score on the scale indicates the increase in the severity of the complaints. Also, it shows that the quality of life is negatively affected.
2. International Physical Activity Questionnaire Short Form (IPAQ-SF)
The physical activity status of the women participating in the
study was obtained by evaluating the activity frequency and duration, which they declared in the International Physical Activity Questionnaire Short Form. The IPAQ was developed by the International Group for Consensus of Physical Activity Measurements and has been used in 25 countries with the approval from the World Health Organization. The validity and reliability study of the IPAQ was first conducted at 14 centers in 12 countries. The validity and reliability study of the Turkish version of the questionnaire was made by Karaca (2007). The test-retest reliability of the IPAQ short form was found to be r = 0.69 .
Data were analyzed with the SPSS package program (software). Frequency and percentage distributions for descriptive categorical variables, means and standard deviations for continuous variables were calculated. The level of significance in statistical test results was accepted as p≤0.05 and interpreted. Chi-square and Fisher’s exact tests for categorical variables, t-test for continuous variables, ANOVA analysis of variance and Pearson correlation test were used in comparative analyzes.
One hundred seventeen women in the postmenopausal period with a mean age of 55.26 ± 6.24 years participated in the study. Figure 1 shows a flow chart of the study design. The demographic and health-related data of the participants are shown in Table 1.
Among the participants, 84.6% had no current or past smoking history. When the physical activity level of the women participating in the study was examined, it was seen that 60 (51.3%) women were inactive, and 57 (48.7%) women were minimally active (Table 1).
Considering the relationship between the total score of the women participating in the study on the MRS scale and their IPAQ-SF scores, it was observed that 58.3% of women with no menopausal symptoms were physically active (minimal or very active), and 53.3% of women with severe menopausal symptoms were inactive. The total IPAQ and MRS scores and subscores of the women are shown in Table 2. The relationship between the women’s IPAQ-SF scores and the MRS somato- vegetative, psychological and urogenital symptoms subtests and total scores was as follows: r = -0.561, p = 0.054, r = -0.668, p = 0.040; r = -0.936, p = 0.008; r = -0.937, p = 0.007, respectively (Table 3).
In our study, we aimed to evaluate the relationship between physical activity level and menopausal symptoms in postmenopausal women, and we found that physical activity level was inversely associated with menopausal symptoms in postmenopausal women.
The menopausal period causes hormonal, physical and emotional changes. These changes are not at the same level for all woman, because they are affected by cultural differences, education level and some personal factors . The low scores of women in our study on the assessment of menopausal symptom made us think that they were severely affected by the symptoms in this period. Similar effects were reported in other studies conducted in our country [8,9].
Hormone Replacement Therapy, which is considered the basic and most effective treatment option for symptoms experienced by women during menopause, directs women to alternative methods (lifestyle changes, weight control, physical activity) due to concerns of some risks and side effects. While the effect of such lifestyle changes on general quality of life is evident, their relationship with menopausal symptoms is contradictory .
We encounter different results in studies that examine the relationship between menopausal symptoms and physical activity levels, which is among alternative treatment approaches. In the literature, in addition to all the positive contributions mentioned above, it has been reported that the symptoms of menopause do not decrease with physical activity, but the quality of life increases in the postmenopausal period . Among the contradictory data, studies showing that there is insufficient evidence to determine whether physical activity has a positive or negative effect on these symptoms have also been reported .
The relationship between physical activity status and menopausal symptoms may vary depending on the intensity of the activity . A study showed that women who were physically active or min active had fewer somato-vegetative, psychological, and urogenital complaints. A statistically significant negative correlation was found between the physical activity status of women and somatic complaints in the form of joint-muscle disorders, sleep problems, dryness of the vagina, sexual problems and urinary problems. There was no significant relationship between anxiety, malaise, irritability, mental and physical fatigue, hot flashes and heart problems and physical activity. Weight control and regular physical activity have been recommended as lifestyle changes for women with menopausal symptoms. . In another study examining the relationship between physical activity level and menopausal symptoms, high- intensity exercise had little effect on menopausal symptoms; it has been observed that mild physical activity in leisure time and gardening, at work or while carrying something is more effective in menopausal symptoms. It has been reported that with regular physical activity, individuals feel more comfortable, less severe and less frequent menopause symptoms .
The most typical finding of the climacteric period is vasomotor symptoms. Discigil et al., in their study investigating the perception of menopause, reported that the most common symptom experienced by women in the menopausal period in the last 3 months was vasomotor complaints, and women most frequently associate hot flashes, night sweats and nervousness with menopause .
Mood disorders and mood changes are observed under the influence of hormonal changes in the central nervous system during premenopause and postmenopause. The decrease in serotonin hormone due to estrogen deficiency makes it difficult for women to fall asleep and causes insomnia. The study reported that 91% of menopausal women had irritability, 86% of them had depression, 82% had a loss of concentration, 81% had personality changes, 77% had sleep problems, 77% had lack of motivation, 75% had memory loss, 37% had hot flashes, 19% had a headache and 18% had excessive sweating . There were studies showing that physical activity had a significant effect on menopausal symptoms, especially in terms of vasomotor symptoms [17, 18], and also it was reported that it was not related . In our study, we found a moderately positive significant relationship between physical activity level and vasomotor symptoms. Regular physical activity reduces the body’s response to stress. The severity and frequency of symptoms such as hot flashes and sweating can be reduced by the combined use of relaxation techniques such as deep breathing that reduce sympathetic activation.
Elavsky and Mcauley reported in their study that menopausal women with more physical activities had less perception of menopausal symptom violence and increased psychological well-being . Daniel et al. stated that after intense physical activity, women in the menopausal period tend to be significantly more calm, relaxed and pleasant, free from depression, anger and confusion, and this is due to the increase in endogenous endorphin levels in response to activity . In a study conducted with menopausal women between the ages of 42- 52, depressive symptoms decreased as the intensity of physical activity increased . A study from Italy reported that the complaints of depression, forgetfulness and nervousness were more common in menopausal women with low physical activity levels . When the relationship between physical activity level and the Menopausal Quality of Life Scale (MOYKO) was examined in 2606 women in menopausal period, it was reported that physically inactive women had increased levels of anxiety, depression, decreased well-being, memory and concentration problems compared to active women. It has also been reported that physically active women have a better quality of life . In our study, it was found that most of the women with psychological complaints were physically inactive. This period may also lead to an increase in feelings of loneliness, aging, uselessness and pessimism, as the general health condition that is moderate or poor, retirement, parental deaths, children leave home due to reasons such as school, work, marriage, etc. The inadequacy in the mechanism of coping with physical health and emotional problems may have caused women to feel more severe menopausal symptoms by reducing their activity levels. This result is actually a reflection of our country, we believe that individuals in our country gaining physical activities and hobby activities that they can enjoy in daily life from childhood will transform individuals into more active and happier individuals in life in the future.
A decrease in muscle tone around the reproductive organs is observed with menopause. Li et al. reported that physically active women had fewer complaints of vaginal dryness and lack of sexual desire. It was reported that sexual symptoms of physical activity during the transition to menopause helped to recover . Similar to the literature, we found that women who were inactive during the postmenopausal period had more urogenital complaints. We thought that these complaints could be reduced by increasing the physical activity of postmenopausal women, therefore they should be informed about this issue. Although we thought that the limitation of our study was that the study was conducted on a small population, we believed that it was a useful study in terms of creating a role model representing our society in determining the relationship between physical activity level and menopausal symptoms. Conclusion and Recommendations
In our study, it was observed that somato-vegetative, psychological and urogenital symptoms related to the postmenopausal period decreased with the increase in the level of physical activity. Most women who experienced symptoms such as sleep problems, hot flashes, heart problems, muscle- joint disorders, malaise, irritability, anxiety, physical and mental fatigue, urinary problems, sexual problems and vaginal dryness were found to be inactive. Especially when the negative effects of the postmenopausal period are combined with a sedentary life, the health problems that occur during this period increase even more and may cause a person to experience this period of poor quality. The changes that occur due to menopause, which is a period of life, affect each woman differently and direct women to seek alternative treatment. Regular physical activity and weight control are recommended lifestyle changes. In this direction, studies and publications on women’s health may recommend to investigate the effect of physical activity on menopause symptoms, conduct more interventional studies in physical therapy units and menopause clinics related to the subject, sharing the results and influencing hospital policies to raise women’s awareness of menopause and increase exercise training in this field.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328_ACAM.20464
Bilge Basakcı Calık, Elif Gur Kabul, Fatma Taskın, Güldane Dınc, Ummuhan Bas Aslan. Investigation of the relationship between menopausal symptoms and physical activity level in the postmenopausal period of women. Ann Clin Anal Med 2021;12(8):840-844
Development of healthcare employee satisfaction scale: Reliability and validity study
Fatma Kantaş Yılmaz 1, Ahmet Uğur Kevenk 2
1 Department of Health Management, Faculty of Health Sciences, University of Health Sciences Turkey, Istanbul, 2 Department of Health Management, Faculty of Health Sciences, Bilgi University, Istanbul, Turkey
DOI: 10.4328/ACAM.20465 Received: 2021-02-06 Accepted: 2021-03-21 Published Online: 2021-04-08 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):845-849
Corresponding Author: Fatma Kantaş Yılmaz, University of Health Sciences Turkey, Haydarpaşa Campus, Tıbbiye Street No:38 34668 Uskudar, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 216 418 96 16 / +90 216 346 36 36 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0512-382X
Aim: This study aimed to develop a scale that would help assess the levels of employee satisfaction among healthcare professionals.
Material and Methods: In this methodological study, the routine steps of scale development were followed, including the formulation of items, receiving specialist opinion, application, validation and reliability. In the data analysis, exploratory factor analysis and confirmatory factor analysis for “the Employee Satisfaction Scale” were performed. Cronbach’s alpha coefficients were calculated for each dimension and overall reliability.
Results: The data were found to have excellent fitting in exploratory factor analysis with a probability value of p<0.05 and a Kaiser-Mayer’Olkin (KMO) value of 0.866 by Bartlet’s test. The overall concept explanatory factor was 70.99%, which was sufficient to assess employee satisfaction. In the confirmatory factor analysis, all covariance values across the sub-dimensions were significant (p<0.05). Factor loadings of items were between 0.57 and 0.96. Cronbach’s alpha coefficient for the overall ESS was 0.869. The composite reliability coefficients were >0.70, which meant sufficiency for composite reliability. In addition, the variance for each dimension showed the desired level with a mean of variance (MVE) >0.50.
Discussion: In this study, a comprehensive and practical scale with a high reliability-validity level was added to the literature in order to quantify employee satisfaction which is one of the most important components of the healthcare system.
Keywords: Employee satisfaction scale; Healthcare worker; Healthcare professional; Health science; Health management; Reliability; Validity
The roles of decision-makers and participants in health-care provision have become the most important element in the provision of high-quality healthcare. Since the health sector is a labor-intense field, it is important to employ and train skilled labor, and to support sustainable development and career. The fact that ensuring the satisfaction of healthcare providers improves the quality of healthcare and contributes to financial resources of healthcare organizations has led to focusing the attention of policy-makers and healthcare executives on this issue [1,2,3].
Employee satisfaction indicates feelings of employees toward the work . Locke defined employee satisfaction as “a favorable and satisfying emotional state resulting from the assessment of job and job experiences by an individual” and suggested a set of primary dimensions of satisfaction, including the job itself, payment, promotion, working conditions, benefits, colleagues, personal values and employee relations . Employee satisfaction, job satisfaction, and work satisfaction are concepts that are often used interchangeably in the literature. In some studies, job satisfaction was addressed as a subdimension of employee satisfaction .
Given the intense work-load together with the complexity of delivering services to patients and their relatives requiring psychological support, the concept of satisfaction is more important in healthcare providers . Healthcare providers with higher employee satisfaction can create high motivation in teamwork and cooperation, ensure improvements in healthcare quality, and become successful in problem-solving and effective decision making, thus, minimizing errors. In addition, high employee satisfaction also improves job satisfaction with decreased absent days, personnel turnover rates and exhaustion levels, relieves mental and physical problems, and enhances personnel reliability [1-3].
Dissatisfied healthcare employees may reflect negative feelings to patients, provide insufficient care and tend to leave early or abandon work [1,3]. Several studies have shown that the satisfaction of healthcare providers also affects patient satisfaction . Decreased employee contribution to the facility negatively affects the revenue of hospital either in direct or indirect ways. Employees with a poor satisfaction are more likely to experience stress, resulting in low productivity . In healthcare settings, studies of employee satisfaction have been generally conducted in different professions including nurses, clinicians and therapists. Currently, there seems to be a lack of a global approach covering all employees regarding employee satisfaction in the healthcare sector. . Studies evaluating employee satisfaction in healthcare in Turkey are mainly based on the Employee Feedback Questionnaire of the Turkish Ministry of Health (available at: https://kalite.saglik. gov.tr/Eklenti/30308/0/anket-uygulama-rehberi-son-basim- 11042019pdf.pdf).
This study aimed to develop a reliable and validated employee- satisfaction scale for all professions working in healthcare facilities. This assessment has gained particular importance in terms of the sustainability of the healthcare system during the Coronavirus (COVID-19) pandemic.
Material and Methods
In this methodological study, the steps of scale development, including the formulation of items, receiving a specialist opinion, preliminary application, validation and reliability were followed .
In the first stage, a 6-question semi-structured interview with answers was designed to identify item pool, including employee rights, relations with senior management, work environment, social opportunities and job security. Following focus group discussions with 10 healthcare providers, 37 items were identified. At the second stage, the draft scale was prepared via assessment of 37 items by an expert panel including 8 members specializing in quality in a healthcare facility and health management. The items were designed to be rated by a 5-points Likert scale “strongly disagree, disagree, undecided, agree, strongly agree”. There is no reverse-scored item on the scale. The draft scale also included sections regarding consent and demographic data.
The sample size calculation was based on a number of items x 10 in exploratory factor analysis; thus, the sample size was estimated to be 370 (37×10). The questionnaire was designed as an online survey on Google surveys by adding 8 items on sociodemographic data and informed consent. The questionnaire was applied between December 2019 and March 2020 by sending an invitation link via e-mail, SMS or social media to participants working in healthcare facilities. Overall, the draft scale was completed by 477 participants, and the data obtained were analyzed. Among these, 2 participants had insufficient response rates in the questionnaire, thus, they were excluded from the analysis. Finally, data from 475 participants were analyzed.
The study was approved by the Hamidiye Ethics Committee on Non-Interventional Studies of Health Sciences University (08.11.2019-19/131). The study was conducted in accordance with the tenets of the Helsinki Declaration.
The data were analyzed using SPSS for Windows and AMOS software. In the study, exploratory factor analysis and confirmatory factor analysis were applied to the Employee Satisfaction Scale. Cronbach’s alpha and composite reliability values were calculated for sub-dimensions of the scale.
Data from 475 participants were analyzed. Among the participants, 57.1% were females, while 42.9% were males; 30.7% of the participants were aged ≥41 years. Again, 38.5% of the participants were single, while 59.6% were married; 8.4% of the participants were graduated from primary school, while 16.0% from high school, 18.5% from an associate degree program, 36.8% from an undergraduate program and 20.2% from the graduate program. When work duration was assessed, it was seen that work duration was 0-1 years in 8.6%, 1-5 years in 35.8%, 6-10 years in 21.3% and ≥11 years in 34.3% of participants.
Factor Analysis of Employee Satisfaction Scale (ESS)
Exploratory Factor Analysis
As probability value (p<0.05) and KMO value were 0.866 in Bartlet’s test, performed for the fitting of results obtained from 37-item scale to exploratory factor analysis, the dataset was found to have excellent fitting in factor analysis.
In the factor analysis (Table 2), the overall concept explanatory was found as 70.99 % ; thus, it was considered that the scale can explain employee satisfaction. The scale was found to have a high reliability level since the scale consisted of 7 sub-dimensions and Cronbach’s alpha was >0.80 for all 7 sub- dimensions in the factor analysis. In the sub-dimensions, factor explanatory was found as 15.45 in employee rights/relationship with senior management, 11.6% in food services, 10.91% in cleanliness-hygiene, 9.56% in the work environment, 8.89% in belonging, 7.77% in social opportunities and 6.81% in job security dimensions.
Eight of 37 items, were excluded from analysis, since factor loading values were <0.50. The items excluded were as follows: “I am satisfied with workplace organization (food, transportation, etc.) in case of off-time work and extra-ordinary situations”, “I will continue to work in this organization, even if I find a job with better financial potential”, “I think that appropriate and effective in-service training is provided”, “I think that the work environment is ergonomic”, “I feel safe in the unit I worked”, “I am satisfied with the manner of work (job rotation) and working hours”, “I can readily access the tools needed for the job” and “I am asked about my opinion during the supply of materials that I would use for my job”.
Confirmatory Factor Analysis
By excluding 8 items from the exploratory factor analysis, the ESS scale with the remaining 29-items was analyzed for 280 participants and a confirmatory factor analysis was performed. Of 280 participants, 55% were female while 45% were male. The mean age was 37.1±1.44 years. Among the participants, 10.0% graduated from primary school, while 15.5 % from high school, 14.5% from an associate degree program, 45.6% from an undergraduate program and 14.4% from the graduate program.
The significance of the quantification model was assessed by confirmatory factor analysis using AMOS version 22.0 . In the assessment, it was seen that the quantification model was acceptable. In 29-items ESS, all covariance values across sub- dimensions were significant in confirmatory factor analysis (p<0.05). Factor loadings of items (Figure 1) ranged from 0.57 to 0.96.
All sub-dimensions included in exploratory factor analysis were preserved. All items assessed in exploratory factor analysis were also included in confirmatory factor analysis; no items were excluded, as the factor loadings were found to be >0.50. Table 3 presents detailed data from confirmatory factor analysis. The confirmatory factor analysis was considered significant since the model fitting values x2 and x2/df were found as 832.766 and 2,807 (p<0.05). Since the fitting indexes of model [GFI (0,874), CFI (0,958), SRMR (0,0720), RMSEA (0,062)] were within the acceptable range, the confirmatory factor analysis was considered valid for ESS .
Cronbach’s alpha reliability score was found as 0.869 for ESS, while it was 0.881 in employee rights-relationship with senior management (ER-RSM), 0.867 in food services (FS), 0.854 in cleanliness-C (H), 0.841 in work environment (WE), 0.838 in belonging (B), 0.812 in social opportunities (SO) and 0.811 in job security (JS) sub-dimensions. As composite reliability (CR) coefficients were >0.70, the composite reliability was considered sufficient. In addition, the mean variance explained (MVE) values were found as >0.50, the mean variance explained was at the desired level for each dimension.
In the current study, we have developed a scale aiming at measuring satisfaction levels among healthcare providers, with reliability and validation analyses. The Employee Satisfaction Scale included 29 items in 7 dimensions, including employee rights/relationship with senior management, work environment, belonging, social opportunities, job security, cleanliness-hygiene and food services.
In factor analysis, the dataset was found to have an excellent fitting, with a probability value of <0.05 and a Kaiser Mayer’Olkin (KMO) value of 0.866 in Bartlet’s test. The scale was shown to reflect employee satisfaction at a high level. All covariance values across sub-dimensions were significant in confirmatory factor analysis (p<0.05), with an overall concept explanatory of 71.0%. Factor loadings of the items ranged from 0.57 to 0.96. Cronbach’s alpha coefficient was 0.869. The composite reliability was considered sufficient, with a composite reliability coefficient of >0.70. The mean variance explained was at the desired level for each dimension (>0.50). These findings suggest that the ESS is a reliable and valid quantification tool. Compared with the 29 items and 7 dimensions of the present scale, Erken previously developed an employee satisfaction scale for a thesis study in Turkey, but with 15 items and 3 dimensions, including organization-manager, work satisfaction- environment and payment (available at: https://tez.yok.gov.tr). The authors are of the opinion that the current scale has a higher representative power in reflecting employee satisfaction, with a higher overall concept explanatory of 71.0% versus 66.57%. In terms of reliability, the present study provided a high Cronbach’s alpha coefficient of 0.869, which was comparable to 0.88 of the Employee Satisfaction Scale of the Turkish Health Ministry in 2011 . Kumar and Khan reported a higher level of reliability (0.909) in their 49-item and 7-dimension employee satisfaction scale developed for healthcare providers in India . These investigators proposed that their scale was distinct from those developed for Western countries, particularly for two sub-dimensions, human resources and patient relations, emphasizing the role of these two sub-dimensions in job satisfaction in the Indian healthcare sector .
Hsieh et al. developed a 34-item and 7-dimension employee satisfaction scale to measure employee satisfaction in healthcare providers in Taiwan. . The main difference of the present scale from theirs was the inclusion of two dimensions, i.e, cleanliness-hygiene and food services.
As for all administrative levels, the determination of employee satisfaction is an essential part to improve administrative processes. Encouragement of employees to express their feelings and thoughts will contribute to enhanced organizational communication. Finding solutions for problems based on employee responses will lead to favorable outcomes, including reductions in negative employee emotions to patients and decreased levels of quitting work and absent days. The higher the employee satisfaction, the greater the patient satisfaction and loyalty, and the higher the efficiency and revenues of hospitals. In the current study, the authors attempted to develop a comprehensive and practical scale with high reliability-validity levels in order to better quantify the satisfaction levels of healthcare providers, who are the most important component of the healthcare system. On the other hand, the present scale can be used by other investigators to improve clinical practice.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328_ACAM.20465
Fatma Kantaş Yılmaz, Ahmet Uğur Kevenk, Development of healthcare employee satisfaction scale: Reliability and validity study. Ann Clin Anal Med 2021;12(8):845-849
Effects of Lactobacillus Rhamnosus on dental implant osseointegration in osteoporotic rabbit model
Ayşegül Göze Saygın 1, Oğuzhan Görler 1, Ali Yıldırım 2, Nazlı Ercan 3 , Ömer Fahrettin Göze 4
1 Department of Prosthodontics, Sivas Cumhuriyet University, Faculty of Dentistry, 2 Department of Periodonthology, Sivas Cumhuriyet University, Faculty of Dentistry, 3 Department of Biochemistry, Sivas Cumhuriyet University, Faculty of Veterinary Medicine, 4 Deparment of Pathology, Sivas Cumhuriyet University, Faculty of Medicine, Sivas, Turkey
DOI: 10.4328/ACAM.20467 Received: 2021-01-06 Accepted: 2021-03-11 Published Online: 2021-03-24 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):850-854
Corresponding Author: Ayşegül Göze Saygin, Department of Prosthodontics, Faculty of Dentistry, Sivas Cumhuriyet University, 58140, Sivas, Turkey. E-mail: email@example.com P: +90 507 706 97 60 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2826-5011
Aim: The effect of Lactobacillus rhamnosus (LR), probiotic bacteria that manage inflammatory disease, on osseointegration is unknown. The study aimed to evaluate the effects of LR administration on osseointegration in experimental osteoporosis induced by ovariectomy.
Material and Methods: Sixteen New Zeland female rabbits were randomly divided into the following groups: SHAM (SH), SHAM and LR (SH+LR), Ovariectomy (OVX), OVX and LR (OVX+LR). Animals in the OVX group were subjected to bilateral ovariectomy to create artificial osteoporosis. After 16 weeks, a titanium dental implant was bilaterally implanted into each tibia of the animals. Animals in the SH+LR and OVX+LR groups were given oral probiotics. All animals were sacrificed and all tibia bones were separated at postoperative 8 weeks after implantation. Cardiac blood was taken to determine biochemical markers. Reso- nance frequency analysis (RFA) and bone-to-implant contact area (BIC) were administered.
Results: RFA and BIC area were statistically significant for osseointegration in OVX+LR compared with OVX (p<0.05). The BIC area in the OVX group was statistically lower (p<0.05). ALP, BALP, Trap5b and MPO were highest in OVX groups(p<0.05).
Discussion: This study concluded that osseointegration may be improved by LR administration in an estrogen-deficient state. The success rate of the implant may be increased by using probiotics in patients with osteoporosis.
Keywords: Biochemistry; Histomorphometry; Lactobacillus Rhamnosus; Osseointegration; Osteoporosis; Probiotics
Bone metabolism is directed by two opposite events: the formation of new bone by osteoblasts and removal of old bone by osteoclasts. The balance between cells found in the same tissue at the same time is important in terms of bone mass. A decrease in bone mass and deterioration in the structure of bone cells may result from some systemic disorders such as osteoporosis . The disorder is more prevalent in women because of estrogen deprivation, which is an important risk factor. It is presented to be responsible for the increase in the incidence of low bone density in postmenopausal women and is associated with tooth loss in them due to this fact . Nowadays dental implant in the treatment of edentulousness is preferred as an alternative treatment instead of traditional methods, and its primary stability is necessary to achieve the osseointegration of implants. Osseointegration, known as the contact between the bone tissue and implant surface, depends not only on the biocompatibility of materials, but also on the health of the adjacent tissue. Dental implant treatment in patients with osteoporosis is considered a risk factor for implant osseointegration since it is characterized by bone loss in addition to alteration of the microstructure of bone. Many studies have shown a positive relationship between bone quality and implant success [2-4]. It is known that estrogen deprivation in women accelerates osteoclastic activity and positively correlates with bone destruction [5-7]. August et al. reported that the success rate of maxillary implants in postmenopausal women receiving estrogen is twice as high as those who do not receive it . Although there are many treatments to prevent bone loss for the disorder, treatments are not always successful. For this reason, the use of dental implant treatment in patients with osteoporosis is a possible contraindication.
The use of probiotics to maintain oral health is a new field of research. Although there are some common views on the effects of microbiota on bone, there are few studies on this subject. As the intestinal system plays a key role in the metabolism of calcium and vitamin D, probiotics have the potential to regulate bone health. The effect of microbiota on bone is described in the form of nutrient uptake (calcium and phosphate), immune regulation and the production of small molecules such as direct serotonin or estrogen-like molecules. Studies have shown that inflammation in the bone marrow occurs during intestinal inflammation and ovariectomy [9,10]. Mc Cabe et al. reported positive effects of probiotics on cytokine release in rats in addition to an increase in volume and mineral density of the bones displayed by micro-CT in their study .
Current studies have investigated the oral and systemic effects of various probiotic bacterial species. One of the widely used probiotics, the gram-positive anaerobic bacterium Lactobacillus rhamnosus (LR), reduced gut inflammation and improved barrier function of the intestine . The bacterium, as a new avenue in the management of postmenopausal osteoporosis, inhibits osteoclastic activity . LR has been shown to accelerate bone calcification and regulate osteocyte formation, but the effects of bone healing around the implant are still unknown [14,15]. In the present study, we have hypothesized that osteoporosis affects the establishment of osseointegration, and LR- administration has a positive effect on bone healing around the implant material in a rabbit model.
Material and Methods
The study was approved by the Local Ethics Committee of Animal Experiments in Sivas Cumhuriyet University. A total of 16 adult female healthy New Zealand rabbits (Harlan, Zeist, The Netherlands), aged 6-9 months and 2,5-3 kg body weight were maintained individually in stainless steel cages in a standard animal facility, and the room temperature remained at 21–24°C with 40–60% relative humidity and a 12-h light-dark cycle. The animals were fed ad libitum. After the quarantine, the animals were randomly divided into SHAM (SH), SHAM and LR (SH+LR), Ovariectomy (OVX), OVX and LR (OVX+LR). The animals were fasted for 24 h prior to operation. Ovariectomy was performed under general anesthesia (Xylazine 25 mg/kg and ketamine 50 mg/kg). In the SHAM-operated group, rabbits were also subjected to the same surgical procedure with the removal of an equivalent amount of fat tissue instead of ovaries (n=8). To create an artificial osteoporosis model, an ovariectomy operation was performed on the other animals under general anesthesia, and bilateral ovaries were removed completely with a midline incision. The rabbits were given 2 daily doses of 50 mg/kg ceftriaxone for 4 days for prophylaxis. It was waited for 16 weeks for the osteoporosis model that requested to be created artificially.
The implant surgery was performed at the end of the 16th week, and only one implant was implanted in each tibia of all subjects. Surgical procedures were performed under general anesthesia with intramuscular injection of pentobarbital sodium (50 mg/ kg). The titanium implants designed hybrid features RBM (resorbable blast media) surface structure of 3.3 mm diameter and 7 mm length (Implance, Trabzon, Turkey) were performed bilaterally to the proximal region. Implants were fixed to the tibia by adhering to the surgical procedure and primary stability was obtained. Following intramuscular antibiotic (50 mg/kg Ceftriaxone) and analgesic (4 mg / kg Carprofen) injections, an antiseptic solution was applied.
To ensure adequate intake of the bacteria, half of the SHAM and OVX groups were gavaged 1 drop (1×109 cfu/ml) of probiotics (Lactobacillus rhamnosus, Maflor, Mamsel Drug Industry, Istanbul, Turkey) per day until their sacrification . Probiotic drops were prepared and applied according to the company instructions by mixing them with water (300 μl). Eight weeks after implant surgery, all animals were killed with a lethal dose of pentobarbital sodium (100mg /kg). The tibial bones containing implants were bilaterally removed.
RFA values were calculated for each implant via an sstell device (Osstell Mentor, Integration Diagnostics AB, Gothenburg, Sweden) as implant stability quotient (ISQ) values. ISQ values were recorded after implantation and when the animals were sacrificed, 8 weeks postoperatively.
Tissue blocks (implants and surrounding tissue) of each animals’ tibias were collected and the specimens were dehydrated in a graded series of ethanol rinses and embedded in a glycol methacrylate resin (Technovit 7200 VLC, Kulzer, Wehrheim, Germany). The specimens were then trimmed along the longitudinal axis of the implants, and the BIC distance of the section images transferred to the computer was measured using an image analysis program (Analysis LS Research, Version 5.0, Olympus Soft Imaging Solutions). The BIC distance in all groups was automatically calculated by measuring the total length of the BIC areas in the new bone formed at the top of the most basal part of the implant and following bone boundaries adjacent to the implant using the multi-line marking tab in the computer program in μm unit.
Cardiac blood was taken to determine the levels of markers for osteoblastic and osteoclastic activity. Rabbit bone alkaline phosphatase (BALP), rabbit myeloperoxidase (MPO), rabbit osteocalcin (bone gla protein) (OT/BGP), rabbit collagen type I (Col I), rabbit tartrate resistant acid phosphatase 5b (TRAP5b) were spectrophotometrically searched through ELISA method with commercial agents according to their methods described by them in the blood serum of the animals.
SPSS software program (version 22.0 for Windows; SPSS, Chicago, IL) was used for statistical analysis. The data of RFA, BIC percentages, ALP and COL Type I were statistically analyzed by use of statistical Kruskal- Wallis non parametric test. Wilcoxon Signed- Rank test was used for paired data from initial and final measurements of ISQ values. One-Way ANOVA, a parametric test, was used as a statistical method for BALP, MPO, OT / BGP and TRAP5b because of normal distribution. The obtained data were expressed as means ± standard deviations. Differences were considered as statistically significant at p < .05
ISQ values increased in all groups at the 8th week (Table 1). The ISQ values in the SHAM groups detected after implantation were statistically significantly different from the OVX groups (p<0.05). After implantation, while the mean ISQ value of the OVX group increased from 64.061 ± 4.207 to 68.262 ± 4.176, this value for the OVX+LR group increased from 63.125 ± 3.981 to 71.264 ± 2.019, and this difference between the groups was statistically significant (p<0.001).
The bone implant contact (BIC) area was shown in Figure 1. BIC area was evaluated for both groups, and sections were evaluated (by F.G.). The percentage of %BIC was defined as the ratio of the proportion of the dental implant length in direct contact with newly formed bone tissue and the total length of the implant adjacent to native bone (Figure 1a, b, c, d). The sections were evaluated at least three threads in this process. In the OVX group, it was statistically decreased (35.36 ± 6.11) (Figure 1c). The highest proportion of BIC was determined in SHAM+LR (45,68 ± 3,99) compared to others. But there was no difference between SH, SH+LR and OVX+LR groups (Table 2) Eight weeks after implant surgery, new bone tissue was observed around the implants. Osteoblasts and osteoid tissue were observed in all histological sections (Figure 2). The organized bone tissue and already immature bone tissue were observed in the sections. The bone tissue formed around the implants was healthy. Bone tissue formations were observed in both group samples. The newly formed bone tissue was observed as more regular and organized in the probiotic used groups (Figure 2b, d). It was observed that there were intense osteocytes in both group samples (Figure 2a, b, c, d).
Osteoclastic serum markers ALP (U/ml), BALP (mIU /ml), TRAP5b (μU/ml), COL Type I (ng/ml) and MPO (ng/ml) were higher in the OVX group (Table 3). BALP, TRAP5b and MPO values belonging to OVX groups were statistically significant (p<0.05). When compared with others, the data belonging to COL Type I and MPO were higher in the OVX groups, but the difference was not statistically significant (p> 0.05). While the highest mean in the TRAP5b serum marker was obtained in the OVX group, the differences obtained in the binary comparisons were found statistically significant (p<0.05).
Osteoporosis is a common disease among elderly, especially postmenopausal women, characterized by a decrease in bone mass and microarchitectural changes in bone. As a result, these changes lead to increased bone fragility, and the risk of fracture increases . Postmenopausal osteoporosis is a type of osteoporosis that occurs due to decreased ovarian function and blood estrogen level.
Ovariectomy is the most common method to create an animal model of postmenopause . In the literature, there are many animal models (rat, mice, dogs, cats, etc.) used for the osteoporosis model by removing ovaries. The rabbit model was preferred in the current study because of reaching skeletal maturity at about 6 months, faster bone turnover than in other rodents and primates, and induction of significant bone loss within a short period of time . It was reported that osteoporotic deterioration as a negative effect of ovariectomy appears after about 12 weeks . Wanderman et al. noted that bone mineral density in the ovariectomized rabbit’s femur decreased significantly at 16 weeks . It can be assumed that ovariectomized animals were affected by estrogen deficiency during the osseointegration period since the 16-week term, which was evaluated in the current study. After implant surgery, new bone formation can appear around implants at 15 days, and the osseointegration processes can be completed at 8 weeks. Therefore, it was waited for 8 weeks for complete osseointegration.
Rabbit tibia bones have been widely used for the placement of titanium implants in osseointegration. There are various methods to evaluate bone integration around implants. In the present study, histomorphometry and RFA were preferred as objective measurement methods.
According to the results of histomorphometry, ovariectomy was shown to negatively affect the osseointegration process. The sections belong to the OVX groups showed irregular bone structure and high porosity compared the SH groups. Administration of LR appeared to enhance the BIC of implants in the OVX groups. Lugero et al. stated that their histomorphometric study compared the SH and OVX groups at the 8th week of osseointegration process and found a significant difference between the groups in terms of bone formation around the tibia cortical bone thickness, trabecular volume, mineral apposition rate, and titanium implants . A clinical study on healthy, osteoporotic and osteopenia patients also suggested a positive correlation between primary implant stability and bone density .
It has been stated that there is a significant relationship between decreased bone quality and primary stability of the implant in-vivo researches [2,3,4]. According to RFA measurements in the OVX groups, ISQ values were lower than in the SH groups. It was thought that estrogen deficiency can negatively affect bone quality as well as primary stabilization of the implant. LR administration in SH and OVX groups was significantly higher than in the OVX group. It may be concluded that LR administration to bone quality and primary stability of the implant. Similar to the current study, in their clinical study comparing primary stability values, it was found that the RFA value was lowest in the OVX groups although the RFA value was highest in the sham groups and the difference was statistically significant.
The modeling process of bone is a condition managed by osteoblast and osteoclast activity. Osteoclastic markers such as ALP, collagen type 1 play an important role after the placement of implants . Similar to the current study, Du et al. reported that estrogen deprivation adversely affects osteocyte morphologies. In their study, ALP, OC, collagen type 1 and TRAP levels were found to be significantly higher in the OVX group and determined as an important indicator of bone model in the early recovery period .
There are many studies using different antiresorptive and anabolic agents, which show that osteoporosis affect elderly population by reducing the contact area of bone implant and causing implant failure due to bone structure deterioration. In oral microbiology, the use of probiotics indirectly affected all bone parameters, which can be found in the literature. Studies have shown that microbiota acts on the bone through the host’s immune system by regulating osteoclastogenesis [11,14] As the probiotics selected in this study were Lactobacillus and applied during osseointegration, the data obtained from this study support the literature. Britton et al. have reached the conclusion that oral administration of Lactobacillus bacteria (1×109 cfu/ml probiotics in 300μl water) is effective in preventing bone loss and affect serum markers . Liquid probiotic supplements selected in this study were applied as 1 drop every day during the experiment, as a drop included 1×109 live microorganisms. Probiotics can regulate the gut microbiome (composition and activity), increase barrier function, and decrease intestinal inflammation, resulting in several local and systemic responses, such as (1) reduced inflammation in the gut, blood, and bone, (2) increased metabolite levels such as short-chain fatty acids (SCFA), which can enhance calcium absorption and signal locally in the gut and in the bone increased bacterial secreted factors, (3) and intestinal hormones such as incretins and serotonin that are known to regulate bone density. Finally, the signals result in decreased osteoclast activity and/or increased osteoblast activity leading to enhanced bone density, structure, and strength. However, how this mechanism works is still not fully elucidated.
The results of our study showed improvement in implant osseointegration due to administration of LR in an estrogen- deficient state of bone. Anti-osteoclastic and anti-inflammatory effects of LR could explain this process.
Oral administration of LR has been shown to improve the osseointegration of dental implants that were implanted in the tibial bone of osteoporotic rabbitts. This assumption may be supported by clinical studies assessing the success of dental implants applied to patients.
Scientific Responsibility Statement
Animal and human rights statement
Funding: This work was supported by the Scientific Research Project Fund of Cumhuriyet University under project number DIS-203.
Conflict of interest
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Download attachments: 10.4328_ACAM.20467
Ayşegül Göze Saygın, Oğuzhan Görler, Ali Yıldırım, Nazlı Ercan, Ömer Fahrettin Göze. Effects of Lactobacillus Rhamnosus on dental implant osseointegration in osteoporotic rabbit model. Ann Clin Anal Med 2021;12(8):850-854
A rare agent; Growth of Elizabethkingia Meningoseptica, 11 years of evaluation
Nilüfer Saygılı, Güliz Doğan
Department of Microbiology, Health Sciences University, Tepecik Education and Research Hospital, Izmir, Turkey
DOI: 10.4328/ACAM.20471 Received: 2021-01-07 Accepted: 2021-02-17 Published Online: 2021-03-11 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):855-859
Corresponding Author: Nilüfer Saygılı, Department of Microbiology, Health Sciences University, Tepecik Education and Research Hospital, Güney neighborhood, Yenişehir, Konak, Izmir, Turkey. E-mail: firstname.lastname@example.org P: +90 5539208802 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6905-8241
Aim: In this study, we aimed to present E. meningoseptica infections, which grew on the cultures of inpatients in our hospital’s various clinics.
Material and Methods: All patients with a positive culture of E. meningoseptica admitted to our hospital between April 2008 and July 2019 were retrospectively included in this study. Demographic data, clinical diagnosis, outcomes and antimicrobial susceptibility for all isolates were extracted from patient electronic medical records.
Results: Over an 11-year period, seventeen patients have been infected with E. meningoseptica in our hospital. Most of them (n:11) were from intensive care units (ICU). Eight of the samples from which growth detected, were blood, 6 were endotracheal aspirate, 2 were cerebrospinal fluid, and 1 was wound swab. Most of them were children (76%). Cefoperazone/sulbactam, ciprofloxacin and trimethoprim/sulfamethoxazole were found to be the most effective antibiotics.
Discussion: E. meningoseptica is usually isolated as hospital acquired infection. It can make outbreaks in ICUs and also can be isolated from individual cases. Variable mortality rates of the infection have been reported. E. memingoseptica is resistant to antibiotics frequently used in the treatment of gram-negative infections as carbapenems, beta-lactams and aminoglycosides. In contrast to previous studies, we found lower susceptibility rates (18.1%) against piperacillin/ tazobactam. This infection should be kept in mind for patients at risk group who do not respond to treatment.
Keywords: Elizabethkingia Meningoseptica; Hospital infection; Antibiotic resistance
Elizabethkingiameningoseptica (Chryseobacterium meningosep- ticum), formerly known as Flavobacterium meningosepticum, is a rod-shaped gram-negative bacterium that is widespread in nature (for example, in water, plants and soil). Many environ- mental studies have shown that E. meningoseptica can survive in chlorine-treated municipal water supplies, often colonizing sink basins and taps, and has become a potential reservoir of infections in the hospital environment. Organisms have been recovered from dialysis systems, pharmaceuticals, and medical devices (including intravascular catheters, respirators and intu- bation tubes) . They do not normally exist in the human body, but have been reported to cause various invasive infections like meningitis, pneumonia, endocarditis, and bacteremia in adults and neonates in association with a severe underlying illness . It usually has low virulence and is prone to infecting newborns and immunocompromised hosts. It can also cause nosocomial outbreaks, especially in critical care and neonatal units, and these are difficult to control. Risk factors associated with ac- quiring this infection include immunosuppression, underlying medical diseases, prolonged hospital stay, prior use of higher antibiotics, indwelling central venous catheter and other inva- sive devices . This organism is resistant to many antibiot- ics like beta-lactam antibiotics, aminoglycosides, tetracyclines, and chloramphenicol . Many possess two different types of β-lactamases, namely class A extended-spectrum β-lactamases and class B metallo-β-lactamases (MBLs); the latter confer re- sistance to carbapenems, which are widely used to treat in- fections caused by multidrug-resistant gram-negative bacteria. Two types of MBL, BlaB and GOB, have been identified in iso- lates of E. meningosepticum. They are constitutively resistant to multiple antibiotic classes and has unusual resistance patterns and mechanisms . The selection of appropriate antimicrobial agents for patients infected with E. meningoseptica is difficult due to the lack of data on the clinical response to different treatments, as well as due to multiple drug resistance .
In this study, it was aimed to present the infections of E. menin- goseptica which have grown on the cultures of inpatients in our hospital’s various clinics.
Material and Methods
All patients with a positive culture of E. meningoseptica admit- ted to our hospital between April 2008 and July 2019 were ret- rospectively included in this study. Demographic data, clinical diagnosis, outcome and antimicrobial susceptibilities for all iso- lates were extracted from patients electronic medical records. Moist grey and white colonies on blood agar and, typically lac- tose-negative small colonies on EMB agar are picked up. Iden- tification of isolates was done using conventional methods, the VITEK 2 Compact (bioMerioux, France) automated system and MALDI-TOF MS (Bruker, Germany). Susceptibility testing was performed for all isolates using the Kirby-Bauer disc diffusion method and the VITEK 2 Compact (bioMerioux, France) auto- mated system according to the CLSI and EUCAST standards. When repetitive growth was found, only the first strain of each patient was included in the study.
Over an 11-year period, seventeen patients have been infected with E. meningoseptica in our hospital. Most of them (n:11) were from intensive care units (ICU). Eight of the samples from which growth detected were blood, 6 were endotracheal aspirate, 2 were cerebrospinal fluid and 1 was wound swab. Except for one patient (whose blood culture was positive for E.meningoseptica on the first day of admission to the hospital), the mean-time from admission to the isolation of E.meningoseptica was 50 days range (5-162 days) .All the patients had long term hospi- talization (mean: 71 days, from 19 to 187 days) and had various underlying diseases. Only one of thirteen pediatric patients and all four adult patients died. According to the antibiograms of the strains, the most effective antibiotics were cefoperazone/ sulbactam, ciprofloxacin and trimethoprim/sulfamethoxazole. The clinical characteristics of the patients (Table 1) and anti- biotic susceptibilty of the strains (Table 2) are presented in the tables.
E. meningoseptica are isolated primarily as hospital acquired infection agents and can cause outbreaks, especially in ICUs. It has been observed that the number of patients with E. meningo- septica bacteremia is increasing; indeed, at a medical center in Taiwan, the incidence (per 100,000 admissions) of E. meningo- septica bacteremia increased from 7.5 in 1996 to 35.6 in 2006 . The incidence of E. meningoseptica bacteremia in the pres- ent series was not associated with a hospital outbreak, and we did not observe any increase by years. This may be because of the successful implementation of infection control program in our hospital, isolation precautions, and a hand hygiene program. E. meningoseptica infection in humans is usually acquired in the hospital and is most likely associated with the presence of in- vasive equipment, treatment with long-term broad-spectrum antibiotics, or long periods of hospitalization [1,5]. Ratnamani et al. reported eight patients infected with E. meningoseptica in their hospital over a 6-month period. All were on mechanical ventilation and bedside hemodialysis in ICU . Weawer et al. reported nineteen patients on mechanical ventilation and in- fected with E.meningoseptica in ICU and eight died . In our study, patients with severely debilitating diseases who had ICU admission and received antibiotics during a long period of hos- pitalization were at high risk for E. meningoseptica infection.
In previous studies, E. meningoseptica outbreaks have been re- ported, and pediatric patients, especially neonates and prema- ture infants, are at great risk for E. meningoseptica infection [7,8]. Lin et al. searched the relationship between 28 isolates of E. meningoseptica, which they collected over a 3-year period, by pulsed-field gel electrophoresis. They demonstrated that most of the isolates were epidemiologically unrelated . In the pres- ent study, however, we had a neonates clinic in our hospital, all of our patients were older pediatric and adult individuals. Unfortunately, we could not have any molecular analysis of the isolates, to detect if any relationship existed between them, as it is one major limitation of our study.
Previous studies revealed a cumulative mortality rate of 52% in neonates and 33% in non-neonates with E. meningoseptica infections . In the largest series of 118 patients with E. meningoseptica bacteremia at a medical center in Taiwan, the 14-day mortality rate was 23% . The acquisition of the infec- tion in an ICU was a significant predictor of mortality. These results all support previous findings by Lin et al. that host fac- tors were the critical determinant in predicting outcomes . Aldoghaim et al. reported that although most of the patients did not receive appropriate antibiotic treatment, the mortality rate in their study was low (16.5%), which was much lower than that reported in past studies [1,5,10]. In our study, the mortal- ity rate was 29.4% and they were all from ICU. Only one of them was pediatric aged and died within 12 days after isola- tion of E.meningoseptica from endotracheal aspiration material because of septicemia. All of our adult patients have died; three of them had renal failure (all underwent hemodialysis), and one had cardiac arrest because of cerebrovascular disease. In ad- dition, only one of the adult deaths in this study was related to E.meningoseptica septicemia (which underwent hemodialy- sis); while the other cultures were negative for E.meningoseptica when they died.
The choice of optimal antibiotic agents for the treatment of E. meningoseptica infection is difficult because of the unpredict- ability and breadth of antimicrobial resistance of this organ- ism, which is often resistant to antibiotics prescribed for the treatment of serious gram-negative bacteria, such as β-lactam agents, aminoglycosides and carbapenems . Lin et al. re- ported that 54.5% of patients infected with E. meningoseptica bacteremia recovered without receiving appropriate antibiotic treatment . Aldoghaim et al. reported that in their study, among those receiving an inappropriate antibiotic for E. meningoseptica bacteremia, five of six patients recovered . This may be attributable to the low virulence of E. meningoseptica. However, further studies are required to understand the virulence mechanisms of E. meningoseptica.
Chan et al. detected piperacillin/tazobactam as the most effec- tive antibiotic (100% susceptibility) against E. meningoseptica, followed by, trimethoprim/sulfamethoxazole (78.6% susceptibil- ity) and fluoroquinolones (87.5% susceptibility for levofloxacin and moxifloxacin and 33.3% susceptibility for ciprofloxacin) . In a study, they treated all patients with injectible minocycline and co-trimoxazole (Narayan MD, Kumar AL, Kaushik M. Emer- gence of Elizabethkingia meningoseptica nosocomial infections and role of introvenous minocycline therapy. ECCMID Abstract Book. Copenhagen 2016; EVO166). Although some anecdotal reports have revealed the successful treatment of E. meningo- septica meningitis using a combination therapy of vancomycin with other antibiotics [12,13], the use of vancomycin is not sug- gested because of its high minimum inhibitory concentration [14,15,16].
With regard to antimicrobial susceptibility, we observed that E. meningoseptica strains showed resistance to carbapenems, aminoglycosides and β-lactam antibiotics, and sensitivity to cephoperazone/sulbactam, fluoroquinolones and trimethoprim/ sulfamethoxazole. In contrast to previous studies [4,5,16,17], our isolates showed a lower susceptibility (18.1%) against piperacillin/tazobactam. This resistance pattern may be related to prolonged courses of antibiotics in these patients, which might lead to selective pressure for resistance in this organism. The present study has several limitations. It was a retrospective study, and missing data may have obscured potential risk fac- tors that were not documented in medical records. Our sample size was small. However, a prospective study involving a sig- nificant number of patients will require many years of research. In addition, the factors of the pathogenicity, antimicrobial sus- ceptibility and virulence of E. meningoseptica remain unclear. A well-designed prospective study may be required to address these limitations in the future.
In summary, this microorganism, which is resistant to antibiot- ics frequently used in the treatment of gram-negative infec- tions, should be kept in mind for patients at risk group who do not respond to treatment. Once microbiologist suspected this infection, the clinician should immediately be informed so that appropriate antibiotic changes may be done early.
Scientific Responsibility Statement
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical stan- dards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be consid- ered potential conflict of interest regarding the manuscript or its submission.
1. Aldoghaim FS, Kaabia N, Alyami AM, Alqasim MA, Ahmed MA, Al Aidaroos A, et al. Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteraemia: a series of 12 cases at Prince Sultan Military Medical City KSA. New Microbes New Infect. 2019;32:100617
2. Govindaswamy A, Bajpai V, Trikha V, Mittal S, Malhotra R, Mathur P. Multidrug resistant Elizabethkingia meningoseptica bacteremia-Experience from a level 1 trauma centre in India. Intractable Rare Dis Res. 2018;7(3):172-6
3. Chan JC, Chong CY, Thoon KC, Tee NWS, Maiwald M, Lam JCM, et al. Inva- sive paediatric Elizabethkingia meningoseptica infections are best treated with a combination of piperacillin/tazobactam and trimethoprim/sulfamethoxazole or fluoroquinolone. J Med Microbiol. 2019;68(8):1167-72
4. Ratnamani M S, Ratna Rao R. Elizabethkingia meningoseptica: Emerging nosocomial pathogen in bedside hemodialysis patients. Indian J Crit Care Med. 2013;17(5):304-7.
5. Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical centre in Taiwan, 1999-2006. Eur J Clin Microbiol Infect Dis. 2011;30(10):1271-8.
6. Weawer KN, Jones RC, Albright R,Thomas Y, Zambrano CH, Costello M, et al. Acute emergence of Elizabethkingia meningoseptica infection among mechani- cally ventilated patients in a long-term acute care facility. Infect Control Hosp Epidemiol. 2010;31(1):54-8.
7. Tekeroğlu MS, Durmaz R, Ayan M, Çizmeci Z, Akıncı A. Analysis of an outbreak due to Chryseobacterium meningosepticum in a neonatal intensive care unit. New Microbiol. 2003;26(1):57-63.
8. Ceyhan M, Yıldırım I, Tekeli A, Yurdakök M, Us E, Altun B, et al. A Chryseobac- terium meningosepticum outbreak observed in 3 clusters involving both neonatal and non-neonatal pediatric patients. Am J Infect Control. 2008;36(6):453-7
9. Lin YT, Chiu CH, Chan YJ, Lin ML, Yu KW, Wang FD. Clinical and microbiologi- cal analysis of Elizabethkingia meningoseptica bacteremia in adult patients in Taiwan. Scand J Infect Dis. 2009:41(9):628-34.
10. Bloch KC, Nadarajah R, Jacobs R Chryseobacterium meningoseptiucm: an emerging pathogen among immunocompromised adults report of 6 cases and literature review. Medicine. 1997;76:30–41
11. Lin PY, Chu C, Su LH, Huang CT, Chang WY, Chiu CH. Clinical and microbiologi- cal analysis of bloodstream infections caused by Chryseobacterium meningosep- ticum in nonneonatal patients. J Clin Microbiol. 2004;42(7):3353–55.
12. Tai IC, Liu TP, Chen YJ, Lien RI, Lee CY, Huang YC. Outbreak of Elizabethkingia meningoseptica sepsis with meningitis in a well-baby nursery. J Hosp Infect. 2017;96(2):168-71
13. Di Pentima MC, Mason EO, Kaplan SL. In vitro antibiotic synergy against Fla- vobacterium meningosepticum: implications for therapeutic options. Clin Infect Dis. 1998;26(5):1169-76
14. Lin JN, Lai CH, Yang CH, Huang YH. Comparison of clinical manifestations, antimicrobial susceptibility patterns, and mutations of fluoroquinolone target genes between Elizabethkingia meningoseptica and Elizabethkingia anophelis isolated in Taiwan. J Clin Med. 2018;7(12):538.
15. Han MS, Kim H, Lee Y, Kim M, Ku NS, Choi JY, et al. Relative prevalence and antimicrobial susceptibility of clinical isolates of Elizabethkingia species based on 16S rRNA gene sequencing. J Clin. Microbiol. 2016;55(1):274–80
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Nilüfer Saygılı, Güliz Doğan. A rare agent; Growth of Elizabethkingia Meningoseptica, 11 years of evaluation. Ann Clin Anal Med 2021;12(8):855-859
Epidemiology of Tuberculosis with comparison of the efficacy of culture, real-time PCR and direct microscopy in the diagnosis of tuberculosis
Department of Microbiology, Recep Tayyip Erdoğan University, Medical Faculty Hospital, Rize, Turkey
DOI: 10.4328/ACAM.20474 Received: 2021-01-08 Accepted: 2021-02-08 Published Online: 2021-02-17 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):860-864
Corresponding Author: Ilkay Bahceci, Department of Microbiology, Recep Tayyip Erdogan University, Zihni Derin Campus, Fener Street, 53100 Center, Rize, Turkey. E-mail: email@example.com P: +90 464 223 61 26 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3662-1629
Aim: Despite the developments every passing year, tuberculosis is still a major public health problem in Turkey and in the world. Early and correct diagnosis is important for the control of the disease. The aim of this study is to investigate the diagnostic efficiency of the culture (Löwenstein Jensen), real-time PCR (Abbott m2000rt, Bosphore MTBC Detection Kit) and direct microscopic examination of acid-resistant bacillus stained with Ehrlich-Ziehl-Neelsen (EZN), and the study was performed by evaluating the samples coming to our laboratory retrospectively over a 4-year period.
Material and Methods: The samples sent to our mycobacteriology laboratory between January 2016 and December 2019 were evaluated retrospectively. The effects of direct microscopy and real-time PCR method were compared based on culture as a reference method.
Results: Sensitivity, specificity, positive predictive value and negative predictive value of direct microscopy were calculated as 45%, 99.9%, 96.4%, 96.9%, respectively, in pulmonary samples and as 21.7%, 100%, 98.8%, 98.8%, respectively, in extrapulmonary samples. Sensitivity, specificity, positive predictive value and negative predictive value of real-time PCR were calculated as 80%, 98.3%, 98.8%, 97.3%, respectively, in pulmonary samples and as 62.5%, 99.2%, 50%, 99.5%, respectively, in extrapulmonary samples.
Discussion: Although direct microscopic examination method is a cheap, simple, fast and highly specific test, its sensitivity is low. Therefore, patients with suspected tuberculosis should be evaluated together with culture, besides direct microscopy. It was observed that the sensitivity of direct microscopy was lower in extrapulmonary samples compared to pulmonary samples. The real-time PCR method has high sensitivity and specificity, and also gives fast results.
Keywords: Ehrlich-Ziehl-Neelsen; Epidemiology; Löwenstein Jensen; Real-Time PCR; Tuberculosis
It is estimated that 1.7 billion people in the world are infected with tuberculosis, and it is expected that tuberculosis disease developed in a certain period of their lives in 5-10% of the infected population . Approximately 10 million people worldwide suffer from tuberculosis each year, and 1.45 million people died from tuberculosis worldwide in 2018 (available at: www.who.int). Most of the deaths occurred in patients who are coinfected with HIV and have multiple drug resistance . Although the incidence of tuberculosis and deaths from tuberculosis have been declining each year, health problems that occur due to tuberculosis still remain serious in endemic regions (available at: www.who.int). According to the statistics of the tuberculosis department, the incidence of tuberculosis decreases each year in our country, and the incidence in 2018 is 14.1 (in 100.000), the number of cases is11,786 people (available at: www.toraks.org.tr).
Although tuberculosis can occur with many different clinical pictures, it is basically divided into pulmonary and extrapulmonary tuberculosis according to the involvement region of the disease, and the vast majority of cases is pulmonary tuberculosis . It is important to detect the disease early and correctly in order to isolate patients and not to delay the treatment. Early diagnosis and appropriate treatment approach reduce tuberculosis transmission . Bacteriological confirmation, including the detection of acid-resistant bacilli on microscopic examination and the growth of tuberculosis bacillus in culture, is important in people with suspected tuberculosis due to the low specificity of clinical and radiological findings (available at www.hsgm. saglik.gov.tr).
Although many methods can be applied in the diagnosis of tuberculosis, tuberculosis culture is the gold standard method . It is sufficient that the sample contains 10-100/ml bacillus to produce tuberculosis bacillus in culture . Although direct microscopy is simple, cheap, fast and highly specific, it is a diagnostic tool with low sensitivity . The type and quality of the sample, the experience of the assessor, the bacillus load in the sample, the differences inthe procedures applied to the sample directly affect the sensitivity of the microscopy . In order for the bacillus to be visible in the microscopic examination, the sample must contain 5,000-10,000 / ml tuberculosis bacillus . There are different staining methods during sample preparation for direct microscopic examination, but EZN staining is the most commonly used method . Fluorescent staining methods have higher sensitivity rates compared to the EZN method and are preferred in centers that especially have high numbers of samples due to the shortening of the evaluation time [2,8]. Due to the low sensitivity of microscopic examination and the late outcome of culture methods, many molecular methods have been developed for use in the diagnosis of tuberculosis . These molecular methods are mainly based on nucleic acid amplification and include various procedures such as polymerase chain reaction (PCR), strand displacement amplification (SDA), transcription-mediated amplification (TMA), Ligase chain reaction (LCR) . PCR technology has started to be used in the diagnosis of tuberculosis firstly with conventional PCR methods, and then with real-time PCR, which was developed later [10, 11]. The real-time PCR method is faster
than conventional PCR methods and has a higher repeatability . In the diagnosis of tuberculosis, although real-time PCR has advantages such as fast result time, high sensitivity and specificity, it also includes disadvantages such as the needi for trained personnel and high cost . In this study, it was aimed to compare the diagnostic efficiency of diagnostic methods by evaluating direct examination, tuberculosis culture and real- time PCR results of the patients whose samples were sent to our laboratory with the pre-diagnosis of tuberculosis between 2016-2019.
Material and Methods
Arb direct examination, tuberculosis culture and real-time PCR results of the patients whose samples were sent to our mycobacteriology laboratory with the pre-diagnosis of tuberculosis between 2016-2019 at the Recep Tayyip Erdoğan University Faculty of Medicine Education and Research Hospital were examined retrospectively. The number of pulmonary samples was 2282 (%58.8) (sputum, bronchoalveolar lavage, tracheal aspirate), and 1595 (41.1%) samples were extrapulmonary (abscess, tissue, urine, empty, pleural fluid, paracentesis, joint fluid and others).
In the first stage, homogenization and decontamination were applied to the samples from contaminated areas such as sputum, bronchoalveolar lavage, tracheal aspirate, wound, tissue, abscess. Urine samples were centrifuged at 3000 rpm for 20 minutes and then subjected to homogenization and decontamination processes. N-Acetyl L-Cysteine was used in the homogenization process and NaOH was used in the decontamination process. Through homogenization and decontamination processes, it is aimed to make the dense samples homogeneous and to make the tuberculosis bacillus visible by removing the microorganisms from the flora. Samples to which homogenization and decontamination processes were applied, were neutralized with phosphate buffer. Cerebrospinal fluid, joint fluid, pleural fluid and paracentesis fluid samples were not subjected to decontamination processes. All samples were finally centrifuged and concentrated and made ready for processing.
Arb direct examination, tuberculosis culture, and real-time PCR were applied to samples prepared among consideration of the clinical request.
Direct Microscopic Examination:
The presence of acid-resistant bacilli was investigated using preparations, which were stained with the Erlich Ziehl-Neelsen (EZN) staining method for direct microscopic examination. Acid- resistant bacilli samples were scored according to the standards of the American Thoracic Society and reported as “Acid resistant bacillus .
Löwenstein Jensen medium, a solid, egg-based medium, was used for tuberculosis culture. Samples planted on Löwenstein Jensen medium were incubated for up to 8 weeks and were checked for reproductive follow-up, 2 times in the first week, and then at least once a week until the 8th weeks. The presence of acid-resistant bacillus was scanned on positive growth obtained medium stained with the Erlich Ziehl-Neelsen (EZN) staining method and samples, showing acid-resistant bacillus were resulted as “reproduction has occurred in Löwenstein Jensen medium.” The medium, on which no reproduction was obtained at the end of the 8-week incubation period was lastly stained with the Erlich Ziehl-Neelsen (EZN) staining method, and after that, if no acid-resistant bacillus was detected on samples, result was as follows: reproduction did not occur in the Löwenstein Jensen medium (available at: www.hsgm.saglik. gov.tr).
Samples sent between the years 2016-2017 were evaluated with Abbott m2000rt (Abbott Molecular, USA), while samples sent between the years 2018-2019 were with Bosphore MTBC Detection Kit (Geneworks Anatolia, Turkey). The working procedure has been carried out according to the manufacturer’s instructions.
Abbott m2000rt (Abbott Molecular, USA): The procedure was started with a sample inactivation step to reduce the risk of infection regarding clinical samples. The mixture formed using 1.5 ml of inactivation reagent (0.4 M NaOH, 60% Isopropanol, 0.18% Tween-20) according to the 0.5 ml of the sample, was incubated for 1 hour at room temperature. Thereafter, automated DNA isolation was performed with the Abbott m2000sp device (Abbott Molecular, USA) using the mSample Preparation DNA kit (Abbott Molecular, USA). 25 μL of amplification master mix were mixtured with the taken 25 μL of the eluted sample. The PCR reaction was performed by transferring the prepared mixture to the Abbott m2000rt (Abbott Molecular, USA) device. One positive and one negative control were used for each sample.
Bosphore MTBC Detection Kit (Anatolia Geneworks, Türkiye): After the samples, for which the real-time PCR test was requested were ready for process, then 750 ml was received from samples for DNA extraction in the first stage, and DNA isolation process was completed using the ‘Magnesia 16 Nucleic Acid Isolation Kit’ (Anatolia Geneworks, Turkey). 18μL of DNA from the DNA isolation samples was taken into the tubes, adding 22.8 μL of the PCR master mix and 0.2 μL of the internal control. During the PCR reaction, the first denaturation of DNA occurred at 95 °C for 14.5 minutes. This was followed by a denaturation at 97 ° C for 0.5 minutes and a total of 50 cycles, including binding and synthesis at 53 °C for 2 minutes in. After the 50th cycle, an incubation period was performed at 22 °C for 5 minutes. After the thermal cycle, amplification curves were evaluated. Patients’ results with similar logarithmic curves with the clinical sample in the internal control were evaluated as positive, and those without logarithmic curve as negative.
Ethics committee approval for this study was obtained from the Recep Tayyip Erdoğan University Non-Interventional Ethics Committee (Approval no:2020/208). The study was conducted in line with the ethical principles of the Declaration of Helsinki
A total of 3877 patients were included in the study, 2653 (68.4%) of them were male and 1224 (31.6%) were female. When the distribution of samples was analyzed, it was observed that the largest group was the Chest Diseases service, with
2325 (60%) patients; 889 of these patients belonged to the year 2016, 834 to 2017, 991 to 2018 and 1163 belonged to 2019. The average age of the patients was determined as 64. The average age of male patients was 63.5, and the average age of female patients was 65.2.
Direct Microscopic Inspection Findings:
Direct microscopy was requested from 3834 of the patients; 2281 of the samples were grouped as pulmonary, and 1553 as extrapulmonary. Direct microscopic examination findings are summarized in Table 1.
In pulmonary samples, the sensitivity, specificity, positive predictive value and negative predictive values were calculated as 45%, 99.9%, 96.4% and 96.9%, respectively. In extrapulmonary samples, the sensitivity, specificity, positive predictive value and negative predictive values were calculated as 21.7%, 100%, 98.8%, 98.8%, respectively (Table 3).
Culture Methods Findings:
Tuberculosis culture results were positive in 146 (3.8%) samples and negatively in the 3731 (96.2%) samples
Real-Time PCR Findings:
Real-time PCR was requested from 1387 patients. These samples were grouped as 709 pulmonary and 678 as extrapulmonary. Real-time PCR findings are summarized in Table 2.
In pulmonary samples, the sensitivity, specificity, positive predictive value and negative predictive values were calculated as 80%, 98.3%, 98.8%, 97.3%, respectively. In extrapulmonary samples, the sensitivity, specificity, positive predictive value and negative predictive values were calculated as 62.5%, 99.2%, 50%, 99.5%, respectively (Table 3).
Tuberculosis disease remains valid as a major public health problem in Turkey and in the world, despite all the developments. Early and accurate diagnosis is important for disease control. Different methods are being developed to define the tuberculosis bacillus every passing year. The sensitivity and specificity of these diagnostic methods vary among each other. Direct microscopy is one of the most commonly used methods to evaluate the presence of arb. The main disadvantage of direct microscopic examination is its low sensitivity rate. The sensitivity and specificity of direct microscopic examination were calculated as 82.3% and 99.7%, retrospectively in the study performed with pulmonary samples in Brazil . In another study that performed in 2016 in Turkey, 62 456 samples were examined and the sensitivity, specificity, positive predictive value, and negative predictive values of the direct microscopy method reported as 32.8%, 99.4%, 87.5%, 91.4 %, respectively . The effectiveness of direct microscopic examination varies among pulmonary and extrapulmonary samples. In the study conducted in our country by Karadag et al., the sensitivity, specificity, positive predictive value and negative predictive values were calculated as 71.4%, 98.8%, 83.3%, 97.6%, respectively, in pulmonary samples and as 24%, 98.3%, 42.8%, 96.2%, respectively, in extrapulmonary samples . The sensitivity, specificity, positive predictive value and negative predictive values of the direct microscopic examination method were calculated as 60%, 100%, 100%, 96.5%, respectively in pulmonary samples and as 32.3%, 99.5%, 76.9%, 96.9%, respectively in extrapulmonary samples . The gold standard method in the diagnosis of tuberculosis is tuberculosis culture. The main disadvantage of the method is that it gives results in 6-8 weeks. In recent years, liquid-based culture methods have been developed that yield earlier results. Liquid-based culture systems produce results in a shorter time than solid media, but they are more costly . Both the sensitivity and specificity of the culture are higher than microscopic examinations . Molecular tests have been started to be used in the diagnosis of tuberculosis over time. Molecular methods contain systems including different methods. Recently, nucleic acid amplification tests have become widely used. Although many nucleic acid amplification tests are available, the most widely used test is real-time PCR. Real-time PCR has a high sensitivity and specificity compared to direct microscopic examination . The sensitivity, specificity, positive predictive and negative predictive values of real-time PCR were calculated as 82.3%, 97.6%, 93.3%, 93%, respectively, in the study performed by Bajrami et al .
The effectiveness of real-time PCR varies between pulmonary and extrapulmonary samples. There are studies that report the sensitivity of the real-time PCR as 59%, 66.9% and 68% when performing research on pulmonary samples [12, 16, 17].
PCR sensitivities were calculated as 61.1% and 65.6% in a study comparing two different PCR systems in extrapulmonary samples . In meta-analyzes, it was published that the sensitivity of real-time PCR method was 82%, 80.8% in pulmonary samples and was 70%, 58.6% in extrapulmonary samples [10, 11].
Conventional PCR methods were compared with real-time PCR methods in the study performed by Tortoli et al. In this study sensitivity of conventional PCR was reported as 81% in pulmonary samples, and as 60.3% in extrapulmonary samples and also the sensitivity of real-time PCR reported as 81.1% in pulmonary samples and as 64.2% in extrapulmonary samples .
Our study had limitations such as not performing direct microscopic examination, culture and real-time PCR for all samples and not performing advanced identification for all cultures, which showed growth. When advanced identification is not performed, mycobacterium growths other than tuberculosis are considered false positive, and the patient can be treated incorrectly.
Although the direct microscopic examination method is cheap, simple, rapid and highly specific test, its sensitivity is low. Direct microscopic examination has a wide sensitivity range in the studies we examined. For this reason, patients with suspected tuberculosis should be evaluated with culture besides direct microscopy. It was observed the sensitivity of the direct microscopic examination was lower in extrapulmonary samples compared to pulmonary samples. Besides providing rapid results, the real-time PCR method has high sensitivity and specificity as well.
In the studies we examined, it was shown that the sensitivity of PCR is high compared to direct microscopic examination. It was observed that the sensitivity of PCR was lower in extrapulmonary samples compared to pulmonary samples. Culture methods remain valid as reference methods, but advanced identification should be performed on samples, which have grown positively Some patients were treated with antibiotics unnecessarily because they were misdiagnosed due to late results of the culture methods, and some tuberculosis patients could cause disease spread because of not being diagnosed during this period.
In the light of all this information, real-time PCR is evaluated as a suitable method for use due to its high sensitivity among early diagnosis methods, although it has a high cost.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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8. Akduman Alaşehir E, Balıkçı A, Partal M, Çatmabacak G, Yaman G. Evaluation of mycobacterial microscopy and culture results of Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital: A 3-year analysis. Tuberk Toraks. 2016;64(3):211-16. DOI:10.5578/tt.28058.
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13. Lewinsohn DM, Leonard MK, Lobue PA, Cohn DL, Daley CL, Desmond E, et al. Official American Thoracic Society/Infectious Diseases Society of America/ Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017;64(2): e1- e33. DOI:10.1093/cid/ciw694
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Ilkay Bahceci. Epidemiology of Tuberculosis with comparison of the efficacy of culture, real-time PCR and direct microscopy in the diagnosis of tuberculosis. Ann Clin Anal Med 2021;12(8):860-864
Dermatological complications and quality of life: A cross-sectional study in Saudi female population
Amal Sulaiman Alanazi, Shruti Shiromwar
Department of Pharmacology and Toxicology, Faculty of Pharmacy, Northern Border University, Kingdom of Saudi Arabia
DOI: 10.4328/ACAM.20477 Received: 2021-01-09 Accepted: 2021-02-23 Published Online: 2021-03-07 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):865-870
Corresponding Author: Shruti Shiromwar, Department of Pharmacology and Toxicology, Faculty of Pharmacy, Northern Border University, Rafha 91911, Northern Province, Kingdom of Saudi Arabia. E-mail: firstname.lastname@example.org P: +966-509575638 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8880-784X
Aim: The present study aims to understand the pattern of skin diseases and their impact on female patient quality of life, as well as the Dermatological Life Quality Index (DLQI) across the Kingdom of Saudi Arabia.
Material and Methods: A pre-validated cross-sectional questionnaire-based survey (English and Arabic language) was adopted all over Saudi Arabia. The study contains 32 questions, which were divided into three parts as patient demography, characteristics of skin problems, and DLQI questions. Data was collected by online and offline tools and analyzed by MS-excel.
Results: Among the 410 participants, the major skin problem was acne vagaries (36.8%), followed by dry skin (24.4%), eczema (12.7%), and pigmentation (11%). Most of the patients (42.4%) first consulted the pharmacist and only 5.9% to the nurses. Over 83.2% have represented the localized lesions, especially on the neck and face (44.4%). Psoriasis and vitiligo have shown low-frequency but high DLQI scores (27.4 and 24.1, respectively) in contrast to high-frequency dry skin and acne (13.3 and 16.2, respectively). A total of 296 patients between 21-30 years of age showed a very large effect on patient life (score- 11 to 20).
Discussion: Dermatological complications have a significant negative impact on patient quality of life. Patients with psoriasis and vitiligo suffer more than any other skin problems due to the untreatable nature of the diseases and a sense of embarrassment. To address this issue, a psychotherapist should be considered as an integral part of the treatment to counsel and boost patient self-confidence and morale.
Keywords: Dermatological complications; Female; Saudi Arabia; Quality of life, DLQI
The skin is the largest organ and primary observable external features of the body that determines the person’s social appearance and beauty. Psychodermatology deals with the correlation between in-between psychiatry and skin problems . Both, acute and chronic dermatological complications (DC) are associated with a range of psychological problems. Patients with DC are more prone to develop psychological problems and endangered quality of life as compared to normal healthy people .
As per the report published by the WHO, the prevalence of DC is higher in developing countries, ranging from 21 to 87% in the general public, requiring immediate attention to address the issue (WHO 2005: Epidemiology and management of common skin diseases in children in developing countries). A survey conducted by the British Association of Dermatologists urges an immediate need for psycho-dermatology services to deal with the patient with psychological effects due to skin problems . To date, a few surveys were carried out to study the impact of DC on psychological illness, and its negative effect on the patient’s quality of life.
The outcome of the past survey indicated a few common findings i.e., higher prevalence of depression, anxiety, and suicidal tendencies in patients with DC compared to control groups . Skin complications like eczema, acne, psoriasis, and chronic urticaria hurt the patient’s quality of life and self- confidence . DC not only affects the patient’s psychology but also has a significant impact on their daily routine. A study conducted by Graham-Brown in 1996 has found that patients with chronic skin disease face financial loss due to a greater number of leaves from the workplace, large expenses spent on medicines, clothing, laundry, consultations, and finding an alternative treatment option . A few other cross-sectional multicentered studies have reported patients with chronic dermatological problems who are concerned about their public look and appearance, inability to develop personal relations, and impaired sexual function due to physical and psychological effects [7, 8].
The prevalence of skin disease depends upon many factors, including race, inheritances, and dietary status, weather, hygiene, cosmetic use, etc. As per the study conducted by W Chen in 2010 on gender differences and DC, “males are generally more commonly afflicted with infectious diseases, while women are more susceptible to psychosomatic problems, pigmentary disorders, certain hair diseases, and particularly autoimmune, as well as allergic diseases” .
So far, no studies were conducted to understand the impact of dermatological problems, especially in the female gender. The present study aims to correlate the impact of DC in the female patient’s psychological aspects and quality of life in the Kingdom of Saudi Arabia.
The present study was designed to add information to what is known about the epidemiology and prevalence of skin diseases in the population by means of the validated questionnaire. In addition to that, this study aims to describe the incidences and pattern of skin diseases in Saudi females along with their Dermatological life quality index (DLQI), published in 1994 to assess the impact on the quality of life of patients.
Material and Methods
The cross-sectional questionnaire-based study was conducted in the female population in-between the period October-2019 to February-2020 (5 months) in the out-patient department when visiting the dermatologist at private and government hospitals all over Saudi Arabia. The sample size was 410 female participants aged 15 years and more.
Online and off-line questionnaires (English and Arabic language) were used with a total of 32 questions. Questions were divided into three parts: 1. Demographic characteristics (8 questions), 2. Characteristics of skin problems (14 questions), 3. Dermatology Life Quality Index (DLQI) (10 questions).
The questionnaires contain a wide variety of information concerning socio-demographic data (city, age, gender), identification and causes of dermatologic issues, and the next part of the questionnaire was to evaluate patient’s quality of life, adopted from the Dermatology Life Quality Index questionnaire .
Before finalizing, questionnaires were validated in 20 patients randomly. Based upon the response of the patients, a few modifications were done to make it available to the rest of the patients. Google forms (on-line) and paper prints (off-line) were used as tools for data collection. All the data were tabulated and graphs were drawn in an MS-excel spreadsheet.
Various parameters were studied during the study to satisfy the mentioned objectives. In the first section of the study, patient demography was taken into consideration including gender, religion, nationality, marital status, occupation, education, age, place/city.
In the second part of the study, the characteristics of skin problems were analyzed, including the type of skin problem/ infection, reported cause/reason, the duration/ how long time the participant faced such a problem, frequency of recurrence, family history of the same lesion, the spread of skin lesion, patients’ hygiene level, the presence of any comorbidity, where the participant tried to get help, the affected area/part of the body, suggested precautions and provided drug treatment, type of treatment (allopathic/homeopathic/Ayurvedic/other), formulation/s and category of the medication used.
The third phase of the questionnaires covers the information, which helped us decide the patient’s DLQI that includes over the last week (how itchy, sore, painful, or stinging has their skin was? how embarrassed or self-conscious the patient was due to skin condition? how much has the patient’s skin interfered with going shopping or looking after their home or garden? how much the patient’s skin influenced the selection? how much has participants’ skin affected social or leisure activities? how much has the patients’ skin made it difficult to do any sports activities? has the patients’ skin prevented her from working or studying? how much has patients’ skin created problems with their partner or any of their close friends or relatives? how much has patients’ skin caused any sexual difficulties? During the skin treatment, how much has patient suffered like by leaving their home messy or taking up time to arrange it in order?
The answer to the above questions was scored based upon the severity like very much (scored 3); a lot (scored 2); a little
(scored 1); not at all (scored 0). A maximum score of 30 was calculated for each participant. A higher score represents more adverse effects on the patient’s quality of life. The final score of the patient’s quality of life was divided into 5 segments: No effect at all (0-1), small effect (2-5), moderate effect (6-10), very large effect (11-20), and extremely large effect (21-30).
Demographic characteristics of the participants:
A total of 410 female patients of different age groups participated in the study from all over Saudi Arabia. The maximum number of patients was in-between age group of 15-20 years (156 patients), while only 9 participants were above the age of 50 years. Among 410 participants, 192 were married, while 208 were unmarried, and the rest were divorced. Concerning the educational level, 201 participants have completed their tertiary education, while 11 participants did not response (Figure 1 A).
Number of patients with dermatological problems:
Among 410 (100%) participants, 151 (36.8%) had acne, which is the highest reported problem. Whereas 100 (24.4%), 52 (12.7%), and 45 (11%) participants had dry skin, eczema, and pigmentation as main dermatological problems, respectively. Only 11 (2.7%) participants reported vitiligo and 17 (4.1%) had itching problems, while 15 patients complained of psoriasis (3.7%). Six patients showed more than one DC. (Fig 1 B)
Features of DCs:
Among 410 participants, 83.2% and 16.8% of them suffered from localized and generalized lesions, respectively. Among all the participants, the affected area was the allover body (7.8%), face/neck (44.4%), arms (28.8%), back (5.6%), and legs/feet (13.4%).
Concerning the hygiene level, 82.9% of patients showed a high hygiene level, whereas only 0.2% of patients showed a very little hygiene level. Out of 410 participants, 88% showed no comorbidity and 12% represented comorbidity. For patients suffering from dermatological complications, 42.4% consulted directly to the pharmacists, while only 5.9% consulted to the nurses and 14.9 % of patients relied on traditional remedies (Figure 1 C).
Reasons and characteristics of DCs:
Among participants with dermatological complications, 172 (42%) mentioned that it was due to weather conditions, whereas 12 (3%) stated it was because of drug reactions. Nearly, 176 (43%) and 110 (27%) patients stated that they were suffering for more than 2 years and less than 6 weeks, respectively. Concerning family history, 103 (25%) patients mentioned that family history was the cause of their problem (Figure 2 A). Stated cause of dermatological problems:
Among the patients who were suffering from dry skin (100), 63 patients reported weather as the main reason, and only 3 patients responded as a genetic cause. Among the total
number of acne patients (151), 73 patients responded that it was because of cosmetic use, and 13 patients stated that it was because of contamination/pollution. Among the eczema patients (52), 25 patients mentioned it was because of genetic origin, whereas 4 patients responded as it was due to cosmetic reactions. Patients suffering from pigmentation (45) blamed weather conditions and cosmetic use as the main reason for their complications (Figure 2 B).
Suggested precautions and medications:
The health practitioners suggested the drug treatment for 176 (43%) of the patients and only 45 (11%) were suggested to change the food habits. Health practitioners suggested to 254 (62%) of the patients for the topical application in-contract only 12 (3%) patients were suggested for the injectable formulation for the management of the skin problems. Antimicrobials and antihistamines were prescribed to 230 (56%) and 12 (3%) of the patients, respectively (Figure 2 C).
Average Dermatological Life Quality Index Score:
Incidents of acne, dry skin, pigmentation exhibited a very large effect (score 11-20), whereas low-frequency vitiligo, psoriasis, and eczema exhibit extremely large effects (score 21-30) on average DLQI score. Among all the DC, psoriasis exhibited the highest effect (score 27.4), whereas warts had the lowest (score 7), which is considered a moderate effect on average DLQI (Figure 3 A).
Distribution of the study population by age and life quality measures:
Among the various age groups (296 patients, 72.2%), the age group between 21-30 years showed a very large effect on patient life (score- 11 to 20), followed by 31-40 years and 41 – 50 years. A significant number (77 patients, 18.8%) of patients showed an extremely large effect on their life (score- 21 to 30). A total of 30 patients (7.3%) showed moderate effect on their life, especially the age group between 21-30 years (Figure 3 B).
The present cross-sectional survey has indicated a significant impact of DC on patient psychology and quality of life. The main objective of this survey was not only to study the pattern of DC in the female population, but also to study how these multiple symptoms compromised patient quality of life, as measured by the DLQI score.
Based upon patients’ demography, unmarried participants, aged between 15-20 years, and those who completed their tertiary school education presented more complaints.
Acne vagaries and dryness of the skin were most frequently observed in 38.8 and 24.4% of the participants, respectively. Our findings are consistent with the earlier study carried out by Bassam et al, 2018. . Skin dryness was correlated with weather conditions. In many parts of Saudi Arabia, including the northern region and the north-west coast, seasonal variations are extreme from 0o C to 54oC . During the dry-cold weather, water from the skin evaporates more quickly that makes skin dry and flaky, causing itching and redness.
Acne vagaries are mostly related to hormonal changes in adolescents . The presence of skin bumps, pustules, white and blackheads, and redness around the erupted skin makes patients a sense of embarrassment, shame, and left isolated. The average DLQI score for dry skin and acne was 13.3 and 16.2, which is comparatively lower than vitiligo and eczema. Among all stated skin problems, psoriasis (27.4) showed the highest DLQI, followed by vitiligo (24.1) and eczema (21.1). The highest score of psoriasis may be due to the presence of red patches on the skin, which is covered with silvery scale, dry cracked bleed skin, stiff joints, pain, and incurable nature of the disease causes discomfort to the patient, leads to psychological stress, which excruciates the symptoms like depression, anxiety, aggression, and suicidal tendency . Our study also found a relationship between age and quality of life measures. The female patients’ age in-between 21 to 30 years have shown a very large effect on the quality of life (11-20 scores). In adults, dermatological problems deeply affect their self-esteem due to neurohormonal changes and the problem facing in their daily routine while attending college, office, family, and friends.
In our study, we also analyzed the patient’s first visit to a medical or paramedical staff. Most of the patients consulted a pharmacist and family doctors instead of a dermatologist. This approach of the patients may be due to casual contact to pharmacists without any prior appointments in contract to specialists in the field needs appointment and consultation fees etc.
Most of the participants have shown the high-hygiene levels indicate other factors like weather, age, genetic, food contamination, and cosmetics play a significant role in dermatological problems. In our study, a reasonable number of participants blamed inheritance and weather conditions for their skin problems. Though inheritance plays important role in vitiligo, psoriasis, and eczema, not all skin diseases are considered in our study . More than half of the participants were suggested to use topical antimicrobial agents, and nearly half of the participants were suggested to go for drug treatment options, indicating that topical antimicrobial drugs play a vital role in the management of skin diseases.
Our current study findings indicate that the patients with DC, especially psoriasis, vitiligo, and eczema, have psychosocial comorbidities that negatively impact their social life, as clearly demonstrated by high average DLQI scores.
To address the above issue, a dermatologist may play a vital role by helping patients to overcome such problems and improve the patient’s quality of life through appropriate discussion and interaction with the patient. For a few untreatable and/or recurring conditions like psoriasis, vitiligo, acne, dermatologists should council how to live with the conditions with minimum symptoms (assuming that perhaps some symptoms will remain). Moreover, based on outcomes of this study, we also recommend considering psychotherapists as an integral part of the treatment to boost patient confidence and self-esteem.
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Conflict of interest
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The importance of procalcitonin in the diagnosis and prognosis of patients with dyspnea in the emergency department
Arife Erdoğan 1, Ejder Saylav Bora 2, Çağrı Kokkoz 3, Mümin Alper Erdoğan 4, Ferhan Elmalı 5
1 Department of Emergency Medicine, Bakırçay University Çiğli Research and Training Hospital, İzmir, 2 Department of Emergency Medicine, İzmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, 3 Department of Emergency Medicine, Soma State Hospital, Manisa, 4 Department of Physiology, İzmir Katip Çelebi University, Faculty of Medicine, Izmir, 5 Department of Biostatistics, İzmir Katip Çelebi University, Faculty of Medicine, Izmir, Turkey
DOI: 10.4328/ACAM.20478 Received: 2021-01-11 Accepted: 2021-02-08 Published Online: 2021-02-25 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):871-874
Corresponding Author: Ejder Saylav Bora, Izmir Katip Çelebi University Ataturk Research and Training Hospital, Emergency Medicine Izmir, Turkey. E-mail: email@example.com P: +90 532 450 78 55 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2448-2337
Aim: Dyspnea is a common problem in emergency services worldwide. Bacterial pneumonia is a common etiology in patients with acute dyspnea causing mor- bidity and mortality. Early initiation of appropriate antibiotic therapy reduces mortality. However, it is difficult to diagnose pneumonia with symptoms similar to acute heart failure and acute exacerbation of chronic obstructive pulmonary disease, and without definitive diagnostic testing. For this, it is thought that the use of a biomarker that can diagnose pneumonia at the time of admission to the hospital would be clinically useful.
Material and Methods: Patients who came to the emergency department with shortness of breath were analyzed retrospectively. Three hundred patients were examined. Serum procalcitonin values of patients diagnosed with pneumonia by chest radiography or thorax CT were compared with other patients. Patients discharged from the emergency department or hospitalized were classified as a good clinical outcome group, patients who were intubated, in need of intensive care, or who died were classified as a poor clinical outcome group, and procalcitonin values were compared. The data were evaluated using the SPSS Statistics Standard statistical package program. A p <0.001 value was considered statistically significant.
Results: In patients presenting with dyspnea, pneumonia (150), COPD exacerbation (30), lower respiratory tract infection (LRTI) (18), acute coronary syndrome (ACS) (27), and acute heart failure (AHF) (76) were diagnosed. The PCT values of the patients diagnosed with pneumonia were significantly higher than the other groups (p <0.001). In terms of white blood cell (WBC) values, there was no significant difference between pneumonia patients and other patients. When the neutrophil-lymphocyte ratio (NLR) was examined, it was found to be significantly higher in pneumonia patients (p <0.001). When we examined the progno- sis of pneumonia patients, the PCT values of the patients with a poor prognosis were found to be significantly higher (p <0.001).
Discussion: We have seen that PCT has an important role in the diagnosis and prognosis of pneumonia in patients admitted to the emergency department with shortness of breath.
Keywords: Procalcitonin; Dyspnea; Pneumonia
One of the most common admissions to emergency services in the world is shortness of breath . Bacterial pneumonia is an important cause of morbidity and mortality in patients with acute dyspnea . Early initiation of appropriate antibiotic treatment reduces mortality [3,4]. However, the diagnosis of pneumonia can be difficult because it coincides with the symptoms of other causes of dyspnea, such as acute heart failure and acute exacerbation of chronic obstructive pulmonary disease, and there is no definitive diagnostic test . Besides, the fact that many patients presenting with dyspnea have more than one disease at the same time makes their diagnosis and treatment difficult.
When biomarkers are evaluated in combination with clinical risk scores, they are being used more to identify specific patients at risk, to evaluate the severity and prognosis of the disease, and more recently to guide antibiotic treatment . Procalcitonin (PCT) is normally a calcitonin prohormone and is produced by thyroid C cells. Serum PCT levels are too low to be detected in healthy individuals, its production increases in bacterial infections, and its production by cytokines is reduced in viral infections [6,7]. PCT has received much attention as a good biomarker of bacterial infection, as it has good specificity for severe bacterial infections in patients with clinically suspected sepsis, and can distinguish infections from general inflammation [8,9]. Therefore, in order to diagnose or exclude pneumonia correctly, potential values of PCT have been examined in many recent studies [10,11]. However, there are not many studies examining the use of PCT in patients with acute shortness of breath. Therefore, in this study, we aimed to examine the diagnostic and prognostic results of PCT in patients presenting with acute dyspnea.
Material and Methods
This study was approved by the decision of Izmir Katip Çelebi University non-invasive clinical studies ethics committee dated 25.04.2019 and numbered 185.
In our study, the files of patients who applied to the 2nd step Emergency service with complaints of dyspnea between January 2018 and March 2019 were retrospectively scanned. Patients under 18 years of age and whose results could not be seen through the hospital information system were not included in the study. Three hundred patients were included in the study. Patients due to acute respiratory reasons
The diagnosis of decompensated heart failure (CHFF) and acute coronary syndrome (ACS) was made due to pneumonia, lower respiratory tract infection (LRTI), COPD attack and acute cardiac causes.
Blood values and procalcitonin values of the patients were recorded. The normal range of procalcitonin measured in our hospital was found to be 0-0.05 ng / ml. We compared the serum procalcitonin values of patients diagnosed with pneumonia by chest X-ray or thorax CT with those of other patients. Patients discharged from the emergency department or hospitalized were classified as a good clinical outcome group, patients who were intubated, required intensive care, or died, were classified as a poor clinical outcome group and procalcitonin values were compared. We also compared PCT with white blood cell (WBC) and neutrophil-to-lymphocyte ratios (NLR).
The data were evaluated using IBM SPSS Statistics Standard Concurrent User V 25 (IBM Corp., Armonk, New York, USA) statistical package program. Descriptive statistics were given as the number of units (n), percentage (%), median (M), 25th percentile (Q1), and 75th percentile (Q3). The normal distribution of the data of numerical variables was evaluated using the Shapiro Wilk normality test and Q-Q graphics. The Kruskal- Wallis analysis was used to compare groups for variables that did not show normal distribution. If a difference was found as a result of the Kruskal-Wallis analysis, multiple comparisons were made using the Dunn-Bonferroni test. Comparisons of two groups were made using the Mann-Whitney U test for variables that did not show normal distribution. P <0.05 value was considered statistically significant.
Three hundred patients were included in the study. Thirty patients were diagnosed with ACS, 76 with DCHF, 18 with LRTI, 26 with COPD attack, and 150 with pneumonia. PCT values were compared between these groups. There was a statistically significant difference in PCT between the groups of patients with pneumonia and all other groups (p <0.001) (Table 1).
In addition, we compared the PCT values of the patients with their WBC and NRL values (Table 2). There was a significant difference between the PCT of pneumonia patients and the PCT of all other patients. When we compare the WBC and NRL values, we found a significant difference between patients with pneumonia and patients with ACS, DCHF and COPD attacks. Classifying the patients with pneumonia as good and bad outcomes according to their clinical outcomes, PCT; We compared the WBC, NLR and PCT values (Table 3). We found statistically significant difference in the NEU and LEU variables. We found that PCT would be more useful in predicting worse outcome in patients with pneumonia.
Over the years, numerous studies have been conducted investigating the clinical usefulness of biomarkers in the diagnosis, prognosis, staging and monitoring of sepsis [12,13]. Thus, many studies have focused on the use of a single biomarker, but interest has increased in the search for new sepsis biomarkers, especially using high-throughput methods for screening patient samples . In this study, we investigated the importance of procalcitonin in diagnosis and prognosis in patients who came to the emergency department with shortness of breath.
We found that PCT provides a good distinction between patients with acute dyspnea in the emergency room for diagnosing and excluding pneumonia. More importantly, we have found that PCT concentrations provide an accurate diagnosis of pneumonia, especially in patients with comorbidities such as heart failure. PCT, a precursor of calcitonin, has received widespread attention as a biomarker of bacterial infection, as it has good specificity for severe bacterial infections in patients with clinically suspected sepsis and can distinguish infections from general inflammation . Serum PCT levels are found to be low under normal conditions. PCT does not increase significantly in immunological diseases and viral infections, besides it is accepted as specific for bacterial infections . Based on recent studies, the literature has shown that PCT has sometimes conflicting benefits in the diagnosis and management of infectious syndromes, including pneumonia [17,19].
There are markers that we traditionally used to evaluate inflammation in the clinic, such as white blood cell (WBC), C-reactive protein (CRP) levels, and neutrophil-lymphocyte ratio (NLR) . Studies have shown that NLR is a useful measure in determining systemic inflammation .
In our study, when we examined patients who came to the emergency room with shortness of breath, we showed that PCT was significantly better than WBC and NLR in diagnosing pneumonia. This provides early initiation of pneumonia treatment and increases survival.
Clinically, biomarkers are important for both diagnostic and prognostic efficiency. PCT also has an important potential in optimizing the correct diagnosis for pneumonia and predicting prognosis. Our results also support the diagnostic and prognostic value of PCT in patients with acute dyspnea, contributing significantly to clinical variables and other biomarkers for these applications.
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Animal and human rights statement
Conflict of interest
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Arife Erdoğan, Ejder Saylav Bora, Çağrı Kokkoz, Mümin Alper Erdoğan, Ferhan Elmalı. The importance of procalcitonin in the diagnosis and prognosis of patients with dyspnea in the emergency department. Ann Clin Anal Med 2021;12(8):871- 874
Investigation of patients with temporal lobe epilepsy using quantitative electroencephalography and magnetic resonance spectroscopy
Mustafa Çam 1, Yılmaz Kıroğlu 2, Eylem Değirmenci 3
1 Department of Neurology, Çanakkale Onsekiz Mart University School of Medicine, Çanakkale, 2 Department of Radiology, BSK Denizli Cerrahi Hospital, Denizli, 3 Department of Neurology, Pamukkale University School of Medicine, Denizli, Turkey
DOI: 10.4328/ACAM.20481 Received: 2021-01-13 Accepted: 2021-02-22 Published Online: 2021-03-04 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):875-879
Corresponding Author: Mustafa Çam, Department of Neurology, Çanakkale Onsekiz Mart University School of Medicine, Barbaros neighborhood, Prof. Dr. Sevim Buluç street, Terzioğlu campus, A Block No:2 B Block No:4 Çanakkale, Turkey. E-mail: firstname.lastname@example.org P: +90 286 263 59 50 F: +90 286 263 5956-57 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3116-203X
Aim: Temporal lobe epilepsy (TLE) is the most common focal epilepsy in adulthood. Magnetic resonance spectroscopy (MRS) is an MRI technique used to mea- sure regional variations in neurochemistry and display the concentrations of various brain metabolites in preset regions of interest in the brain. In this study, we aimed to evaluate the correlation of qEEG abnormalities and MRS findings in patients with temporal lobe epilepsy (TLE).
Material and Methods: Power spectrum analyses of each multi-channel EEG were performed in all patients with the concomitant MRS measures of Choline (Cho), total Creatine (Cr), N-acetyl aspartate (Naa) concentrations, and ratios of Cho/Cr, Naa/Cr, and Naa/Cho.
Results: Mean qEEG band powers of anterior alfa, anterior beta, central alfa, central beta, posterior alfa, and posterior beta in the right temporal area was significantly larger in patients whose Naa/Cho+Cr ratio was lower than 0.71 compared to patients whose Naa/Cho+Cr ratio was equal and larger than 0.71. In addition, correlation analyses between Naa/Cho+Cr, Naa/Cho+Cr, and Naa/Cho ratios and qEEG band power values showed low-medium correlations.
Discussion: A relationship detected between the biochemical changes of the epileptogenic focus due to neuronal dysfunction and the QEEG data may help prove the presence of the focal point.
Keywords: Temporal epilepsy; Quantitative electroencephalogram; MR spectroscopy
According to the World Health Organization (WHO), more than 50 million individuals are living with epilepsy, of whom nearly 80% live in middle- and low-income countries and do not get the proper treatment. Approximately 2.4 million individuals are diagnosed with epilepsy annually, and about %0.2 of all deaths in the world occur among this group of patients every year (available at: http://who.int).
Temporal lobe epilepsy (TLE) is the most common focal epilepsy in adulthood. In case of resistant seizures in TLE, further evaluation is required in terms of surgical intervention . In mesial temporal lobe epilepsy (mTLE), seizures mostly originate in the hippocampal formation. The ipsilateral mesial temporal lobe is compatible with sclerosis in approximately 60% of patients with MTLE on magnetic resonance imaging (MRI) . While 20-30% are normal, the rest have structural lesions (e.g, tumors or vascular malformations). Epileptogenic activity is usually not restricted to the hippocampus, but spreads to other brain regions as well, particularly to the temporal lobes, insula, and frontal lobes. . Seizure symptoms are prominent in the evaluation of epileptic patients. However, the localizing value of seizure semiology is debated because currently seizure analysis is qualitative and based on visual inspection of seizure semiology .
Quantitative electroencephalogram (qEEG) is an attractive clinical tool, given its non-invasive nature, its ability to reflect real-time changes in local cortical activity, and a load of objective bioelectrical measurements that can be derived from it . qEEG analyses have been used for evaluating and understanding neuro-psychiatric diseases nearly for the last fifty years. It is reported that fractional theta power was lower in patients with mesial temporal lobe epilepsy (MTLE) . To improve spatial resolution, qEEG analysis has also been combined with medical imaging technology like magnetic resonance (MR).
MR spectroscopy (MRS) is a unique technique that allows the assessment of brain metabolism associated with cerebral compounds  and could detect certain metabolites such as between 0.5 and 1.0 mM concentrations in brain tissue . Although it is known in theory that many compounds can be detected by MRS, in reality, compounds, where H protons are relatively high, can be detected. However, some of these components have clinical importance, such as N-acetyl aspartate (Naa), creatine (Cr), choline (Cho), lactate, lipids, and myoinositol .
MRS is a useful adjunct consistently demonstrating changing metabolites in the epileptogenic region, and the reduction of NAA is a typical finding in this area [8,10]. In addition, metabolite changes can also be identified outside the seizure focus in patients with TLE, reflecting a widespread disorder [11-12].
The most frequent findings were reported as decreased ratios of Naa to Cho and increased choline concentration in a study MR spectroscopic study of patients with MRI- negative extratemporal epilepsy. With these advances, qEEG may play a role in basic research and clinical studies on brain injury, neurological disorders, epilepsy, sleep studies and consciousness, and brain function . With regard to this knowledge, in this study, we aimed to evaluate the correlation of qEEG abnormalities and MRS findings in patients with TLE.
Material and Methods
Forty-four patients (29 women and 15 men) aged between 13 and 70 years (mean age= 30.07±12.4) were included in this study, who were diagnosed as TLE according to the seizure semiology, examination findings, and qualitative EEG parameters. Patients with structural lesions, hippocampus atrophy, and/or sclerosis on conventional MRI and patients using any medication except antiepileptic drugs were excluded from the study.
EEG was recorded by the digital 32 channel apparatus Profile machine (Medelec Ltd U.K.) using the international 10/20 system and Ag/AgCl electrodes. EEG data were collected with linked mastoid reference. The power spectrum of each multi-channel EEG segment was computed on the basis of a Fast Fourier transformation of the data. For each channel, the powers in the delta, theta, alpha, and beta-band were calculated by summing components in bands from 0.5 to 3.5 Hz, 4 to 7.5 Hz, 8 to 13 Hz, and 13.5 to 20 Hz respectively. Amplified signals were bandpass filtered from 0.5 to 70 Hz. For each subject, 1 epoch of 10 s of multichannel EEG signals free of signs of impaired wakefulness, ocular movements, and other artifacts. qEEG analyses were performed according to the means of three areas: Fp1-Fp2-F3- F4-F7-F8-FZ (anterior), A1-A2-T3-T4-C3-C4-CZ (central), and P3-P4-T5-T6-O1-O1-PZ (posterior).
All subjects were scanned with a 1.5-T VISION MR system (GE Medical System, Milwaukee, WI, USA). Multi-slice MRS data (TR/TE = TR/TE: 3000/85), FOV; 14, Matrix; 352×352, Next; 1) were acquired from three 15-mm-thick slices aligned using T2 weighted fast spin-echo secants.
A single voxel was sequentially prescribed in hippocampal regions of each temporal lobe of each subject with an approximate dimension of 10 mmx10 mm. The volume of interest (VOI) placement was manual, and visual inspection ensured that these regions contained a predominantly hippocampal area of temporal lobe tissue. The very rostral slices of these volumes partially included basal ganglia structures, while the temporal pole and the anterior mesial temporal lobe structures were invariably excluded to ensure that the data quality remained acceptable. In both cases, the water signal was suppressed using 3 chemical-shift selective (CHESS) pulses, with the flip angle of the final pulse tailored to ensure slight under- suppression. Point-resolved spectroscopy (PRESS) localization was used to select the spectroscopy volume (TE/TR = 30/3000 ms). Finally, the short and medium timed TE of the VOI areas in both temporal areas was taken and data were analyzed using the program of the General Electric software spectral analyses. Monovoxel (TE, 35 ms) and multivoxel (TE, 144 ms) H-MR spectroscopy were performed on the temporal lobe tissue. Values of Cho, total Cr, Naa concentrations with the ratio of Cho/Cr, Naa/Cr, and Naa/Cho were used. The metabolic peak amplitudes were 3.23 for Cho, 3.03 for Cr, and 2.02 for Naa. Statistical analyses
SPSS 25.0 (IBM Corporation, Armonk, New York, United States) program was used to analyze the variables. The univariate data for normal distribution were evaluated with the Shapiro-Wilk Francia test. In the diagnosis of MTLE and an epileptogenic focus, the most sensitive MRS finding was reported as a decrease in Naa / Cho + Cr ratio, and in various studies, 0.70- 0.71-0.72 and above rates were considered pathological margins, and 0.71 and below were used in our study . Mann- Whitney U test was used with Monte Carlo simulation results in comparison of the grouped MRS findings (Naa / Cho + Cr) according to qEEG bands measurements. When comparing grouped MRS findings (Naa / Cho + Cr) by gender, Pearson Chi- Square and Fisher Exact tests were tested using Exact results. Partial Correlation test was used to examine the correlations between MRS findings and qEEG bands measurements in terms of gender and age. Quantitative variables were stated as median (minimum/maximum).
In the tables, categorical variables were shown as n (%). Variables were examined at a 95% confidence level, and p <0.05 was considered statistically significant.
The mean age of the patients was 29.66 years, and the median value was found to be 24.50. The seizures started at the age of 17 on average, and the median value was 16.0. The annual average seizure frequency was 4.68 and the median value was 4.0. Patients’ seizure characteristics were summarized in Table 1. Naa/Cho+Cr ratios were equal and higher than 0.71 in 19 (48.2%) and lower than 0.71 in 25 (56.8%) of the patients, and the difference was not statistically significant (p=0.366). The patients whose Naa/Cho+Cr ratio was lower than 0.71 were classified as Group 1 and the patients whose Naa/Cho+Cr ratio was equal and bigger than 0.71 were classified as Group 2 because the cut-off value for the Naa/Ch+Cr ratio is reported 0.70 in the hippocampal injury which is seen in patients with TLE. Mean qEEG band powers of anterior alfa (Ant A), anterior beta (Ant B), central alfa (Cent A), central beta (cent B), posterior alfa (post-A), and posterior beta (post B) on the right temporal area (right monovoxel) was significantly bigger in group 1 than group 2 but there was no significant difference in qEEG band powers of the left temporal area between groups and right multivoxel area (Table 2). Naa/Cho+Cr ratios and qEEG band power values showed a low-medium negative correlation between right monovoxel Naa/Cho+Cr anterior beta and central beta band powers. The other analyses between left monovoxel Naa/Cho+Cr, left multivoxel Naa/Cho+Cr, right multivoxel Naa/ Cho+Cr between qEEG band power values were not statistically significant. Correlation analyses between Cho/Cr ratios and qEEG band power values showed a low-medium negative correlation between right multivoxel Cho/Cr ratio and anterior delta band power value (r=-0.353 p=0.022) and low-medium positive correlation between right multivoxel Cho/Cr ratio and posterior alfa and posterior beta band powers (r=0.361 p=0.019). The other analyses between left monovoxel Cho/ Cr, left multivoxel Cho/Cr, right monovoxel Cho/Cr, and qEEG band power values were not statistically significant (p>0.05). Correlation analyses between Naa/Cho ratios and qEEG band power values showed a low-medium negative correlation between right monovoxel Naa/Cho ratio and anterior beta band power value. In addition, low-medium positive correlation was found between the right multivoxel Naa/Cho ratio and anterior delta band power values (Table 2). Other analyses between left monovoxel Naa/Cho and left multivoxel Naa/Cho with qEEG band power values were not statistically significant ((p>0.05). Naa/Cr ratios and qEEG band power values were not statistically significant. Correlations were summarized in Table 3. There was not a statistically significant correlation between MRS findings with clinical (seizure frequency) and EEG (existence of left temporal, and bilateral temporal EEG abnormality) properties (p>0.05).
Quantitative EEG plays a significant role in investigating brain activity. In a study evaluating the qEEG power in sclerotic and non-sclerotic MTLE patients, the authors reported that total and delta band power was lower in sclerotic patients, while there was no difference in the gamma and beta powers . Most of the studies had focused on the correlation of qEEG findings with conventional MRI; however, this study mainly focuses on the association of qEEG findings with MRS.
Proton magnetic resonance spectroscopy (1H-MRS) has played an important role in detecting metabolic alterations in patients with TLE, although its popularity lags behind PET and single-photon emission computed tomography (SPECT) in the presurgical evaluation of MRI-negative TLE. N-Acetyl aspartate (NAA) is synthesized only in neuronal mitochondria, and a relatively higher concentration of creatine is found in astrocytes. The reduction of NAA signal is believed to be associated with neuronal loss or dysfunction, whereas an increase in creatine (Cr) signal suggests gliosis. Hence studies tend to use the NAA/ Cr ratio as a marker of the neuronal function of the neuronal- glial unit. Perhaps more importantly, the NAA/Cr alterations picked up by MRS imaging have been shown to reflect neuronal and glial dysfunction rather than neuronal cell loss . This makes the marker relatively independent of tissue atrophy. Reduced levels of NAA/Cr or NAA/Cr+Cho in patients with TLE have been found beyond the ipsilateral hippocampus, involving regions such as the thalami, insula, frontal lobes, parietal lobes, and contralateral hippocampus [17,18].
Atrophic hippocampus typically does have lower Naa/Cr and is generally regarded as clearly injured, the ratio is not specifically determined by volumetric loss, and likely more reflects mitochondrial function . In this study, we could not find any relation between Naa/Cr ratio and qEEG band power. This result would be explained by concomitant but different pathogenetic factors causing both MRS pathologies and qEEG abnormalities. It is known that, with the exception of the thalamus and Wernicke area, there are no significant differences in metabolite concentrations between hemispheres in the healthy brain . However, it is well known NAA/Cr, NAA/Cho, and NAA/ (Cho+Cr) are decreased in both temporal and extratemporal epilepsies . In a study performed by Bernasconi et al, no significant difference was found in the amount of delta activity in the temporal lobe between the controls and patients, and no correlation was found between the delta activity and the neuroimaging measures . In our study, we found some significant differences in qEEG measures according to Naa/ Cho+Cr ratios. Our results suggest that means of high-frequency powers in qEEG (anterior alfa and beta, central alfa and beta, posterior alfa and beta) are significantly higher in patients whose Naa/Cho+Cr ratio was lower than 0.71. Naa/Cho+Cr ratio reflects a neuronal dysfunction in the interested area of MRS analysis (right temporal area – monovoxel), however, there was not any significant difference in the right multivoxel measures. These results can be explained by the technical properties of MRS, in which long TE time MRS measures are better in fluid attenuation and lessening artifacts due to fat contamination [22-23].
Correlation analyses between ratios of Naa/Cho+Cr, Cho/Cr ratio, and Naa/Cr with qEEG band powers were performed in this study. Although the correlation analyses of left and right hemispheres were not always compatible, we think these results would be explained by localized back-ground rhythm properties and neuronal dysfunction due to epileptic activity . Results of evaluations focusing on correlation of MRS values with some qEEG band powers were statistically significant in our study, but we think it is not convenient to attribute some pathogenetic associations with these electrophysiological and imaging findings without any clinical consistency.
In this study, correlation analyses between seizure frequency and temporal abnormalities with MRS findings were also performed. A positive correlation between MRS findings with lateralized epileptogenic focus and seizure frequency had been reported before , however we did not get similar results. This result would be explained by the differences in the criteria for patient selection. Because seizure frequency was low in most of the patients in our study, the patients with structural lesions, hippocampus atrophy, and/or sclerosis on conventional MRI were not included.
Lateralization of the epileptic focus with localization by the help of seizure semiology and routine EEG and performing more limited qEEG analyses instead of performing all qEEG band powers in anterior, central, and posterior parts of the hemispheres would be more compatible for the present study.
Despite limitations, such as lack of control group and a detailed clinical questionnaire that would be helpful to lateralize epileptic focus, our study’s results suggest that there is no strong but low-medium correlation between qEEG and MRS findings of patients with TLE.
We would like to thank Professor Atilla Oğuzhanoğlu for his valuable contribution during the design and writing of our study.
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Conflict of interest
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Mustafa Çam, Yılmaz Kıroğlu, Eylem Değirmenci. Investigation of patients with temporal lobe epilepsy using quantitative electroencephalography and magnetic resonance spectroscopy. Ann Clin Anal Med 2021;12(8):875-879
Knowledge, attitude and practices (KAP) regarding COVID-19 and Coronavirus anxiety levels in the Turkish population
İsmail Biçer 1, Cuma Çakmak 2, Cemil Örgev 3, Halil Demir 4
1 Medical Documentation and Secretarial Program, Istanbul Arel University, Istanbul, 2 Department of Healthcare Management, Hacettepe University, Ankara, 3 Environmental Protection Technologies, Sakarya Upplied Sciences University, Sakarya, 4 Medical Documentation and Secretarial Program, Istanbul Rumeli University, Istanbul, Turkey
DOI: 10.4328/ACAM.20482 Received: 2021-01-13 Accepted: 2021-02-14 Published Online: 2021-02-28 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):880-887
Corresponding Author: İsmail Biçer, Medical Documentation and Secretarial Program, Istanbul Arel University, Kemalpaşa neighborhood, Halkalı street, No:101, 34100 Istanbul, Turkey. E-mail: email@example.com P: +90 507 416 51 75 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1878-0546
Aim: The knowledge, attitude and practice level of the people about the disease can provide data on behavioral change for the health authorities.
This study aims to measure the knowledge, attitude, and practice levels of people living in Turkey towards COVID-19 and determine their anxiety levels.
Material and Methods: Eight hundred sixty people were reached through online surveys between May 20-30, 2020. Along with questions measuring demo- graphic features, Knowledge, Attitude, and Practices (KAP) Towards COVID-19 and Coronavirus Anxiety Scale (CAS) were used in the research. Descriptive statistical analysis, chi-square tests, t-tests, one-way analysis of variance (ANOVA), multiple linear regression analyses, and logistic regression analysis were used in the study.
Results: The overall mean of the KAP scale was 10.65 ± 1.26. This shows that Turkish people have a high level of knowledge about COVID-19. Moreover, the overall mean of the anxiety scale was 1.96 ± 3.30, and the general anxiety levels of the participants were determined to be very low. Most of the participants showed positive attitudes towards the successful control of COVID-19 (65.9%) and Turkey’s ability to defeat the disease (82.1%).
Discussion: It can be stated that this study is important because it is the first study evaluating the KAP and CAS levels for COVID-19 in Turkey. As a result, health education programs and awareness-raising activities targeting individuals with less knowledge about COVID-19 can be important in controlling the outbreak.
Keywords: COVID-19; Knowledge; Attitude; Anxiety; Turkey
Coronavirus disease, also known as COVID-19, is an expanding pandemic caused by a new human coronavirus (available at: https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/situation-reports -) . COVID-19 was first reported in December 2019, in Wuhan. According to the COVID-19 situation report by WHO on 1 February 2021, there were 102.399.513 total confirmed cases, and the total confirmed death number increased to 2.217.005 (available at: https://www.who.int/publications/m/item/weekly-operational- update-on-covid-19—1-february-2021).
Understanding individuals’ knowledge, attitude, and behavior towards COVID-19 in the early stages of the epidemic helps governments and authorities to effectively apply the preventive and control measures . Knowledge, attitudes, and practices regarding COVID-19 (KAP) play an important role in determining whether the community is ready to accept the behavior change measures taken by healthcare authorities. Evaluation of the society’s KAP level in relation to COVID-19 will help in the development of preventative strategies related to the disease and programs aimed at encouraging and improving health . Collecting more information about anxiety, knowledge, and attitude of the society during an outbreak is crucial for the improvement of public health authorities’ and clinicians’ efforts. This study aims to measure the knowledge, attitude, and practice levels of people living in Turkey towards COVID-19 and determine their anxiety levels.
Material and Methods
The population of this research consists of people who are above 18 years old and living in the seven regions of Turkey. The questionnaire was distributed via e-mail and expanded via snowball sampling. Data were collected for ten days. A total of 860 people participated in the study.
In the research, a questionnaire form was used as a data collection tool. The first part was devoted to the demographic features of the participants. In the second part, KAP which is developed by Lee (2020)  was used; in the third part, Coronavirus Anxiety Scale (CAS), which is a short mental screening to identify possible cases of dysfunctional anxiety related to the COVID-19 crisis and whose reliability and validity was completed by Bicer et. al. (2020)  was used. CAS is a 5-point Likert scale. KAP consists of 16 questions in total. Questions from 1-12, related to knowledge dimension, were answered as “true”, “false”, and “I don’t know”, and they evaluated the level of knowledge. The highest score from this dimension was calculated as 12. Also, the 5th, 6th, and 9th questions of the scale were reverse coded. Two questions were included for the measurement of Attitude and Practice each, and these questions were dichotomous, which were answered as “yes” or “no”.
The independent samples method was used to compare KAP scores according to demographic characteristics. T-test, the appropriate one-way variance analysis (ANOVA), or Chi-Square tests were made. Multivariate linear regression analysis, in which all demographic variables are used as independent variables and the knowledge score as the result variable was used to define factors related to information. Similarly, binary logistic regression analysis was used to identify the factors related to attitude and practice. In order to measure the relations between the variables and KAP and CAS, standardized regression coefficients (β), probability ratio (OR), and 95% confidence intervals were used. Data analyses were made with SPSS 22.0 version. The statistical significance level was identified as p<0.05.
The necessary permissions for the scales used were obtained from their authors via e-mail. In addition, permission for the study was taken from the COVID-19 Scientific Research and Evaluation Committee within the body of The General Directorate of Health Care Services of the Republic of Turkey’s Ministry of Health (approved document number: 2020-05- 12T13_15_57). Finally, ethics committee permission was taken from the Non-Interventional Clinical Research Ethics Committee of Sakarya University of Applied Sciences numbered 044.
Women accounted for 66.4% of the participants and 33.6% of the participants were male. In addition, 62.9% (541) were single, 34.1% (293) were married and 3% (26) were divorced. Among the participants, 4.9% (42) had primary school education, 31.5% (271) had a high school education, 26% (224) had associate degree, 26% (224) undergraduate and 11.5%, (99) graduate education. The average age in the sample was calculated as 29.35 (SD: 10.23, range: 18-72) years, and the average household income was 5.559,92 (SD: 3.611,50, range: 1.000-20.000). Among the survey participants, 52% (447) lived in the Marmara Region, 26.3% (226) in the Central Anatolia Region, and 21.7% (187) in other regions. It was also reported that 17.4% (150) of the participants were diagnosed with COVID-19.
In the dimension used for the measurement of the knowledge levels of the participants within the scope of the study, the highest score was reported as 12. The average knowledge score in the sample was calculated as 10.66 (SD: 1.26, range: 3-12). In the knowledge scale, the question with the highest frequency was K12, and the question with the lowest frequency was K5 (reverse question). Most of the participants indicated that COVID-19 was controlled successfully (65.9%), and they had positive attitudes toward Turkey’s ability to overcome the disease (82.1%). It was also seen that the participants highly adopted the practices such as avoiding crowded places (82.1%), and wearing masks when going out (96%). The highest score to be taken from the Coronavirus anxiety scale was 20. The anxiety score average was calculated as 1.97 (SD: 3.30, range: 0-20) in the sampling. Most of the participants answered questions such as “I felt dizzy, I had sleeping problems, I lost my appetite, I had nausea and stomach problems” with “rarely, less than a day or two or not at all”.
It was analyzed using t-test and ANOVA test (one-way variance analysis) whether the KAP evaluations of the participants and assessments of anxiety levels differ according to demographic variables. Tukey HSD test was used to determine from which groups the difference originated for the factors with statistically significant difference as the result of the ANOVA test. The result of the analysis shows that the KAP scores of the participants show significant differences with gender (p<0.05). There was a significant difference between the participants’ KAP scores and their educational status (p <0.05). A significant difference was detected mainly between the graduates of primary school, high school, associate degree, and higher- level education graduates. Also, a significant difference was also detected between the marital status and ages of the participants (p<0.05). A significant difference was reported between married and single groups and between people aged 18-29 and older age groups. As a result of the analysis, it was seen that there was a significant difference between the CAS levels and genders of the participants (p<0.05). There was also a significant difference between the ages and CAS levels of the participants (p<0.05). The significant difference was determined between the age groups of 18-29 and 50-72. The CAS levels of the participants differed with the coronavirus diagnosis of someone they know (p<0.05).
In the study, correlation analysis was conducted to examine the relationships between KAP and CAS. A strong negative relationship was detected between KAP and CAS (r=-0.730; p<0.05). A small positive relationship was detected between the belief that COVID-19 will be taken under control in the World and Turkey’s success on COVID-19 r=0.235; p<0.01).
According to the results of the multiple regression analysis, in which demographic questions were the dependent variables and KAP was independent variable (Table 1), there was a significant effect on gender (β=-0.137: p<0.001), education (β=0.167: p<0.001), marital status (β=0.088: p<0.001), and age (β=0.093: p<0.001). There was no versatile evidence between the region of residence, total household income, coronavirus diagnosis of a person they know, and knowledge (VIF range = 1.016 and 1.237: p> 0.05). In the multiple linear regression analysis conducted to determine the effect of demographic questions on CAS (Table 1), gender (β=-0.169: p<0.001), region of residence (β=0.070: p<0.001), and coronavirus diagnosis of a person known (β=- 0.086: p<0.001) showed a significant relationship with anxiety score. There was no versatile evidence between the education, marital status, age, a total household income with anxiety (VIF range=1.187 and 1.738: p>0.05).
The ratio of the right answers in the attitudes in KAP scale was generally high (Table 2); 65.9% of the participants believe that COVID-19 can be successfully controlled. Also, 82.2% of the participants believe that Turkey can win the war against the COVID-19 virus. Univariate analysis is significantly related to education and total household income (p <0.005); 83.3% of primary school graduates, 69.2% of associate degree graduates, 63.4% of undergraduate graduates believe that COVID-19 can be successfully taken under control. Furthermore, 82.6% of the people whose total household income is between 1000-3999 and 86.8% of the respondents with income between 4000-7999 believe that Turkey could win the war against the COVID-19 virus.
The level of correct answers was found to be high in the implementation questions on the KAP scale (Table 2) in general; 82.1% of the participants have not visited crowded places in recent days. In addition, 96% of the participants have worn masks when they left home recently. Univariate analysis is significantly related to gender, age and total household income (p <0.005); 85.8% of women have not gone to crowded places in recent days, and 97.2% have used masks in recent days; 87.3% of participants between the ages of 50-72 have not visited crowded places in recent days, and 98.2% of them wore masks when leaving the house. While 78.7% of the participants with a total household income of 8000 and above did not go to crowded places, 97.8% of them used masks when they left home recently.
Results of Logistic Regression Analysis evaluating the relationship between socio-demographic features of the participants and their attitude towards COVID-19
It was detected that the knowledge score of COVID-19 (OR: 1.01: p>0.005) has no significant relationship between beliefs that COVID-19 will be taken under control successfully. However, the 18-29 age group believed 0.11 times more, and the 30-49 age group believed 0.14 times more than the 50- 72 age group that Turkey will win the war against COVID-19. However, people living in the Mediterranean Region believe 0.13 times more than the people from other regions that Turkey will win the war against COVID-19. Compared to people with an income of over 8000 TL, people whose income is between 1000-3999 TL believe that Turkey will win the war against COVID-19 2.39 times more, and people with an income of 4000-7999 believe 1.66 times more. Table 3 shows the results of Logistic Regression Analysis evaluating the practices of the socio-demographic characteristics of the participants towards COVID-19. It was determined that the COVID-19 knowledge score (OR: 0.93: p> 0.005) has no significant relationship with going to crowded places in recent days. However, it was seen that women pay attention to going to crowded places 2.27 times more than men. The COVID-19 knowledge score (OR: 0.65: p <0.001) was found to be significantly associated with wearing a mask when leaving home recently. It was detected that those with a total household income of 1000-3999 TL were 4.01 times more careful about wearing a mask when leaving home than the group with an income of 8000 or more.
The general knowledge level about COVID-19 is critical to applying precautions and controlling the epidemic. In this sense, it is significant to increase the level of knowledge, attitude, practices towards the virus, and decrease anxiety. This study determines the level of anxiety in society and KAP level of COVID-19. KAP level is high in Turkey. This shows that people in Turkey have a high level of knowledge about COVID-19. Most of the participants have positive attitudes towards the successful control of COVID-19 and Turkey’s ability to overcome the disease; 98.5% of respondents know that people who come into contact with someone infected with the COVID-19 virus should be isolated in a suitable place immediately, and the overall observation period is 14 days. It is also seen that participants have highly adopted practices such as not going to crowded places or wearing masks when going out. At the same time, 97.8% of the participants know that they should avoid public transport to prevent COVID-19 infection. Also, the low levels of general CAS average indicate very low anxiety levels.
As a result of the analysis, it was found that the variables such as gender, age, total household income, and education were related to KAP. Most of the society took measures such as avoiding crowded places and wearing masks when going outside to prevent the spread of COVID-19. These strict preventive practices are primarily restrictions by the government, but the high level of community participation is important for prevention and control. The epidemic-preventative behavior results from the society’s awareness of the COVID-19 virus, which can spread easily. This study shows that 17.9% of the participants went to crowded places and 4% of them did not wear a mask. Potentially, this is seen as a result of low knowledge of COVID-19, and people showing this behavior were mainly men, primary school graduates, and had a total household income lower than 1000-3999 TL. In terms of regions, people from East Anatolia and the Black Sea regions show this kind of behavior. KAP level is high in Turkey. The findings of this research coincide with the findings of many studies in the field [3-6–16]. However, studies conducted in some countries show that KAP levels are low [17-20].
Within the scope of this study, based on the meaningful relationships between knowledge, attitude, and practice, it is understood that KAP levels in the Turkish community are high and its anxiety level is low. Strong health care system of Turkey, serious measures taken from a scientific point of view by government and health authorities since the outbreak first occurred in China, the daily and transparent share of information about the virus, and public awareness raised by specialists through media can be shown as the reasons for this situation. Although the general level of the society is high, for individuals with low knowledge, application, and practice, awareness can be raised through measures such as health education programs, encouraging positive attitudes, and maintaining safe practices. It is important to stay away from social media in order to prevent information pollution, to adhere to the recommendations and precautions of healthcare authorities. Combining rumors is extremely harmful because wrong information can cause harmful effects on public health. Disadvantaged and vulnerable groups, such as the elderly population and rural residents, are more likely to have low knowledge, negative attitudes, and practices regarding COVID-19 due to their limited access to the internet and online health information resources. For this reason, the knowledge, attitude, and practice of vulnerable groups towards COVID-19 should also be improved. Moreover, it is recommended for future researches to study the KAP levels of disadvantaged groups and people living in rural areas. Revealing general knowledge, attitude, and practice levels and anxiety levels in Turkey through a randomized selected, high- volume sampling, covering the entire country by the Ministry of Health or the Turkish Statistical Institute (TUIK), can provide significant information. As any other study, this study has some limitations. A web-based research method was used for the study, and participation in the study was not obtained by the probability sampling method.
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Conflict of interest
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İsmail Biçer, Cuma Çakmak, Cemil Örgev, Halil Demir. Knowledge, attitude and practices (KAP) regarding COVID-19 and Coronavirus anxiety levels in the Turkish population. Ann Clin Anal Med 2021;12(8):880-887
Suicidal poisoning in Alexandria, Egypt-An updated statement
Heba Abdel Samie Mohamed Hussein 1, Hamed ELsayed Mustafa Elsawaf 2
1 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, 2 Medico-legal Department, Ministry of Justice, Alexandria, Egypt
DOI: 10.4328/ACAM.20484 Received: 2021-01-14 Accepted: 2021-03-03 Published Online: 2021-03-16 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):888-894
Corresponding Author: Heba Abdel Samie Mohamed Hussein, Lecturer of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt. E-mail: firstname.lastname@example.org P: 00201002957439 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0022-4640
Aim: Suicide patterns and sociodemographic descriptions vary widely from country to country and over time. The study presented updated data about magni- tude and pattern of suicidal poisoning deaths and attempts in Alexandria, Egypt.
Material and Methods: A retrospective descriptive study was performed, by investigating autopsy and criminal laboratory reports of confirmed suicide cases by poisoning, at the Medicolegal Authority Alexandria department, and patients’ admission files at Alexandria Poison Centre (APC), Alexandria University, Egypt from January 2017 to December 2019.
Results: Suicidal deaths by self-poisoning accounted for 4.9% of autopsies. There was a significant increase in the annual rate of complete suicide by self- poisoning (p<0.001); 62.4% of complete suicide cases were between the ages of 10 and 20 years; 67.3% of cases were females; 87.1% were from rural areas, 30.7% of cases were in secondary school; 43.6% of cases were unemployed; 69.3% were single; 96% of suicidal deaths were due to pesticides, 51.5% of them were due to Zinc phosphide. The highest percentage of cases was in spring (36.6%); 7205 cases (34.3%) were attempted suicides admitted to APC, 42% of them were between the ages of 10-20 years, 74% were females and 72.7% were from urban areas. Medications were mostly used for attempting suicide (57.3%), followed by pesticides in 26.9% of cases. The highest percentage of cases was admitted in July (12.8%) then May (10.4%).
Discussion: Complete suicide and suicide attempts by self-poisoning in Alexandria, Egypt, were mostly among teenage females. The most common poisons used for attempting suicide were medications in urban regions. However, most of the deaths occurred due to pesticides in rural areas.
Keywords: Complete suicide; Suicide attempts; Pattern; Sociodemographic; Alexandria; Egypt
One of the most commonly used ways of suicide is the intentional intake of large quantities of prescribed or non- prescribed substances. This includes overdose of therapeutic or recreational substances, carbon monoxide poisoning from car exhaust, ingestion of flammable liquids, solvents, pesticides or cyanide .
In fact, intentional self-poisoning for the purpose of suicide is a growing public health problem with numerous emergency department admissions. According to the WHO, yearly, almost one million peoples die from suicide and 20 times more peoples attempt suicide (World Health Organization. (2014). Preventing suicide: A global imperative. Retrieved from https://www.who. int/mental_health/suicide-prevention/world_report_2014/en/). Unlike other usually used ways of suicide, hanging and poisoning by carbon monoxide from car exhaust gases, the toxic effects of drug overdose may not occur for numerous hours or days after the attempt. For this purpose, most people who take overdoses reach hospital alive, and the medical interventions they receive in hospital are likely to prevent a proportion of deaths .
In fact, prevalence, characteristics and methods of committing or attempting suicide differ extensively between different societies and over time. Accordingly, up-to-date investigation of suicides and suicide attempts is a crucial element of national and local suicide prevention efforts.
Egypt has always been listed by the World Health Organization (WHO) to have the lowest suicide rate, at less than five suicides per 100,000 people. However, as a cultural belief, suicide is considered a stigma and a sinful act. That is why suicide cases in Egypt are often registered as accidental deaths by families of the deceased.
Although many previous Egyptian studies concerning suicide have been carried out, the growing number of suicides and attempted suicide by self-poisoning in Alexandria in recent years, urges continuous updating of research. Thus, the present study aimed to provide an updated data on the magnitude and pattern of suicidal poisoning deaths and suicidal poisoning attempts in Alexandria, Egypt.
Material and Methods
I. Cases of complete suicide:
A retrospective descriptive study was carried out by investigating autopsy and criminal laboratory reports of cases of confirmed suicide by poisoning, at the Medicolegal Authority Alexandria Department, Egypt, between January 2017 and December 2019. The Medicolegal Authority Alexandria department as well as Alexandria Poison Centre (APC), in Alexandria, Egypt serves many governorates besides Alexandria Governorate, such as Marsa Matrouh Governorate, El-Behera and Kafr Elshikh.
At the Medicolegal Authority Alexandria department, all cases of suspected suicide by poisoning were subjected to external and internal autopsy to rule out any signs of violence, after which samples (gastric contents, blood and urine) were taken and transferred to the criminal laboratory for analysis. Organophosphorus pesticides were analyzed using GC-NPD and GC-MS, while carbamate pesticides were analyzed using HPLC- UV and GC-MS. Pyrethroid and chlorinated pesticides were detected using GC-ECD and GC-MS. Moreover, Zinc phosphide and Aluminum phosphide were detected by silver nitrate test and head space GC.
For every confirmed case of suicide by poisoning, all available data were collected. It included socio-demographic data of individuals like age, sex, residence, occupation, level of education and marital status, as well as information about the poison used (type and time of incidence).
II. Cases of attempted suicide:
A retrospective descriptive study was done by examining patients’ admission files at Alexandria Poison Centre (APC), Alexandria University, Egypt, from January 2017 to December 2019.
All available data were collected on the sociodemographic characteristics of patients (age, sex, residence) and data related to patient’s admission, such as the substance used for attempting suicide and time of admission.
Suicide attempts resulting in death were omitted from the section of attempted suicide and included in the section of complete suicide to avoid duplication of cases.
Approvals from the Ethics Committee of Alexandria Faculty of Medicine (IRB No: 00012098, FWA No: 00018699) and the Medicolegal Authority Alexandria department, Egypt were taken prior to the study.
Quantitative data were described by mean and median as measures of central tendency and standard deviation, minimum and maximum as measures of dispersion, while categorical variables were summarized by frequency and percent. Chi- square test was used to study significant association between two categorical variables. Monte Carlo significance was used if more than 20% of total expected cell counts was <5 at .05 level of significance.
For categorical variables > 2 categories (types of poison and years of suicide), we performed either analysis of variance (ANOVA) or Kruskal-Wallis tests to compare mean and median quantitative variables. The choice of either test was based on variables’ distribution by Kolmogorov-Smirnov test and sample size per group.
All statistical tests were two-sided and were performed using IBM SPSS statistics program version 21.
I. Cases of complete suicide:
During the study period, 2077 autopsies were performed in the Medico-legal Authority Alexandria Department, Egypt. Out of which, 101 autopsies (4.9%) were related to suicidal deaths by self-poisoning, 57% were autopsied in 2019, 33% in 2018 and the least percentage (10%) in 2017.
Ten autopsies were related to suicide by self-poisoning out of 588 autopsies performed in 2017.
Thirty-three of 691 autopsies in 2018 were due to suicide by self-poisoning, while in 2019, 58 of 798 autopsies were due to suicide by self-poisoning. Significant increase in the annual rate of complete suicide by self-poisoning was observed in the present study, where p<0.001 (Figure 1).
The age group 10-20 years accounted for 62.4% of complete suicide cases, while the least percentage (2%) was in the age group of 60-70 years, 67.3% of the cases were females (Table 1).
Figure 2 shows that the highest percentage of cases in the age groups of 10-20 years, 20-30 years, and 40-50 years were females. While in the age group of 30-40 years, the highest percentage were males, 87.1% of them were from rural areas; 30.7% of cases were in secondary school, an equal percentage of 27.7% was given to illiterate, as well as intermediate education. While only one case had higher education, 43.6% of cases were unemployed, 30.7% were students and about one- quarter of cases, (25.7%) were workers; 69.3% were single, 22.8% of cases were married, 5.9% were divorced and only 2% were widows (Table 1).
Significant increase was noted in the number of females compared to males who committed suicide by self-poisoning throughout the study period, where p=0.005 (Table1).
Data related to the accident of suicide:
Pesticides were used in 96% of suicides. Out of them, 51.5% used Zinc phosphide, and 24.8% of them used Aluminum phosphide as the substance of suicide.
The highest percentage of cases was in spring (36.6%), followed by summer (30.7%), then winter (28.7%) and 4% in autumn.
There was a non-significant difference in the type of poison and season of poisoning according to the year of poisoning, where MCp= 0.875 and 0.298, respectively.
Among those who committed suicide using pesticides, 62.9% were in the age group 10-20 years, with a significant difference from other age groups (MC p=0.035), 68% of them were females, 88.7% were from rural areas. The highest percentage of them (29.9%) were secondary school students with a significant difference between different education levels (MC p= 0.035); 43.3% of those using pesticides for committing suicide were unemployed, and 69.1% of them were single with a significant difference from other groups (MCp=0.042); 36.1% of suicide by pesticides were in spring months. (Table 2)
II. Cases of attempted suicide:
During the three years of study, 20983 cases of acute poisoning were admitted to Alexandria Poison Centre (APC); 7552 (36%) of these cases were admitted in 2019, with the least percentage (29%) in 2017.
Out of all acute poisoning cases admitted to APC, 7205 cases (34.3%) were related to suicide attempt. The highest suicidal rate (36.8%) was in 2017, while the least (31.7%) in 2019. A significant decrease in the annual suicide attempt rate was noted in this study (p <0.001) (Figure 3).
The mean age of patients was 24.88±9.84 years (min-max =10- 75 years). The highest percentages (42%) of suicide attempts were in the 10-20 years age group, 36.6% of them were in the 20-30 years age group; 13.7% of cases were in the 30-40 years age group, the least percentage (0.5%) was in the seventh decade of life (60-70 years); 74% of suicide attempts were females; 72.7% were from urban areas, while the remaining percentage (27.3%) from rural areas.
Type of poison and date of admission:
Drug use was the most common method of attempting suicide in the total study period (57.3%), followed by pesticides in 26.9% of cases. In 4.02% of cases, household products were used to attempt suicide.
The highest percentage of cases was admitted in July (12.8%), followed by May (10.4%), and the least percentage (5.4%) was in January; 41.7% of suicide attempts by medications, 43.9% of those taking pesticides, 46.3% of those taking unknown combinations and 31% of those using household products were from the 10-20 years age group; 61.2% of cases that used drugs of abuse for attempting suicide were from the 20-30 years age group. Significant difference was noticed between different age groups and the type of poison used for attempting suicide, where MCp<0.001 (Table 3).
Significant difference was observed between males and females regarding type of poison used to attempt suicide. Females preferred to use unknown combinations (75.5%) and pesticides (64.7%), while males used drugs of abuse (59.7%) and household products (51.4%) (Table 3); 80% of cases using household products for attempting suicide, 59% of those using pesticides, 78.4% of cases using medications, 73.1% of those taking drugs of abuse and 73.5% of cases taking unknown combinations were from urban areas. Significant difference was noted between urban and rural residence according to type of poison taken with p<.001.
Significant relation was noticed between date of admission and type of poison taken for attempting suicide (p<.001). The highest percentage of cases taking household products (17.2%), pesticides (12.8%) and medications (13.5%) was admitted in July. The highest percentage of those taking drugs of abuse (28.4%) and the highest percentage of cases taking unknown combinations (15.5%) were admitted in May and February, respectively.
Pattern and socio-demographic description of the problem of suicide, whether complete or attempts, differ widely in different societies and over time. Egypt, as a developing country, suffers from underreporting and lack of registration of suicide and suicide attempts. This may be due to the religious background that considers suicide as a sinful act. Moreover, the cultural beliefs in Egypt may cause stigmatization of suicide and attempted suicide. 
Alexandria is the second-largest city in Egypt located on the Mediterranean coast, with a population of 5,200,000. Alexandria Poison Centre (APC) and Medicolegal Authority Alexandria department, in Alexandria, Egypt serves many governorates beside Alexandria Governorate like Marsa Matrouh, El-Behera and Kafr Elshikh Governorates.
The aim of the present study was to provide updated data on the magnitude and pattern of suicidal poisoning deaths and suicidal poisoning attempts in Alexandria, Egypt.
During the three-year study period of this work, 7205 cases of attempted suicide and 101 autopsies were related to suicidal deaths by self-poisoning. These numbers represented about one third of all acute poisoning cases admitted to Alexandria Poison Centre and 4.9% of all autopsies performed in the Medico- legal Authority Alexandria department, Egypt. The present research showed significant decrease in the annual rate of attempted suicide with significant increase in the annual rate of death from self-poisoning. This may reflect the use of highly hazardous substances to commit suicide in recent years.
In an earlier study done in Alexandria Governorate, Egypt, from 2008 to 2012 , there were 25 cases of suicide by self- poisoning over the studied five years, that is in comparison with the present study, denotes, unfortunately, continuous increase in the number of deaths due to self-poisoning in the governorate. Regarding Cairo city, a study performed by Taha et al (2011)  showed that complete suicide by poisoning was diagnosed in only 36 cases over the five years from 1998 to 2002, most of whom were females (n = 26, 72.20%). Moreover, Gad El Hak et al (2009)  carried out their study in Port Said city from 1998 to 2004. They concluded that 20 cases were dead due to suicidal rodenticide intake. On the other hand, in their study, Kordrostami et al (2017)  found that in a five-year study period, 1667 suicide cases were investigated in Legal Medicine Organization, Tehran, Iran, of which, 674 cases (40.43%) were due to self-poisoning.
In the present work, less than two-thirds of complete suicide cases were in the 10-20 years age group, while the least percentage (2%) was in the 60-70 years age group. Moreover, the present study found that the highest percentage of cases in the age groups 10-20 years, 20-30 years and 40-50 years were females. While in the 30-40 years age group, (the highest percentage were males. This result coincided with Prajapati et al (2013)  and Singh et al (2017) . This may be attributed to the fact that teenagers, during this period of life, may suffer from many problems such as failure or low scores the exams, reproofing from parents or teachers, failure in love or family problems. On the other hand, people in their extremes of ages might suffer less stress than younger people. Moreover, according to WHO, suicide is considered the second leading cause of death in the ages 15–19 years.
On the other hand, this result demonstrated a lower age group than that obtained by Gad El Hak et al (2009) , Moneim et al (2011)  and Sherif et al (2014) , who found that the highest percentage of cases was in the 3rd decade of life, followed by those in the 4th decade. Moreover, Taha et al (2011)  concluded that the highest number of cases in both sexes was in the middle age group from 20 to 34 years. In a study from Kuwait (2015) , they found that the 4th decade accounted for most cases of suicide by poisoning.
Furthermore, in the present work, more than two thirds of complete suicide cases were females with significant increase in their numbers compared to males that committed suicide by self-poisoning throughout the study period. This result was in agreement with Schaffer et al (2017)  in patients with bipolar disorder. At the same time, Moneim et al (2011)  concluded that poisoning was the first most common cause of suicide in 70% of females and 29% of males included in their study.
On the other hand, this result contradicted many previous studies [1, 4, 8, 9, 11]. This difference in results may be due to the fact that many of these researches studied all methods of suicide, not only self-poisoning, that included other violent ones like hanging and firearms, which are mostly used by males.  In the present study, the majority of suicidal deaths due to self- poisoning occurred in rural areas. This may be due to many factors, here in Egypt as a developing country, such as easy accessibility of the means for suicide especially pesticides, difficulties in retrieving health care and in getting the necessary care. This result contradicted that of Prajapati et al (2013) , who found more suicide cases in urban regions.
Regarding the educational level, less than one third (30.7%) of cases were in secondary school, followed by illiterates as well as intermediate education, while only one case had higher education. This result coincided with Prajapati et al (2013).  Furthermore, in their study in Italy, Pompili et al (2013)  tried to study the association between educational accomplishment and complete suicide. They concluded that suicide victims had significantly higher educational level compared to the people of the same sex and age deceased from natural causes. However, in a Japanese study, Kimura et al (2016)  found that high educational levels were linked to a decreased risk of suicide for both Japanese men and women. Phillips and Hempstead (2017)  concluded that male study participants with a high school degree had twice the rate to die from suicide than those with a college degree in 2000-2014.
On the other hand, 43.6% of cases were unemployed, 30.7% were students and about one quarter of cases, (25.7%) were workers. This result was in agreement with Singh et al (2017) , Kordrostami et al (2017) . Kposowa et al (2019)  concluded that unemployment was significantly linked to suicide, and the influence of unemployment on suicide was much higher among females than males. In a study carried out in Hong Kong, Yip and Caine (2011)  found that in despite a strong correlation between unemployment and suicide rates in 2006, suicide rates among employed and unemployed groups turned into the opposite direction. This meant, suicide rate among the unemployed fell during economic collapse and increased during retrieval.
As for marital status, the highest percentage of cases (69.3%) was single, 22.8%- married, 5.9% -divorced and only 2% -widows. This coincided with many previous studies [1, 4, 9]. However, it was contrary to Singh et al (2017)  who found higher suicidal rates by poisoning among married persons more than the unmarried ones.
Concerning the substance used in suicide, in the present study, most of death cases in 96% of suicide were due to pesticides. Out of them, more than half (51.5%) used Zinc phosphide and less than one quarter (24.8%) used Aluminum phosphide as substance of suicide. This finding was in agreement with many previous studies. [1, 6, 8, 17]
In fact, using pesticides for self-poisoning especially in developing countries, is not a new phenomenon. It is a common incident in all developing countries not distinctive to a certain country. However, although being an old and universal problem, no comprehensive solution was taken. This may be due to the agricultural pattern in developing countries, where large numbers of people living in rural areas cultivate small land areas. Therefore, pesticides are available where most people live. This pattern is completely diverse from that in industrialized countries, where a small number of farmers cultivate large zones of land. Hence, access to pesticides is largely restricted to a few individuals involved in farming. Also, the pesticide trade is a multi-billion -dollar business that raises the tension between commercial benefits and population health. Industry cannot recognize the influence of the easy obtainability of lethal pesticides on patterns of suicide. Moreover, the self- inflicted nature of suicide, and the fact that there are fewer suicide deaths than deaths from other global health problems, may cause strategy makers giving it lesser importance than the number of premature deaths due to other causes.  Regarding the season of the year during which attempted and completed suicide cases happened in this work, the highest percentage of cases was in spring (36.6%), followed by summer (30.7%), then winter (28.7%), and the least percentage was in autumn (4%). Moreover, the present study demonstrates non-significant difference in the type of poison and season of poisoning according to the year of poisoning. As for suicidal attempts in the current study, the highest percentage of cases was admitted in July (12.8%) followed by May (10.4%) and the least percentage of cases (5.4%) was in January. Many previous studies concluded that suicides peak during spring and summer. A common and reasonable theory to explain this relationship is that increased exposure to sunshine changes biological mechanisms through dysregulation of serotonin and or melatonin production or metabolism. [1, 19-22]. However, it was contrary to Raut et al (2017) , who found the highest percentage of cases during winter.
The present research demonstrated that about two thirds of those committed suicide using pesticides (62.9%) were in the 10-20 years age group, with significant difference from other age groups, 68% of them were females and 88.7% were from rural areas. The highest percentage of them (29.9%) were secondary school students with significant difference between different education levels. Out of those using pesticides for committing suicide, 43.3% were unemployed and 69.1% were single, with significant difference from other groups. Moreover, 36.1% of suicides from pesticides were in spring months. Regarding suicidal attempts, in the current study, the mean age of patients was 24.88±9.84 (min-max =10-75 years). The highest percentage (42%) of attempted suicides was in the 10- 20 years age group, while the least percentage (0.5%) was in the 7th decade of life (60-70 years). Significant difference was noticed between different age groups and the type of poison used for attempting suicide; 41.7% of cases who attempted suicide by medications, 43.9% of those taking pesticides, 46.3% of those taking unknown combinations and 31% of those using household products were from the 10-20 years age group 10-20 years. While 61.2% of cases that used drugs of abuse for attempting suicide were from the 20-30 years age group, this range of age was significantly less than those obtained by Gunnell et al (2004)  and Assadi and Afshari (2016) . Regarding sex, about three fourths of suicide attempts (74%) were females. These findings coincided with Imtiaz et al (2015) , Assadi and Afshari (2016)  and Spiller et al (2019) . Concerning residence in the present work, less than three- fourths (72.7%) were from urban areas. This result coincided with Gondim et al (2017) .
The present study demonstrated that use of medications was the most common method of attempting suicide over the total study period (57.3%), followed by pesticides in 26.9% of cases. The least percentage of cases (4.02%) used household products as a method for attempting suicide. This was in agreement with Gunnell et al (2004) . However, it was in contrary to that obtained by Imtiaz et al (2015)  and Gondim et al (2017) , who concluded that insecticides, and kerosene oil were the most commonly chemicals used for attempting suicide. Conclusion
Based on the data of the present research, complete suicide and suicide attempts by self-poisoning, in Alexandria, Egypt, were more common among teenage females. The most common poison used for attempting suicide was medications in urban regions. However, most deaths occurred due to pesticides in rural areas.
Reporting and registration of suicide and suicide attempts should be mandatory in all hospitals in Egypt in to help assess the magnitude of the problem and developing a prevention program. Suicide prevention programs should be targeted at teenagers. Implementation of psychological autopsy in complete suicide cases may help in collection of information about the high risks associated with suicide, but it needs consent from decedents’ families. Furthermore, controlling access to hazardous pesticides, like limiting their sale and securing their storage. In addition, better treatment of poisonings could help in minimizing numbers of suicide, especially in rural areas in Egypt. Further research is recommended to study the groups particularly at risk for attempted and completed suicide here in Egypt.
As this is a retrospective study, some information about factors related to chemical poisoning was missing in the current study, like the exact doses and the causes of suicide. Also, poor registration and health information systems affected collection of data.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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Heba Abdel Samie Mohamed Hussein, Hamed ELsayed Mustafa Elsawaf. Suicidal poisoning in Alexandria, Egypt-An updated statement. Ann Clin Anal Med 2021;12(8):888-894
Stature estimation from the length of the distal phalanges prints among Egyptian using regression analysis
Wael Saad Kholeif
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, University of Alexandria, Egypt
DOI: 10.4328/ACAM.20488 Received: 2021-01-16 Accepted: 2021-03-15 Published Online: 2021-03-28 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):895-899
Corresponding Author: Wael Saad Kholeif, Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, University of Alexandria, Egypt. E-mail: email@example.com P: 01221371021 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3303-5237
Introduction: Identification is critically important in forensic medicine in cases of mass disasters where mutilated and amputated body parts are frequently found. Stature estimation is the main element of identification. Fingerprint anthropometry can provide useful data to estimate stature for identification pur- poses. The current research aimed to identify the stature from the length of the distal phalanges prints among Egyptians using regression analysis.
Material and Methods: The study was conducted on 150 adults in the age group of 18 to 40 years. The cleaned hands were set on an inked plate and measure- ments of the distance between the most projecting points on the tip of the fingerprints and to the distal digital crease mark were taken.
Results: The mean stature was significantly longer in males than in females. The mean length of the distal phalanges prints was higher in the right hand than in the left hand in males, and in the left hand than in the right hand in females. Correlation coefficient (R) values were comparatively higher in males. Also, the coefficient of determination (R2) was higher in males and all measurements showed a significant positive correlation with the stature, where P < 0.05.
Discussion: The regression equations of distal phalanges prints measurements could be valuable for the determination of stature among adult Egyptians for forensic purposes.
Keywords: Forensic; Fingerprints; Stature; Distal phalanges; Egyptians
Identification is the assessment of the individuality of a living or dead individual. It is the backbone of any forensic examination, regardless of whether it is of the suspect from the actual proof at the crime scene or of the victim. Various kinds of identification are available as criminal, civil, personal, and lawful identification . Thus, the identification of the obscure body is a moral and human duty that lies on the shoulder of the forensic pathologist, anthropologist, dentist, and police . Anthropometry alludes to the measurement of the human individual. It has been utilized for recognizable proof, to understand actual human variety [3,4]. The investigation of forensic and archaeological human remaining parts depends on the assessment of bio-demographic parameters, including stature, age, weight, and gender. Thus, the estimation of human stature is a significant parameter in identification in cases as homicide, theft, housebreakings, and bomb blasting incidents dependent on the physical evidence presented in the crime scene. Human stature could be predicted through the measurements of various body parts that are known as mathematical procedures [5-7]. In the mathematical techniques, stature is assessed from independent variables using equations that depend on the linear relationship between height and the variable [8,9]
Numerous researches have been led on the prediction of stature from different body parts like the trunk, intact vertebral column, upper and lower limbs, foot and footprints, hands, and handprints .
Fingerprints are unique characteristics of human beings. Notably, they are highly distinctive among persons . The principal reason that fingerprints are so significant in a forensic setting is that the hands are in usual constant physical contact with surroundings and leave a personal signature behind . The fingerprint makes a significant biometric system used throughout the world. It is valuable physical evidence found in crime scenes .
Therefore, the current work aimed to identify the stature from the length of the distal phalanges prints among Egyptians using regression analysis.
Material and Methods
The present work is a prospective cross-sectional study that was carried out at the Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, the University of Alexandria during the academic year 2019- 2020. Ethical approval was obtained from the Ethics Committee of the Faculty of Medicine, Alexandria University (IRB Number: 00012098, FWA Number: 00018699, Approval serial number: 0304539).
Informed consent was obtained from all the individuals before participation in the present study. Persons with any apparent hand-related disease or injury and those with orthopedic deformity were excluded from the research.
Stature was measured using a portable body meter measuring device following the standard procedure; the height of the individual was taken at a fixed time. The height (stature) of the subject was measured in a standing posture with bared head and foot. The person stands barefoot in an erect position with their heels, buttocks, back and the back of their head against the wall with both feet kept beside and hands presented down on the sides and the measurement was taken from the vertex to the floor in centimeters .
The cleaned hands were set on an inked plate with gentle pressure and then impressed on an A4 size white paper. The thumb was in the abducted position and other fingers in the extended position and the distance between the most forwarding projecting points on the tip of the fingerprints Thumb [T], Index [I], Middle [M], Ring [R] and Little [L] to the distal digital crease mark (A) was taken .
The landmarks and measurement of the length of the distal phalanges on the right-hand print are illustrated in Figure 1.
I. AT – length, the measurement taken from the most forwarding projecting points on the tip of the thumb fingerprint to the distal digital crease.
II. AI – length, the measurement taken from the anterior point of index fingerprint to the distal digital crease.
III. AM – length, the measurement taken from the anterior point of the middle fingerprint to the distal digital crease.
IV. AR – length, the measurement taken from the anterior point of ring fingerprint to the distal digital crease.
V. AL – length, the measurement taken from the anterior point of the little fingerprint to the distal digital crease.
Statistical analysis of the data
Information was entered into the computer and analyzed using IBM SPSS software package version 20.0. Student’s t-test was evaluated to match two groups for normally distributed quantitative variables. Paired t-test was utilized for correlation between various sides for normally distributed quantitative variables. From the analyses, Pearson’s correlation coefficient (R) and standard error of estimate (SEE) were obtained and the coefficient of determination (R2) was found to be the most proper one for estimation of stature. The linear regression analysis method was utilized for stature determination from different distal phalanges prints measurements as the estimation of stature from distal phalanges prints length with regression analysis is more reliable and accurate . The level of significance was set at p ≤ 0.05
The study was carried out on 150 adult Egyptian persons (104 males and 46 females) of known and confirmed age (18-40 years).
• In males, the stature ranged from: 165.0 to 196.0 cm (mean 177.0 cm)
• In females, the stature ranged from: 160.0 to 176.0cm (mean 166.8 cm).
• The research demonstrated that the mean stature was significantly higher in males than females (p <0.001). (Table 1)
• Distal phalanges lengths (cm) in males in both right and left hand:
The mean length of the thumb distal phalanges prints was found to be longer than other distal phalanges prints lengths both in right and left hands in males, followed by the mean length of the ring distal phalanges prints, while the mean length of the little distal phalanges prints was found to be shorter than other distal phalanges prints lengths.
The mean length of the distal phalanges prints was found to be longer in right hands than in left hands, except for the length of the index distal phalanges prints, which was equal in both hands.
There was no significant difference between the mean length of the right and left hands distal phalanges prints, except the length of the little distal phalanges prints, which was significantly higher in right than left hands.
• Distal phalanges lengths in females in both hands:
The distal phalanges prints measurements in females were found to be longer in left hands than in right hands, except for the mean length of the index distal phalanges prints, which was equal in both hands. There was no significant difference between the length of the distal phalanges prints in left and right hands, except for the length of the ring distal phalanges prints and the length of the little distal phalanges prints.
• Distal phalanges lengths in a pooled sample:
The pooled sample showed the combination of male and females distal phalanges measurements in which there was no significant difference between the length of the distal phalanges prints in both right and left hand. (Table 2)
• Stature estimation through measurement of distal phalanges lengths in adult males and females using linear regression equations:
The different linear regression equations established to estimate stature from various distal phalanges lengths in both hands in both males and females. The correlation between stature and distal phalanges lengths is demonstrated as Karl Pearson’s correlation coefficient (R). The R values showed to be higher in males (0.014 – 0.550) than females (0.097 – 0.391). Regarding the coefficient of determination (R2), the predictive accuracy showed to be higher in males when compared with females, and all measurements showed a positive correlation with the stature. The established linear regression equations to estimate stature from distal phalanges prints lengths in both males and females illustrated accuracy and reliability, as the values of the standard error of estimation (SEE) showed to be low.
• Stature estimation through measurement of distal phalanges lengths in pooled samples using linear regression equations: The R values in pooled samples of Egyptians ranged from 0.156 to 0.596, and the standard error of estimation values ranged from 6.718 to 8.264, which showed to be low. In the case of a fingerprint of unknown gender, the regression equations derived for the pooled sample may be used to determine the stature (Table 3).
Stature is considered one of the main features for the identification of an unknown person and is usually assessed through the measurements of the limb bones. However, stature relies upon various variables like gender, genetic make-up, racial and geographical origin, social stratum, and physical activity . The stature of a person is an inherent feature and it is one of the main parameters for individual identification. There is an established relationship between height and dimensions of various body landmarks, that helps forensic experts to assess stature from various body landmarks, and consequently, for forensic identification of persons .
One of the main purposes of a medicolegal investigation is to determine the character of an individual, particularly in situations where traces such as fingerprints are recovered and brought for assessment. A literature review revealed that fingerprint anthropometry has provided valuable data to determine the height for the aim of identification. Fingerprints are precious physical evidence frequently accessible in scenes of crime as robbery, homicide, rape, and firearm incidents . Thus, the current study aimed to predict the stature of the person implicated or injured in a crime when hand impressions are present.
This study has been carried out among a sample of adult Egyptians for the identification of the stature from the length of the distal phalanges prints of both hands using regression analysis.
This study was concerned only with the length of distal phalanges print rather than whole finger length, as usually in the crime scenes, the print found to belong to the distal phalanges, since they are the part of the finger that deals with different objects.
The current research was conducted on 150 adult male and female individuals. The age of the participants ranged from 18 to 40 years, the average length of the adult’s hand attained its final dimensions by the age of 16 years in males and 14 years in females .
Analysis of the study and comparison of stature done by researchers in other countries with our findings demonstrates a close relation of body height of Egyptian with Saudi Arabians and Chinese populations, while individuals from Slovakia and Australia were considerably taller. On the other hand, the shortest were the inhabitants of India and Bangladesh . The research illustrated that the mean height of males is higher than that of females, demonstrating the presence of a statistically significant gender difference in the Egyptian population. This may be due to earlier skeletal maturation in girls than in boys; consequently, boys have two more years of physical growth .
Similar results were detected by other researchers in their studies .
Also, the mean distal phalanges print length measurements were found to be larger in males than females in both hands. Similar results were obtained by Krishan and Sharma, (2007)  where they found a statistically significant difference between the mean measurements of the hands of males and females.
Bilateral variation was statistically significant only for the hand length of the little distal phalanges prints in the male group (p < 0.001) and the hand length of the ring and little distal phalanges prints in the female group (p < 0.001).
However, the study by Moorthy and Yin (2016)  on Malaysian Chinese showed that the size of left and right hands did not show any significant bilateral asymmetry in both genders.
The R values showed to be comparatively higher in males compared with females. This is consistent with the study by Jasuja (2004)  who studied the stature determination from hand and phalange length on Indian persons.
However, the study by Moorthy and Yin (2016)  on the Malaysian Chinese population showed that the R values were almost similar in both genders.
The coefficient of determination (R2), the predictive accuracy showed to be higher in males than females, and all measurements are found to correlate positively with stature determination, which is similar to the research done by Kornieieva and Elelemi (2016) , who studied the determination of stature from handprint measurements in a sample of the Saudi population. Our research showed a statistically significant correlation of stature with distal phalanges lengths in both sexes, suggesting a linear and a nearby relationship between stature and these measurements, and illustrated that the length parameters are useful for stature determination, which coincides with many studies [22, 23].
From this work, it was concluded that using regression equations, distal phalanges prints measurements can provide useful information for stature determination in the forensic field among adult Egyptians.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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Download attachments: 10.4328_ACAM.20488
Wael Saad Kholeif. Stature estimation from the length of the distal phalanges prints among Egyptian using regression analysis. Ann Clin Anal Med 2021;12(8):895-899
Strain relatedness in gram-negative bacteremia: Cause or contamination?
Ilkay Bahceci 1, Aziz Ramazan Dilek 1, Kazim Sahin 1, Ilknur Esen Yildiz 2, Omer Faruk Duran 3, Zihni Acar Yazıcı 1
1 Department of Microbiology, Recep Tayyip Erdoğan University, Medical Faculty Hospital, 2 Department of Infectious Diseases, Recep Tayyip Erdoğan University, Medical Faculty Hospital, 3 Department of Medical Microbiology, Recep Tayyip Erdoğan University Medical Faculty, Rize, Turkey
DOI: 10.4328/ACAM.20490 Received: 2021-01-16 Accepted: 2021-03-11 Published Online: 2021-03-28 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):900-902
Corresponding Author: Ilkay Bahceci, Recep Tayyip Erdoğan University, Medical Faculty Hospital, Microbiology Department, Zihni Derin Campus, Fener street, 53100 Rize, Turkey. E-mail: firstname.lastname@example.org P: +90 464 223 61 26 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3662-169
Aim: Bloodstream infections are a major cause of mortality, 25% of which are associated with gram-negative bacteremia. To avoid the inappropriate use of antibiotics, it is important to differentiate the bacteremia from contamination. In general, gram-positive bacteria were more likely to be contaminants than gram-negative-bacteria. There is little information in the literature concerning the epidemiology of gram-negative bacteria isolated from sequential blood cultures. Therefore, we aimed to examine the molecular epidemiology of gram-negative bacteria isolated from sequential blood cultures.
Material and Methods: A total of 56 patients (112 samples and strains) with two or more sequential positive blood cultures for gram-negative bacteria with the same antibiogram were included in the study. Pulsed-field gel electrophoresis (PFGE) and arbitrarily primed PCR (AP-PCR) were performed for the deter- mination of strain relatedness.
Results: While PFGE analysis demonstrated relatedness in 6 isolates, AP-PCR demonstrated 9 relatedness in 112 isolates.
Discussion: The results of our study suggest that, although the possibility of contamination is very low in gram-negative bacteremia, this can still take place, as shown in sequential blood cultures with the same antibiogram.
Keywords: Bacteremia; Strain relatedness; Pulsed-field gel electrophoresis; Arbitrarily primed PCR
Nosocomial infections contribute to significant morbidity and mortality and occur in approximately 4% of hospitalized patients . Bloodstream infection (BSI) is a major cause of mortality and healthcare costs worldwide . BSI causes the prolonged length of stay in hospital and mortality in many cases. BSI is an acute event leading to life-threatening organ dysfunctions such as sepsis and septic shock . Accurate diagnosis and appropriate antimicrobial treatment are essential in order to increase the survivability of the patient and to decrease high rates of morbidity and mortality .
The culturing of blood for pathogens is a simple procedure and provides information essential for the evaluation of a variety of infectious diseases . One-fourth of sepsis cases are associated with gram-negative bacteremia . Gram- negative bacilli such as Enterobacteriaceae and Pseudomonas aeruginosa are the leading causes of nosocomial bloodstream infections. Antibiotic-resistant strains have emerged among the gram-negative bacilli and are being increasingly recognized . This significant increase in the incidence of infections caused by antibiotic-resistant Gram-negative bacilli has been a great concern in recent years.
To avoid the inappropriate use of antibiotics, it is important to differentiate the bacteremia from contamination. In general, gram-positive bacteria were more likely to be contaminants than were gram-negative-bacteria . Appropriate antimicrobial therapy has been demonstrated to reduce mortality in Gram-negative bacteremia patients . There is only a little information in the literature about the epidemiology of gram-negative bacteria isolation from sequential blood cultures. The aim of the current study was to examine the molecular epidemiology of gram-negative bacteria isolated from sequential blood cultures.
Material and Methods
Approval for the study was obtained from the institutional review board (No: 18824186-799). A total of 56 patients (112 samples and strains) with two or more sequential positive blood cultures for gram-negative bacteria that had the same antibiograms within a one-week period were included in the study. Clinical data including age, sex, underlying disease, symptoms of infection, other infection sites, and exposure to antibiotic therapy were collected.
Isolation of gram-negative bacteria from blood cultures was carried out using the Bact/Alert automated system (bioMerieux Industry, Hazelwood, MS, USA). The isolated strains were identified by the VITEK 2 system, using GN cards. All isolates were stored frozen at -70°C. Susceptibility testing for all isolates was performed by a disk-diffusion assay using antibiotic disks (Oxoid, UK) on Mueller–Hinton agar in a rich CO2 atmosphere and by VITEK 2 GNS cards. Pulsed-field gel electrophoresis (PFGE) of the samples treated with XbaIrestriction enzyme (Vivantis) was performed by means of a commercially available kit (GenePath Group 1, Bio-Rad Laboratories, Hercules, CA). Strain relatedness was defined as identical (no difference in banding), closely related (2 to 3 different bands), or unrelated (>3different bands) . In addition, we used a well-known effective PCR method (arbitrarily primed PCR: AP-PCR) for genotyping of the strains. To prepare templates for AP-PCR, single colonies were inoculated into L broth and were incubated as stationary cultures at 37°C for about 16 hours. Then, 0.5 ml of the resultant stationary-phase culture was boiled for 10 min, diluted 10-fold in distilled water, and used immediately or stored at 4°C until needed. Phenol-extracted template DNA was prepared for AP-PCR. The previously described arbitrary primers (P1:5’-AAGAG CCGT; P2: 5’-CCGC GCCAA; P3:5’-AACGCGCAAC; P4:5’-GCGATCCCCA) were used . Gels were photographed.
Demographic data of the patients are shown in Table 1.
A total of 112 episodes of bacteremia were identified. The majority of these episodes were due to Escherichia coli (26 patients, 52 isolates), with the remainder due to Acinetobacter baumannii (19 patients, 38 isolates), Klebsiella pneumoniae (7 patients, 14 isolates) and Klebsiellaoxytoca (4 patients, 8 isolates). Sequential isolates had similar antibiotic sensitivity. Most of the strains were extended-spectrum β-lactamase positive. PFGE analysis demonstrated relatedness in 4 out of 112isolates (Figure 1). These isolates were E.coli. The remaining isolates were identical. AP-PCR analysis revealed differences in six E.coli, two K. pneumoniae and one A. baumannii isolate.
Understanding epidemiological and microbiological data is critical in order to struggle with potentially life-threatening infections such as BSI, because understanding pathogens and their resistance patterns is of great importance for successful treatment. In this study, molecular epidemiology of gram- negative bacteria isolated from sequential blood cultures was investigated. However, resistance patterns are not discussed in detail here, since they are beyond the scope of this study. Blood culture is a critical tool for the healthcare professional, a positive blood culture can suggest a definitive diagnosis but, like any test, false positive results can limit the utility of this important tool . Contamination is not uncommon during the sample preparation process, which creates serious problems for interventions. Most contaminants are probably introduced from the patient’s skin during blood collection . Frequent contaminants included coagulase-negative staphylococci, Bacillus species and Corynebacterium species . Several clinical studies of bloodstream infections have provided guidelines for differentiating true pathogens from contaminants, but there is no gold standard for differentiating pathogens from contaminants .
Gram-negative bacteremia accounts for approximately 25% to 27% of bloodstream infections . Gram-negative bacilli such as Enterobacteriaceaeand P. aeruginosa are the leading causes of nosocomial bloodstream infections, and appropriate antimicrobial therapy has been shown to reduce mortality among patients with gram-negative bacteremia . The identification of the organism has been shown to be the most important prognostic factor in a predictive model for differentiating contamination from infection in blood culture results of bacteremia . In general, gram-positive bacteria were more likely to be contaminants than gram-negative- bacteria . It is accepted that E. coli and other members of the Enterobacteriaceae and P. aeruginosa always or nearly always (>90%) represent true bacteremia, which our study confirms .
One proven methodology that can help differentiate blood culture contamination from a true infection is the number of blood culture sets that grow organisms. For true bacteremia, multiple blood culture sets usually grow the same organism . In our study, we included two or more sequential positive blood cultures for gram-negative bacteria with the same antibiograms within a one-week period. We found 4 related Escherichia coli isolates and two closely related isolates of Klebsiella (K. pneumoniae and A.baumannii).
Even though there are numerous relatedness studies on gram- positive bacteria, there are very few studies in the literature on the gram-negatives [15-21]. We believe that this is due to overlooking gram-negative bacteria as potential contaminants. In conclusion, the results of our study suggest that although the possibility of contamination is very low in gram-negative bacteremia, it can still take place even in sequential blood cultures with the same antibiograms. This must be taken into account in bacteriemia, especially when antibiotic therapy fails.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some
of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
Conflict of interest
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4. Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90–2.
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15. Khatib R, Riederer KM, Clark JA, Khatib S, Briski LE, Wilson FM. Coagulase- negative staphylococci in multiple blood cultures: strain relatedness and determinants of same-strain bacteremia. J Clin Microbiol. 1995; 33(4):816-20.
16. Wendt C, Messer SA, Hollis RJ, Pfaller MA, Wenzel RP, Herwaldt LA. Molecular epidemiology of gram-negative bacteremia.Clin Infect Dis. 1999; 28:605-10.
17. Liao CH, Lai CC, Chen SY, Huang YT, Hsueh PR. Strain relatedness of methicillin-resistant Staphylococcus aureus isolates recovered from patients with repeated bacteremia. Clin Microbiol Infect. 2010; 16:463-9.
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Download attachments: 10.4328_ACAM.20490
Ilkay Bahceci, Aziz Ramazan Dilek, Kazim Sahin, Ilknur Esen Yildiz, Omer Faruk Duran, Zihni Acar Yazıcı. Strain relatedness in gram-negative bacteremia: Cause or contamination? Ann Clin Anal Med 2021;12(8):900-902
The mental health of intensive care unit healthcare workers who care for critical patients in pandemics
Veysel Garani Soylu, Öztürk Taşkın, Ufuk Demir, Ayşe Yılmaz
Intensive Care Clinic, Kastamonu Training and Research Hospital, Kastamonu, Turkey
DOI: 10.4328/ACAM.20494 Received: 2021-01-18 Accepted: 2021-03-10 Published Online: 2021-03-21 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):903-906
Corresponding Author: Veysel Garani Soylu, Intensive Care Clinic, Kastamonu Training and Research Hospital, 37150, Kastamonu, Turkey. E-mail: email@example.com P: +90 5065417935 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4617-3367
Aim: In addition to examining the pathophysiology and treatment of the coronavirus 2019 disease (COVID-19), it is very important to investigate the psycho- logical effects of the pandemic on healthcare workers.
Material and Methods: Our study was conducted in a group of nurses (85 people) who worked for at least 2 weeks in the COVID-19 intensive care unit of the Kastamonu Education and Research Hospital. Participants answered the questionnaire applied via the internet and sent the answers in the same way. For each participant, Patient Health Questionnaire-9 (phq-9, range 0-27), Generalized Anxiety Disorder-7 (gad-7, range 0-21), Insomnia Severity Index (isi, range 0-28) criteria are respectively depression, anxiety, and it was used to assess the severity of insomnia symptoms.
Results: It was observed that 24.7% of the nurses participating in our study had depression symptoms, 38.8% had anxiety symptoms, and 45.4% had insomnia symptoms. In the female nurse group, we found that depression, anxiety and insomnia symptoms were more pronounced. There was no statistically significant difference in 3 scales according to the years of intensive care work.
Discussion: Nurses treating COVID-19 patients are probably exposed to the highest risk of infection due to their close, frequent contact with patients and working longer hours than normal. The spread of the virus, the health of the family and others, changes in work, and concerns about isolation can affect the mental state of healthcare workers during this pandemic process.
In this study conducted on nurses working in the COVID intensive care unit, high rates of depression, anxiety and insomnia symptoms were observed among the respondents.
Keywords: COVID-19; Intensive care unit; Anxiety; Depression; Insomnia
At the end of December 2019, a new pneumonia caused by the Sars-Cov-2 (COVID-19) virus was reported from Wuhan, China, which rapidly spread to the whole world .
The first case was detected on March 11, 2020 in Turkey. The number of cases confirmed on September 30, 2020 was reported as 318 663 (available at: https://covid19.saglik.gov. tr/TR-66122/genel-koronavirus-tablosu.html). On January 30, 2020, the World Health Organization held an emergency meeting and announced that the global COVID-19 outbreak was an emergency of international public health. In addition to examining the pathophysiology and treatment of the COVID-19, it is very important to investigate the psychological effects of the pandemic on healthcare workers.
In this war that humanity has fought, healthcare professionals dealing with the diagnosis, treatment and care of patients with COVID-19 also experience psychological distress and other mental problems.
The psychological problems of healthcare workers related to the current pandemic stem from many factors such as uncertainty over the duration of the crisis, increasing number of cases, overwhelming workload, inadequate personal protective equipment, lack of specific drugs and vaccines, and insufficient psychological support.
Healthcare professionals are also affected by balanced social distance against the possibility of infecting themselves or their families with COVID-19. Experiences gained from early reports on the 2003 Severe Acute Respiratory Syndrome outbreak and COVID-19 show that healthcare workers experience anxiety, stress and fear [2,3].
Psychological assistance services, including telephone, internet, and practice-based counseling or intervention, are widely implemented by local and national mental health agencies in response to the COVID-19 outbreak.
In our study, to measure the symptoms of depression, anxiety and insomnia in intensive care nurses who provide care to COVID-19 patients, and to evaluate the mental health of intensive care nurses.
Material and Methods
An online questionnaire was applied to a group of nurses (85 people) who worked in COVID intensive care unit for at least 2 weeks in the Kastamonu Education and Research Hospital. The questionnaire applied to the hospital staff was sent via Whatsapp. A brief explanation was made explaining the subject of the research before the questionnaire. Those who volunteered to participate after the explanation filled the forms and sent them to the researchers. Using Turkish versions of validated measurement tools, the symptoms of depression, anxiety, insomnia, and distress were focused on for all participants [4,5]. Accordingly, patient health questionnaire-9 (phq-9, range 0-27) , generalized anxiety disorder-7 (gad-7, range 0-21) , insomnia severity index (isi, range 0 -28)  were used to evaluate the severity of symptoms of depression, anxiety, and insomnia, respectively. The total scores of these measurement tools are interpreted as follows:
– PHQ-9, normal (0-4), mild (5-9), moderate (10-14) and severe (15-27) depression;
– GAD-7, normal (0-4), mild (5-9), moderate (10-14) and severe (15-21) anxiety
– ISI, normal (0-7), threshold (8-14), moderate (15-21) and severe (22-28) insomnia.
These categories are based on the values determined in the literature [4,5].
The cut-off score to detect symptoms of major depression, anxiety, insomnia, and distress was 15, 7 , and 15 , respectively. Participants scoring higher than the cut-off threshold were considered to have severe symptoms. Demographic data of the participants of our survey participants,, gender (male or female), age (18-25, 26-35, 36- 45 or> 46 years), marital status (married or single), presence of children (yes-no), social lifestyle (living alone or together), educational status (high school / associate degree-language / master), years of working in the intensive care (less than 1 year, 1-3 years, 4-5 years, 6 years or more).
Ethics committee permission was obtained from Kastamonu University.
Statistical Data Analysis
Data analysis was performed using SPSS statistical software version 20.0 (ibm corp). The level of significance was set at α = .05. The original scores of the 3 measurement tools were not normally distributed and are therefore presented as medians with intercard intervals (iqr). Ordered data derived from the count of each level for symptoms of depression, anxiety, and insomnia are presented as numbers and percentages. The nonparametric Mann-Whitney-U was used, and the Kruskal- Wallis test was used to compare the severity of both symptoms between 2 or more groups.
The demographic characteristics of the 85 nurses participating in the study are summarized in Table-1. Sixty-eight of the nurses participating in the study (80%) were female, more than 50% [18-25 years old: 32 (37.6%) people, 26-35 years: 32 (37.6%) people] were young population. More than 50% of the participants had less than one year of intensive care experience [46 (54.1%) people]. Forty-one (47.1%) participants were married, 27 (32.9%) had at least one child; 49.7% of the participants were maintaining their social life alone in this process. Thirty-five (41%) participants were those who continued their social life with relatives, and 8 (10%) were those who were not with relatives (Table 1).
Depression, anxiety, and insomnia symptoms of the study participants, comparison by gender, marital status, having children and education levels is summarized in Table 2. Although the anxiety and depression findings of the married participants were not statistically significant compared to the single ones, the insomnia symptoms were more pronounced (p: 0.04). Among the participants of the survey, no difference was found in the statistical analysis between whether they have children, their educational status, whether they continue their social life alone, and the age range of the respondents.
Twenty-one of the participants (24.7%) had symptoms of depression, 33 (38.8%) had symptoms of anxiety, and 36 (45.4%) had insomnia symptoms. In the study, it was found that depression, anxiety and insomnia symptoms were more pronounced in the female nurse group (p: 0.02, p <0.01, p: 0.05, respectively).
In statistical analysis, although there was no significant difference in all 3 scales (depression, anxiety, insomnia symptom) in educational status groups, there was a 2-fold difference in symptom appearance between the high school- associate degree group and the undergraduate-graduate group in the depression scale.
Considering the years of intensive care work, no statistically significant difference was found in all 3 scales.
The median (IQR) scores of the total participants were as follows: PHQ-9 for depression, GAD-7 for anxiety, and isi for insomnia symptoms were 11 (8-15), 8 (6-11), and 14 (10-17), respectively.
Similar to the findings for symptoms severity, a statistically significant difference was found in the comparison of the male and female groups (PHQ median for depression (IQR) male 7 (6- 11), female 12 (8-15) p: 0.04; GAD-7 median for anxiety (IQR) male 4 (4-7) female 9 (7-12) p: 0: 00; ISI median for insomnia symptoms (IQR) male 10 (7-13) female 14 (10-17) p: 0.02).
In the statistical analysis made in relation to the scores of the measurements, no significant difference was found between years of intensive care work, marital status, age, educational status, child ownership, and living alone or living together in social life (Table 3).
This survey study evaluated 85 nurses who worked in the COVID-19 intensive care unit for at least 2 weeks, and showed that the intensive care nurses serving COVID-19 patients during the pandemic had severe psychological health symptoms. Nurses treating COVID-19 patients are probably exposed to the highest risk of infection due to their close, frequent contact with patients and working longer hours than normal [9,10]. Overall, 24.7%, 38.8%, and 42.4% of all participants reported symptoms of depression, anxiety, and insomnia, respectively. Approximately one-third of the total participants had symptoms of psychological disturbance.
In the study conducted by Lai et al., involving 1257 healthcare workers in China during the pandemic process, more than 70 percent of the participants had psychological distress symptoms . In a previous study conducted during the acute SARS epidemic, 89% of healthcare workers in high-risk situations reported psychological symptoms .
Among the nurses participating in the study, the depression, anxiety and insomnia symptoms of women were more severe; 80% of the participants were women, 75% were between the ages of 18-35, 51% were single. In addition, insomnia symptoms of the married participants were more pronounced. Although there was no statistical difference between the two groups in the education group on the depression scale, high school-associate degree graduates were twice as likely to have depressive findings.
The spread of the virus, the health of the family and others, changes in work, and concerns about isolation can affect the mental state of healthcare workers during this pandemic process .
The fact that COVID-19 can be transmitted from person to person can intensify the perception of personal danger associated with high morbidity  and potentially fatal outcome .
In a study by Lai et al., it was found that 71.5% of all nurses had less working experience ; 54% of the nurses participating in our study had less than a year of intensive care experience. When comparing the less experienced and more experienced nurse groups, no significant difference was found in terms of their psychological status.
In this study conducted on nurses working in the COVID intensive care unit, among the survey participants, high rates of depression, anxiety, and insomnia symptoms were observed. Protection of healthcare workers is an important component of public health measures against the COVID-19 outbreak. We think that psychological and social support is necessary to alleviate anxiety and provide peace for nurses working in intensive care units, and especially female nurse groups.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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2. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976. DOI: 10.1001/ jamanetworkopen.2020.3976.
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4. Zhang YL, Liang W, Chen ZM, Zhang HM, Zhang JH, Weng XQ, et al. Validity and reliability of Patient Health Questionnaire-9 and Patient Health Questionnaire-2 to screen for depression among college students in China. Asia Pac Psychiatry. 2013;5(4):268-75. DOI: 10.1111/appy.12103.
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Download attachments: 10.4328_ACAM.20494
Veysel Garani Soylu, Öztürk Taşkın, Ufuk Demir, Ayşe Yılmaz. The mental health of intensive care unit healthcare workers who care for critical patients in pandemics. Ann Clin Anal Med 2021;12(8):903-906
A study of possible toxicological effects of Methylparaben on estrogen receptor-α negative MCF-7 human breast cancer cell line
Wafaa Mohamed Elsehly 1, Ghada M. Mourad 2, 4, Radwa A. Mehanna 3, 4, MennattAllah Hassan Attia 1, Marwa Kholief 1, 4
1 Department of Forensic Medicine and Clinical Toxicology, 2 Department of Histology and Cell Biology, 3 Department of Medical Physiology, 4 Center of Excellence for Research in Regenerative Medicine and Applications (CERRMA), Faculty of Medicine, Alexandria University, Egypt
DOI: 10.4328/ACAM.20499 Received: 2021-01-22 Accepted: 2021-02-28 Published Online: 2021-03-09 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):907-911
Corresponding Author: Marwa Abdelfattah Elsayed Kholief, Forensic Medicine and Clinical Toxicology Department, Center of Excellence for Research in Regenerative Medicine and Applications (CERRMA), Faculty of Medicine, Champollion street, Alexandria, Egypt. E-mail: firstname.lastname@example.org P: +20 1003658572 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8776-5257
Aim: Methylparaben (MP) is the most commonly used preservative in various everyday life products. It is considered one of the xenoestrogens because of its metabolic activity as an estrogen agonist. Hence, it is implicated to play a role in breast cancer development. The human breast adenocarcinoma cell line MCF-7 (Michigan Cancer Foundation-7) is used as a standard model for in vitro cancer research. However, it is now recognized that MCF-7 is heterogeneous concerning both the expression of hormone receptors and the utilization of the signaling pathways linked to these receptors. The present study aimed to study in vitro toxicological effects of MP on estrogen receptor- negative (ER–ve) MCF-7 breast cancer cell line.
Material and Methods: MCF-7 cells were verified immunologically for the presence/absence of ER using immunocytochemistry and flow cytometry. MCF-7 cells were incubated with five MP at serial concentrations of 4×10-5 M, 6×10-5 M, 8×10-5 M, 1×10-4 M and 2×10-4 M. The effect of a single exposure to serial concentrations of MP was studied concerning the proliferation of ER-ve MCF-7 cells. Cell viability was determined using MTT assay.
Results: A single exposure to the experimented doses of MP did not demonstrate any stimulatory effect on proliferation of MCF-7 cells with no significant dif- ferences between the doses compared to untreated cells. Simultaneously, the applied doses exerted no effect on alpha ER expression.
Discussion: In conclusion, a single exposure to MP in various dose ranges did not influence estrogen -ve MCF7 cancer breast cells’ growth.
Keywords: Methylparaben; Breast cancer; ER-ve MCF-7; Flow cytometry
Parabens (4-hydroxybenzoic acid esters) are common ingredients in thousands of processed food, pharmaceuticals, cosmetics, and daily personal care products [1,2]. Since the human consumption of these compounds is frequent through the exposure to the skin, lips, eyes, oral mucosa, nails, and hair, researchers have investigated whether the three most commonly-used parabens (methyl-, ethyl- and propylparaben) can be considered as xenoestrogens; a class of endocrine- disrupting substances .
ERα is a major ER sub-type that plays a crucial role in breast cancer progression. ERα mediates estrogen-induced cell proliferation in ERα-positive breast cancer cell lines in an autocrine mode . The molecular mechanisms by which ERα mediates estrogen-induced cell proliferation in ERα- positive breast cancer cell lines are not clear. It was found that ERα promotes S–phase entry of MCF–7 cells and cellular proliferation, while E2 enhances ERα-induced proliferation of MCF–7cellsbystimulatingtheexpressionofproliferatingcell nuclear antigen (PCNA) and Ki–67 .
Molecular modeling showed that paraben molecules bind into the ligand-binding pocket of the crystal structure of the ligand- binding domain (LBD) of ERα in place of 17β-estradiol . In vivo studies implicated that estrogenic chemicals are capable of binding to ER, activate estrogen-responsive gene expression and subsequently enable the proliferation of estrogen- dependent cells that increase uterine weight in the immature or ovariectomized rodent assay .
Notwithstanding, the majority of the studies addressing interferences of parabens with estrogen hormone action focused on the ER-positive status. The possible interferences of parabens with pre-receptor control enzymes modulating endocrine functions remain to be investigated . Moreover, MCF-7 cell lines are recognized as heterogeneous with respect to both the expression of hormone receptors and the utilization of the signaling pathways linked to these receptors, resulting in their phenotypic heterogeneity .
In an attempt to elucidate the controversies about parabens as breast cancer promoters, the present study aimed to study in vitro toxicological effects of methylparaben on ERα negative MCF-7 human breast cancer cell lines.
Material and Methods
The study was conducted at the Center of Excellence for Research in Regenerative Medicine Applications (CERRMA), Alexandria Faculty of Medicine. The experimental protocols were approved by the Medical Ethics Committee (IRB NO: 00012098-FWA- NO: 00018699), Faculty of Medicine, Alexandria University, Egypt. Chemicals:
Stock solution of methylparaben in 0.1 Methanol (MP/ H5501, minimum purity 99.0% purity, Sigma Aldrich, Egypt/ molecular weight 152.149 g/mol. For the cell culture experiment, five serial concentrations were prepared 4×10-5 M, 6×10-5 M, 1×10-4 M, 2×104 M, taking into consideration that the concentration of ethanol was ≤ 0.1% to ensure cell viability .
MCF-7 (human breast cancer cell line, HTB-22) was obtained from VACSERA – Cell Culture Unit, Dokky, Giza, Egypt. Cells were grown as monolayer cultures in RPMI-1640 complete media (RoswellParkMemorialInstitute,Lonza)containing300mg/L L-glutamine,100 IU/ml penicillin, 100 μg/ml streptomycin (Lonza) and 10% fetal bovine serum (FBS, Lonza). The cells were incubated at 37 °C 5% CO2 atmosphere (Thermofisher CO2 incubator). Cells were continuously monitored (Olympus BX 40 phase contrast inverted microscope) for morphology and confluence. On reaching 80-90% confluence, the cells were subcultured with a suspension with 0.25% (w/v) trypsin EDTA (Lonza), then plated in different culture vessels . Immunocytochemical analysis:
The trypsinized cells were centrifuged, the supernatant cells were removed and the cell pellet was re-suspended in 1ml of phosphate buffer saline (PBS). Semiautomated rotatory microtomed sections with a thickness of 2 μm thick were mounted on positively charged slides. The expression of ER was assessed using mouse monoclonal antibodies (ER- alpha Monoclonal Antibody SP1 1:10/ Invitrogen) with the application of the universal peroxidase-labeled streptavidin-biotin technique. 3,3 diaminobenzidine was applied as a chromogen for antibody detection and was counterstained with Mayer’s hematoxylin. The negative control was a section of the same sample where the primary antibody was replaced by PBS. Breast adenocarcinoma, which previously has shown negative immunostaining of estrogen receptors, was considered positive controls . 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) cytotoxicity assay for Cell viability:
Cells were seeded in 96-well flat-bottom plates at an initial concentration of 5000 cells per well and incubated for 24 hours, after which the media was replaced with phenol red- free media with 5% charcoal-stripped FBS (Fetal bovine serum) (Biowest) containing the different five concentrations of methylparaben and incubated for seven days. On the 7th day, the media was replaced by MTT (3-(4,5-dimethylthiazol-2-yl)- 2,5-diphenyltetrazolium bromide) solution and incubated for four hours.
The media was removed and 100 μl DMSO/well was added and gently rocked in the dark for 20 minutes to dissolve formazan crystals. ELISA plate reader (Tecan, Infinite F50) was applied to detect the absorbance at a wavelength of 570 nm. The percentages of cell viability were calculated as the ratio of treated to control untreated cell absorbances after blank correction. All the samples were run in triplicate .
Cell proliferation assay:
Cells were seeded in a monolayer at a density of 10,000 cells/ well into 24 well plastic culture plates, incubated for 24 hours, followed by media replacement with phenol red-free media with 5% charcoal-stripped FBS. The five different concentrations of MP were added and incubated for 7 days. On the seventh day, the trypan blue exclusion test was applied using a Neubauer hemocytometer slide to assess the number and viability of MCF7 cells (100 μl with a 0.4% trypan blue solution / Sigma-Aldrich, St. Louis, USA). Manual cell count was done by examining the stained (non – viable cells) under the inverted microscope. The calculation of the number of non-viable cells was obtained as average cell count/square and multiplied by dilutional factor x 104). All the samples were run in triplicate .
Quantitative assay for ER expression by Flow cytometry:
To evaluate the expression of the ER receptors of the treated MCF-7 cells relative to control, triplicates of cell samples were plated in 6-well plates at a density of 2 x 104cells/ well. After incubation for 24 hours, the media was replaced with phenol red-free media with 5% charcoal-stripped FBS, including 40 up to 200 μM concentrations of MP, and incubated for seven days. After seven days, the culture medium was removed from the wells, the cells were washed twice with sterile PBS, and a 0.25% trypsin-EDTA solution was added to detach the cells. After 5 min incubation at 37 °C and 5% CO2, fresh culture medium was added to inactivate the trypsin, and cells were collected in flow cytometer tubes. The cells were labeled with Anti-ER alpha antibody [SP1] ab16660 at 1/20 dilution, Alexa Fluor® 488 Conjugate, Abcam) according to the manufacturer’s instructions (available at: https://www.abcam.com/estrogen- receptor-alpha-antibody-sp1-ab16660.html). Analysis was performed using the BD FACS Calibur flow cytometer and cell sorter and Cell QuestTM software. Unstained control cells were used to determine the percentage of ER-positive cells in the samples.
The data obtained from the applied assays were analyzed for statistical significance using tests for analysis of variance (one-way stacked ANOVA/ 95% confidence) followed by Tukey’s Honestly Significant Differences (HSD) multiple range test using GraphPad Prism V.8.0.2 (GraphPad Software, Inc, La Jolla, USA) software.
In all techniques, the mean values for three independent assays and standard deviations were calculated. Differences were recognized statistically significant at P< 0.05.
1- ER-alpha receptor expression:
The immunoreactivity of MCF-7 cells to ER was almost negative throughout the tumor cells. (Fig1)
2- Methylparaben and MTT assay:
There was a non-significant difference between the escalated concentrations of MP compared to untreated MCF7 cells after seven days of incubation. MP exhibited no cytotoxic effect (p>0.1) (Figure 2a, 2b).
3- Cell proliferation assay regulation of proliferation in the absence of ER receptors:
After 7 days, there was a non-significant difference in cell counts with indistinguishable proliferation effects as compared between the MP treated and untreated MCF7 cells. (p>0.1). MP did not stimulate the proliferation of cells even at the highest concentration (200 μM). (Figure 3a, 3b)
4- Quantitative flow cytometry assay for ER- alpha expression:
The α-ER receptor status of MCF7 cells treated with the lowest and highest doses of MP after seven days of incubation showed that MP caused a non-statistically significant expression of ER relative to untreated cells, where the control cells expressed 8.74% only and the concentrations of MP 40 μM and 200μM express 8.21% and 12.52%, respectively. (p>0.1) (Figures 3c,3d)
Since the 90s, the human breast adenocarcinoma cell line MCF- 7 has served as a standard model for in vitro cancer research as well as endocrine disruptive substances on estrogen-sensitive human cells. MCF-7 cell line has been recognized for its utility for the study of ER-alpha, as this cell line expresses substantial levels of ER, mimicking the majority of invasive human breast cancers that express ER. Since the majority of breast cancers are ER+ [12,13], most studies focused on ER +ve MCF-7 cells. The estrogenic effects of parabens such as methylparaben, ethylparaben, n-propylparaben and n-butylparaben have been reported in estrogen-sensitive MCF7 human breast cancer cells as well as in other lines of human breast cancer cells [1,14,15]. Additionally, their accumulation in human breast tissue [16,17] indicates their potential to drive the sustained proliferation of ER +ve breast epithelial cells. Parabens are full agonists with the same efficacy as estradiol when available at high concentrations, as it increases proliferation of human breast cancer cells to about the same level, where the maximal cell yield attained was with 3 × 10−11 M. However, at a concentration on the order of 105 to 107 times higher than that for E2. The main focus, therefore, is not on their low binding affinity to ER, but on the concentration of paraben residing in the target breast tissue .
The affinity of methylparaben (MP) for competitive binding to the ERα of MCF7 cells is considered the lowest among the other parabens, and subsequently the magnitude of its inhibitory action on estradiol binding. Yet, the mechanism of MP toxicity is thought to be ER-mediated and linked to the action of estrogen on the cells. The fact was evidenced by studies observing that the proliferative response was inhibited by the addition of antiestrogen [1,14,15]. Similarly, the MP proliferative effect was recorded in the presence of low levels of estrogen, as well as in the absence of estrogen imitating the in vivo conditions after menopause .
In 2013, Khanna and Dabre  demonstrated the stimulatory effect of MP on non-transformed MCF10A with loss of anchorage dependence, thus evoked the human breast epithelial cells for proliferation in culture suspension. Wróbel and Gregoraszczuk, 2013  have indicated the presence of different mechanisms of the proliferative action of parabens in various investigated cell lines. In estrogen- responsive MCF-7, parabens stimulate their proliferation by increasing estradiol secretion and aromatase activity. Pugazhendhi and Darbre (2010) demonstrated that there were no detectable levels of ERα or ERβ protein in the strain of MCF10A cells and that only over-expression of ERα induced cell growth suspension by estradiol in these epithelial cells. Accordingly, the issue remains a point of research concern to determine whether parabens might act by increasing levels of ERα or whether the mechanism is non-ER-mediated .
To determine whether MP could induce human breast cancer growth in ER-ve types, an estrogen-receptor negative MCF-7 cell line was used in this study. Based on literature reviews, the available data from different studies do not provide sufficient information to be able to reach a conclusion.
In the current study, the proliferation of ER-ve MCF-7 cells was unaffected by the presence of MP up to concentrations of 2 x 10−4 M. The loss of ER-alpha resulted in reduced insulin- like growth factor (IGF)-mediated signaling and growth and reduced insulin-like growth factor-I receptor (IGF-IR) and insulin receptor substrate-1 (IRS-1) mRNA and protein expression in comparison with ER +ve MCF-7 cells, and these effects were not inducible by estrogen . In a study by Oesterreich and associates (2001), they demonstrated that the re-expression of ER-alpha in the same cell line restores ER functions (such as signaling and proliferation) as well as the IGF-responsive phenotype, with re-expression of IGF-signaling molecules and growth in response to IGF. Thus, in MCF-7 cells, ER-alpha is a critical regulator of IGF-mediated signaling and growth . Despite the fact that MCF7, employed in previous studies, predominately expresses ER alpha , the experimented strain failed to express ER, which could be attributed to cell transformation with loss of featuring receptors [24-26]. It is noteworthy that maintaining expression of ERα in cultured immortalized cell lines is difficult, which resulted in the generation of far more ER-negative than ER-positive human breast cancer cell lines . Such facts explained the failure of the immunocytochemical assay in the current study to detect ER-alpha on the different experimented MCF7 cells.
In agreement with our results, Dabre et al. (2002) utilized triple-negative (MDA-MB-231) human breast cancer cells, which are estrogen receptor-negative cell line, to evaluate the proliferation response of these cells to isobutylparaben. They proved that the MDA MB 231 cells did not proliferate in response to 17β-oestradiol, and therefore isobutyl-paraben failed to influence their growth at concentrations reaching up to 10−4 M . These findings provided evidence that the proliferation of cancer breast cells in response to MP is mediated by ERs. Accordingly, the loss of ER-alpha would interfere with the proliferation potentials of MP on breast epithelium . Furthermore, the lack of ER expression indicates both phenotypic and cytogenetic variability for particular clones of breast carcinoma cells [23,26,27]. MCF-7 sub-lines demonstrate a wide divergence in the relative expression of ER, PR and HER2. The proportion of the dominant phenotype may be maintained by growth conditions. For example, the predominance of the ER-positive phenotype could be maintained by the presence of small amounts of estrogen in the fetal bovine serum . To exclude such a conflicting potential, we used charcoal- free FBS in the current study. The latter is free from lipid components, including steroid hormones as estrogen [23,27]. Interestingly, the ER-, PR- and HER2-negative (triple-negative) sub-lines can be originated from the ER-positive MCF-7 cell line . They can be produced by long-term estrogen withdrawal or incubation with fulvestrant, an anti- estrogen, for a prolonged period of time (>12 months) [23,24]. These cell sub-lines might form a useful model for understanding the behavior of triple- negative breast cancers in clinical practice and their response to therapeutic agents in the presence of parabens in general and MP in particular.
The present in vitro study aimed at assessing methylparaben effects on the behavior of ER-ve MCF-7 breast cancer cells. The lack of proliferation of MCF-7 cells was independent of the concentrations used for methylparaben, which confirmed the ER-dependent effects of methylparaben on these cells. Therefore, confirmation of the sensitivity of MCF7 cell line to estrogen and their characterization in terms of the passage number, genetic diversity of the cells and cross-contamination is recommended before using MCF7 cell line for assessing changes in cancer response to various agents. Moreover, the study of variants of a single cancer cell line might enable recapitulating the behavior of multiple phenotypes of breast cancer in the presence of parabens. These data show that ER is a critical requirement for IGF signaling, and for the functional mechanisms of ERα expression that confers estrogen-mediated growth of an ER-negative breast cancer cell line.
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Conflict of interest
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Wafaa Mohamed Elsehly, Ghada M Mourad, Radwa A. Mehanna, MennattAllah Hassan Attia, Marwa Kholief. A study of possible toxicological effects of Methylparaben on estrogen receptor-α negative MCF-7 human breast cancer cell line. Ann Clin Anal Med 2021;12(8):907-911
Evaluation of perceived family burden, care burden and quality of life of caregivers during the pandemic period
Sevler Yıldız 1, Aslı Kazğan 2, Osman Kurt 3, Sevda Korkmaz 4
1 Department of Psychiatry, Erzincan Binali Yıldırım University, Medical Faculty, Erzincan, 2 Department of Psychiatry, Siverek State Hospital, Şanlıurfa, 3 Department of Public Health, Fırat University, Medical Faculty, Elazığ, 4 Department of Psychiatry, Fırat University, Medical Faculty, Elazığ, Turkey
DOI: 10.4328/ACAM.20501 Received: 2021-01-23 Accepted: 2021-02-28 Published Online: 2021-03-08 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):912-917
Corresponding Author: Sevler YILDIZ, Erzincan Binali Yıldırım University, Medical Faculty, Department of Psychiatry, 24100, Erzincan, Turkey. E-mail: email@example.com P: +90 506 803 28 09 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9951-9093
Aim: In this study, we aimed to evaluate the perceived family burden, caregiving burden and the quality of life of people who have to spend most of their time at home with their patients during the pandemic period and who provide home care for patients diagnosed with psychotic disorder.
Material and Methods: The study included caregivers of 91 patients with a diagnosis of psychotic who admitted to the psychiatry outpatient clinic during the pandemic period and met the study criteria. All participants were applied the World Health Organization Quality of Life Form (WHOQOL-BREF-TR), Perceived family burden scale (PFBS), and the Zarit Caregiver Burden Scale (ZBS).
Results: Participants’ mean PFBS score was 65.6±19.1 and their ZBS mean score was 56.2±14.8. A positive correlation was found between PFBS score and ZBS score (p=0,00, r=0,763). Also, a significant negative correlation was found between PFBS score and WHOQOL-BREF-TR scale sub-scales and the ZBS score and the WHOQOL-BREF-TR scale sub-scales.
Discussion: The pandemic period negatively affected caregivers of patients diagnosed with psychosis.
Keywords: COVID-19; Psychosis; Caregiving burden; Perceived burden; Quality of life
Coronaviruses (CoV) are a family of viruses that can previously cause serious diseases such as MERS-CoV and SARS-CoV. COVID-19 infection, which has different characteristics from coronaviruses that cause MERS and SARS, causes asymptomatic cases as well as symptoms of fever, cough, shortness of breath, pneumonia and subsequent severe respiratory failure or even death. The World Health Organization (WHO) declared it a pandemic in 2020 due to its rapid spread and fatal consequences .
During the pandemic period, individuals experience not only physical but also psychosocial problems. The feeling of loneliness at home, separation from loved ones, reduced freedom, and uncertainty about the course of the illness can have negative effects on the mental structure. This can cause anger problems, related behavioral problems, and communication difficulties . Depression, anxiety disorder, panic disorder, other mood disorders, even psychotic disorders may occur as individuals or their immediate surroundings have COVID-19 disease and adverse conditions intensify during the course of the disease. Unfortunately, the prolongation of this process may cause psychiatric symptoms to become chronic and increase in suicidal thoughts in connection with the increase in hopelessness . The caregiver has important duties in the form of routine health care, personal care, transportation, doing small housework, money management and sharing the same house. The difficulties experienced by family members who take care of a person with a serious psychiatric illness are generally defined as “caregiver burden”. It is known that caregivers of individuals diagnosed with schizophrenia and other psychotic disorders are quite tired. The course of the disease, the frequency of exacerbation episodes, as well as social support, the degree of stigmatization of the society, the quality and availability of mental health services also affect the level of difficulty experienced by the caregiver [3, 4].
Family members experience a perception of the burden against the disability that develops in the patient . The perceived family burden is the negative impact of a person with psychiatric illness on the family. It is stated that both the negative results that develop against family routines and the emotional distress experienced by the caregiver . It is known that the perceived burden on caregivers can affect the level of well-being, care satisfaction, relationships with other individuals, and perceived disease severity .
It was known that caregivers of psychosis patients experienced sadness, fatigue, emotional exhaustion, sleep disturbance, guilt, social isolation and financial difficulties before the pandemic . It is estimated that the current problems of caregivers of patients with psychosis are increasing during the pandemic due to the prolongation of time spent at home with psychiatric patients due to social isolation, difficulties in accessing health services and inability to actively use community mental health centers . In the studies we conducted, we could not find studies on the perceived family burden, caregiving burden, and quality of life of caregivers of patients with chronic psychosis in the COVID-19 pandemic. We think that this study will contribute to the literature.
Material and Methods
People who were caring for a patient diagnosed with a psychotic disorder (schizophrenia, delusional disorder, schizoaffective disorder) who was admitted to the psychiatry outpatient clinic of the Faculty of Medicine, XXXX, XXXX during the COVID-19 pandemic were included in this study after obtaining approval from the local ethics committee. This study followed the principles of the Helsinki Declaration. In this way, 91 participants aged 18-65 who were literate and signed written informed consent form were included. Individuals with physical and mental disorders that might hinder responding to questionnaires and scales were excluded from the study. All participants were applied the sociodemographic data form, the World Health Organization Quality of Life Form (WHOQOL- BREF-TR), the Perceived family burden scale, the Zarit Caregiver Burden Scale.
Approvals of the Local Ethics Committee of Firat University and the Scientific Research Platform of the Ministry of Health, Republic of Turkey were obtained for the research. Sociodemographic and Clinical Data Form
The semi-structured form includes socio-demographic information such as age, gender, marital status, education, occupation, economic status, family structure and clinical data. Perceived family burden scale
It was developed by Levene et al. to evaluate family burden in families with members diagnosed with schizophrenia. The scale is filled in by the patient’s relatives. It consists of 24 items in total, and its Turkish validity and reliability study has been conducted [10, 11].
World Health Organization Quality of Life Form
This form is an assessment tool developed by the World Health Organization (WHO) for subjective assessment of the quality of life in various countries. Psychological, physical, social, environmental and national context scores are calculated for all items, except the first two general items. Higher scores lead to higher levels of quality of life . The Turkish validity and reliability study of the scale was conducted .
Zarit Caregiver Burden Scale
The scale, which is used to evaluate the difficulties experienced by caregivers of individuals in need of care was prepared by Zarit et al. It is a 5-point Likert type scale. The scale score range is between 0-56, and the higher the scale score, the higher the problem experienced, and the Turkish validity and reliability study of the scale was conducted [14, 15].
The analyzes were evaluated in the SPSS (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL) 22 package program. The compliance of continuous variables to normal distribution was evaluated with the Kolmogorov-Smirnov Test. Independent Samples t- test was used for comparison of variables that comply with normal distribution, One-Way ANOVA test was used when more than two groups were compared, the Mann- Whitney U Test was used for comparison of variables that do not comply with normal distribution, and the Kruskal-Wallis test was used when more than two groups were compared. In examining the relationship between continuous variables, the Pearson correlation test was used for those who comply with the normal distribution, and the Spearman correlation test for those who did not comply with the normal distribution. The statistical significance level was accepted as p<0.05 in the analysis.
Ninety-one relatives of the patients were included in the study; 50.5% of the participants were women and the average age was 44.9±9.9 (min=23, max=67) years.
It was observed that the patients followed up were mostly diagnosed with schizophrenia (74.7%), and the highest degree was parents (27.5%) and siblings (25.3%). It was determined that 65.9% of the patients admitted 1-3 times during the pandemic period and 34.1% admitted 4 or more times.
ZBS scores of women were significantly higher than men’s scores (p=0.043), and single participants’ PFBS scores were higher than married participants’ scores (p=0.008). A significant difference was observed in terms of PFBS scores between the state of being close to the patient (p=0.007). During the pandemic period, the PFBS score of those who admitted to psychiatry outpatient clinic 4 or more times was significantly higher than the score of those who applied 1-3 times (p=0.049). During the pandemic period, a significant difference was found between inpatient admissions to psychiatry in terms of PFBS and ZBS scores (p<0.001). A significant difference was found between using psychiatric drugs in terms of the ZBS score (p=0.024). It was seen that this difference was related only to the difference between oral and injection treatment (Table 1). The scores of the participants’ quality of life sub-scales were reviewed. A significant difference was observed between economic status in terms of the environmental sub-dimension (p=0.034). The physical health sub-scale score of those who admitted to a psychiatry outpatient clinic 1-3 times during the pandemic was significantly higher than the score of those who admitted 4 times or more (p=0.039). During the pandemic period, a significant difference was found between inpatient admissions to psychiatry in terms of WHOQOL-BREF-TR scale sub-scale scores (p< 0,05). A significant difference was found between using psychiatric drugs in terms of health status (p=0.032) and social relationships (p=0.022) score. It was seen that this difference was related only to the difference between oral and injection treatment (Table 2).
A significant negative correlation was found between the duration of patient care and the general health, physical health, psychological and social relations sub-scales. A significant positive correlation was found between the PFBS score and the ZBS score, and a negative significant relationship between the PFBS score and the WHOQOL-BREF-TR scale sub-scales. A significant negative correlation was found between the ZBS score and the WHOQOL-BREF-TR scale sub-scales. It was observed that there was a positive significant relationship between the sub-scales of the WHOQOL-BREF-TR scale with each other (Table 3).
In this study, we found that during the COVID-19 epidemic period, the perceived family burden and care burden increased in people caring for psychosis patients, and therefore, the quality of life of caregivers was negatively affected.
The ZBS mean score of the participants was 56.2 ± 14.8. We found that the ZBS score for the female gender was significantly higher than the male score, and the general health status, psychological and social relations sub-scales, which are among the sub-parameters of the quality of life scale, were significantly higher than the scores of the women. This shows that the gender of the caregiver affects the caregiver burden. The fact that women have other occupations in home life may explain this. In addition, unlike other studies, we could not find a significant difference between education level and caregiving burden .
The scores of the quality of life sub-scales of the participants were reviewed. General health status average was 6±1.5, physical health sub-scale average was 21.3±4.4, psychological sub-scale average was 17.2±3.5, social relations sub-scale average was 8.4±2.1 and environment sub-scale average was 26.3±5.7. In our study, it was observed that the good educational status of the caregiver increased the scores of the general health status, physical health, environment and social sub-dimensions in the quality of life scale, which supports the literature . As the education level of the caregiver increases, they learn more about psychotic disorder and treatment options. Thus, early interventions will be provided during exacerbation of psychosis during a pandemic process, and the quality of life of the patient and their relatives will increase.
As Czuchta et al., we observed that as the education level of caregivers increased, their quality of life increased . As the education level increases, the caregiver becomes more informed about psychotic disorder and treatment options. This may have provided early interventions during exacerbation of psychosis during a pandemic period, thus increasing the quality of life of the patient and caregiver.
In the study conducted by Lasebikan et al., most of the participants were single, whereas in our study, there were fewer single caregivers . We found that the family burden perceived by single people when caring for psychosis patients was higher than that of married people. In terms of the quality of life of married people, we found that physical health and environment sub-scale scores were significantly higher than the scores of singles.
In our study, due to the difference between siblings and parents, a significant difference was observed between the degree of relationship with the patient and the perceived family burden. Again, a significant difference was found in terms of physical health and environmental sub-scale in the scoring of the quality of life scale in terms of the caregiver being siblings and parents. This supports the finding of Roper et al. in 2014 that the relationship between the siblings of mentally disabled individuals was better. However, in the study, it was stated that the family burden perceived by mothers was higher than that of fathers among caregivers . In our study, we classified caregivers as parents, not separating them as parents.
PFBS scores were found to be significantly higher in the caregivers of the patients who admitted to psychiatry more frequently during the pandemic than those who admitted to psychiatry less frequently. Again, a significant difference was observed in terms of perceived family burden and caregiving burden scale scores with inpatient admissions to psychiatry. During the pandemic period, a significant difference was found between inpatient admissions to psychiatry in terms of WHOQOL-BREFF-TR scale sub-scale scores. This shows that as the hospitalization of the patient increases during the pandemic period, the quality of life of the caregiver decreases. It is known that during the COVID-19 pandemic, psychiatric illnesses are negatively affected by the difficulty in drug procurement, lack of mental health specialists, lack of transportation, quarantine periods, and some of the patients themselves stop using drugs . The applications to psychiatry support this situation as it shows that the patient is not in remission.
During the pandemic period, a significant difference was observed between the ZBS scale scores of the patients who used only oral medication in the treatment of psychotic disorder and the patients who used drugs as a long-acting depot injection (Table 1). It is known that the use of long-acting depot drugs is more effective than oral drug use in terms of maintaining the continuity of treatment and reducing hospitalizations, in which our findings are compatible with this situation . Also, long- acting medication use has been found to increase caregiver’s quality of life in terms of general health status and social relations sub-parameters.
In the correlation analysis performed, a positive relationship was found between the age of the caregiver and the duration of the patient’s care. Once again, there is a significant negative correlation between age and the WHOQOL-BREF-TR general health and physical health sub-scale score. In similar studies conducted with caregivers of chronic patients, it has been found that young caregivers experience more burnout and lower quality of life scores than elderly caregivers . This shows that as the caregiver gets older, psychiatric illness can be accepted more easily.
Our study determined that both BFPS scores and ZBS scores negatively affected the general health, physical, psychological, social and environmental sub-scores of the WHOOL-BREF-TR form. Zeng et al. (2016) reported that the caregiving burden negatively affected the quality of life in their study with caregivers of patients with psychiatric disorders . Once again, Zauszniewski showed that the perceived family burden reduces the quality of life . This shows that the needs of caregivers in areas such as health, social, economic and accommodation should be met during the pandemic period. We think that the perceived family burden and caregiving burden will decrease and the quality of life will increase.
Living with the psychiatric symptoms of a psychosis patient, providing care, supporting financially and spiritually affects the caregivers psychologically and physically. A meta-analysis study showed that early detection of caregiver problems is beneficial for psychotic patients in the long term. It is known that during a pandemic, many people are affected mentally negatively, and the number of psychiatric diseases increase . This shows that in the COVID-19 pandemic, caregivers need more support. For these reasons, it should be ensured that the problems of the caregiver as well as the patient with psychosis are solved. Social workers working in the psychiatric field should continue to communicate with both the caregivers and the patient during the pandemic period, and contact the relevant institutions to provide the necessary support to these people. In addition, psychiatric examinations of the patients should not be neglected during this period, and if necessary, interviews should be made online. In this way, we believe that the necessary support can be given both to the patient with psychosis and the caregiver. The fact that the sample of our study consisted of 91 caregivers was an important limitation. A larger sample may yield more generalizable results. Another limitation of the study was that only the caregivers of the patients who admitted to the psychiatry outpatient clinic were recruited. However, we know that applications to psychiatry polyclinics have decreased considerably due to the pandemic. Also, when planning the study, no control group was formed. It is thought that performing analysis by including the control group in similar studies to be conducted will contribute to the literature.
As a result, this study is important in terms of examining the perceived family burden, caregiving burden and factors affecting the quality of life of caregivers of patients with psychosis during the COVID-19 pandemic. It should be kept in mind that negative situations that may arise if the caregiver is not supported may lead to greater health, social and economic problems.
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Conflict of interest
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Download attachments: 10.4328_ACAM.20501
Sevler Yıldız, Aslı Kazğan, Osman Kurt, Sevda Korkmaz. Evaluation of perceived family burden, care burden and quality of life of caregivers during the pandemic period. Ann Clin Anal Med 2021;12(8):912-917
Combination therapy of cyclosporine A and mycophenolate mofetil in rats with adriamycin-induced nephrotic syndrome
Ayşe Sülü 1, Halide Akbaş 2, Bahar Kılıçarslan Akkaya 3, Arife Uslu Gökçeoğlu 4, Sema Akman 4
1 Department of Pediatric Cardiology, Eskisehir Osmangazi University, Eskişehir, 2 Department of Biochemistry, Akdeniz University Medical Faculty, Antalya, 3 Department of Pathology, Akdeniz Universty Medical Faculty, Antalya, 4 Department of Pediatric Nephrology, Akdeniz University Medical Faculty, Antalya, Turkey
DOI: 10.4328/ACAM.20503 Received: 2021-01-26 Accepted: 2021-03-10 Published Online: 2021-03-31 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):918-923
Corresponding Author: Ayse Sulu, Eskisehir Osmangazi University, Department of Pediatric Cardiology, Eskişehir, Turkey. E-mail: firstname.lastname@example.org P: +90 5541204978 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6384-3935
Aim: The lack of effective treatment for steroid-resistant nephrotic syndrome has led to the search for new treatments and the emergence of combined thera- pies. In our study, we aimed to reduce side effects and increase effectiveness by combination with low-dose cyclosporine and MMF.
Material and Methods: Fifty Wistar albino rats were included in our study. Five groups were formed as follows: untreated nephrotic syndrome, cyclosporine, MMF, low-dose cyclosporine, and a combined therapy group. Nephrotic syndrome parameters were studied. Rats were sacrificed at the end of the study. Glo- merulosclerotic index, interstitial fibrosis score, and total damage score were calculated with histopathological examination.
Results: Urine protein/creatinine significantly decreased in the MMF and low-dose CsA groups after treatment. Serum total protein and albumin levels were preserved better in the combined therapy group. The control of hyperlipidemia was better in the combined therapy group than the others. The best results for oxidative damage were detected in the low-dose CsA and combined therapy groups. Serum creatine was detected to be higher in the CsA group than in other groups. The glomerulosclerotic index and total damage score were found to be significantly higher in the CsA group compared to other groups. The interstitial fibrosis score was found to be significantly higher in the MMF group compared to the combined therapy group. TGF-β was significantly higher in the MMF group compared to the CsA group. Osteopontin was significantly lower in the CsA group than the other groups.
Discussion: This study showed that while MMF and low dose CsA have similar successful effects in protecting serum protein and creatinine, oxidative stress can be kept lower by using low-dose CsA, and hyperlipidemia can be suppressed more successfully with combined therapy.
Keywords: Nephrotic syndrome; Cyclosporine A; Mycophenolate mofetil
In children, nephrotic syndrome is a common and one of the leading disorders that cause chronic kidney failure. Although various treatments and numerous drugs are used in the treatment of steroid- resistant nephrotic syndrome (SRNS), there is still no effective and definitive treatment. In addition, the serious side effects of the drugs used make it necessary to seek new treatment options. Cyclosporine A is the only drug that has shown efficacy in the treatment of steroid- resistant nephrotic syndrome, but its various side effects, especially nephrotoxicity, limit its use and cause difficulties in treatment. For this reason, various drugs and combined therapies have emerged in the treatment of SRNS. Mycophenolate mofetil (MMF) is a drug that has been used effectively in the treatment of steroid- dependent nephrotic syndrome. In previous studies, antiproteinuric efficacy was demonstrated and fewer side effects were found compared to cyclosporine A treatment [1- 4]. In the pathogenesis of SRNS, it has been reported that with chronic severe proteinuria, with the effect of treatments such as cyclosporine A, an increase in free oxygen radicals due to oxidative stress in the kidney tissue, with the development of fibrosis in the kidney tissue as a result of a series of immune reactions, including the concentration of cytokine production at the tissue level, and the progress of fibrosis to sclerosis give rise to the development of end-stage renal failure . A decrease in proteinuria, crescent formation and glomerulosclerosis has been demonstrated in glomerulonephritis rat models treated with MMF. Inhibition in macrophage and osteopontin expression has been shown . In recent years, few case studies have been reported that have used a combination of CsA and MMF [7-9]. Adriamycin-induced nephrotic syndrome is a relevant experimental model .
This experimental model was used in our three previous studies [11,12]. In one of our studies, a significant decrease in proteinuria with cyclosporine A was demonstrated, but impairment of kidney function in rats with adriamycin-induced nephrotic syndrome. On the other hand, MMF moderately reduced proteinuria and did not cause impairment in renal functions (Baysal YE. Effects of Cyclosporin A, Mycophenolate Mofetil, Vitamins A, D, E and N-acetylcysteine in Adriamycin-induced nephrotic syndrome. Akdeniz University Faculty of Medicine, Pediatric Nephrology Minor Thesis, Antalya 2008). Based on this, we thought that the combination of low-dose cyclosporine A and MMF could be more effective and have fewer side effects.
Material and Methods
Fifty adult, male, Wistar albino rats were included in our study. Rats were divided into 5 groups, with 10 rats in each group. They were grouped as an untreated group with adriamycin- induced nephrotic syndrome (group A), cyclosporine A at a dose of 25 mg/kg (Group B), mycophenolate mofetil at a dose of 20 mg/kg/day (Group C), low-dose (10 mg/kg/d) cyclosporine A (Group D) and the combined therapy group (low-dose cyclosporine A + mycophenolate mofetil Group E). Akdeniz University Experimental Animals Ethics Committee approval was obtained for this study.
Rats were fed standard rat chow and water during the experimental process. No diet and water restrictions were applied. All rats were weighed before treatment, 24-hour urine samples were collected, blood samples were taken and adriamycin at a dose of 2mg/kg was administered into the tail vein under ether anesthesia, and a second dose injection of adriamycin was applied on day 21. Treatments were started after the second dose of adriamycin injection. The weights of all rats were measured once a week. Blood pressures were measured from the tail arteries under mild ether anesthesia using a non-invasive method (tail-cuff) once a month. The signals received by the ring-shaped pressure probe attached to the tail were transferred to the computer via the MP 100A- CE data acquisition system (BIOPAC Systems, CA-USA) and the MAY-BPHR200 unit, and the measurements were done with the pressure traces drawn with the “Acknowledge” package program. After the determination of the baseline measurements of all animals before the experiment, blood pressure monitoring was continued with the measurements performed once a month until the end of the experiment. The average of the successfully measured blood pressure levels in each rat was recorded three times.
Blood samples and 24-hour urine samples were taken at baseline, at weeks 4 and 8. Serum and urine samples were stored at -70 degrees until the end of the study. Serum total protein, albumin, creatinine, total cholesterol, triglyceride, total oxidant level (TOS) and total antioxidant status (TAS) were studied from blood samples. Total protein and creatinine were studied from 24-hour urine samples. Based on the data obtained, creatinine clearance, urine protein/creatinine ratio, 24-hour urine protein and oxidative stress index were calculated.
Serum and urine creatinine levels were measured in a Modular PPP autoanalyzer (Roche Diagnostics, GmbH, Mannheim) using the “rate-blanked and compensated” Jaffe method with Roche kits. Serum total protein and albumin levels were measured spectrophotometrically using Roche kits in Modular PPP autoanalyzer (Roche Diagnostics, GmbH, Mannheim). Serum total cholesterol and triglyceride levels were measured by enzymatic spectrophotometric method using Roche kits in a Modular PPP autoanalyzer (Roche Diagnostics, GmbH, Mannheim). The urine total protein levels were measured by turbidimetric method using original Roche kits in a Modular PPP autoanalyzer (Roche Diagnostics, GmbH, Mannheim). Serum Total Oxidant Status (TOS) and Total Antioxidant Status (TAS) analyses were performed spectrophotometrically using the method of Erel. All measurements were made automatically using a V-Twin autoanalyzer (Dade Behring, Syva, Marburg, Germany).
At the end of the study, all rats were sacrificed, their kidneys were removed and weighed. It was then fixed with 6% neutral formalin and covered with paraffin.
After the hematoxylin- eosin, Masson’s trichrome, TGF-Beta, osteopontin staining; GSI (glomerulosclerotic index), IFS (interstitial fibrosis score) scores were calculated. TGF-staining for intersticium and OPN (osteopontin) staining for tubules were evaluated. Grade 1+ indicated pathological involvement of 25% of a glomerulus, 2+ indicated 25–50%, 3+ indicated 50–75% and 4+ indicated 75–100% (Figure 1). The glomerular sclerosis index was calculated by taking the average of the total score of 20 glomeruli for each sample. For instance, if there is 1 (+) lesion in 12 glomeruli, 2 (+) lesions in 1 glomerulus, 3 (+) lesions in 1 glomerulus, and no damage in 6 glomeruli, 0.85 is obtained by dividing 17, which is the total score, by 20, was calculated as the glomerular sclerosis index. The degree of interstitial fibrosis was determined with the ocular grid using the standard point count method. A 21×21 ocular grid containing 441 points was placed on the ocular part of the light microscope, and the spots falling on the stained area with Masson’s trichrome, TGF-β and Osteopontin (OPN) were counted at 40X magnification. The arithmetic mean of the results of 10 consecutive regions that do not overlap in the interstitial area in the biopsy samples was calculated as the interstitial fibrosis scoring.
The data obtained were analyzed using SPSS, percentage, arithmetic mean, chi-square, Mann- Whitney-U and Kruskal- Wallis tests. The mean and standard deviation values were calculated, p <0.05 was considered significant.
The study was planned for 16 weeks, but was terminated at week 9 due to the high loss of rats. Twelve rats, of which 5 rats in the CsA group and 5 rats in the combined treatment group and 2 rats in the low dose CsA group, were exitus. The data of the rats at baseline and at the 4th and 8th weeks after the treatment and the statistical comparisons between the groups are given in Tables 1, 2, 3, respectively.
We demonstrated the development of hypoproteinemia, hypoalbuminemia, and hyperlipidemia, which are laboratory findings of nephrotic syndrome, in all rats at the 4th week after adriamycin administration. However, there was no increase in proteinuria, in the initial urine samples of the rats, proteinuria values were determined higher than the values at the week 4 and 8. Regarding the reason for this, all stages, obtaining samples, storing samples and evaluating the data were reviewed from the beginning, but no reason to explain was found. No changes had been applied in the vital conditions, nutrition and fluid intake of the rats during this period. Serum samples obtained supported the biochemical findings of nephrotic syndrome, therefore no problem was considered regarding adriamycin administration. Since after considering all the reasons, the cause was not found, it was thought that there might be a technical error that we could not explain.
In histopathological evaluation, glomerulosclerosis index was 1.53±0.45, 2.13±0.27, 1.78±0.18, 1.72±0.34, 1.65±0.26 in all groups, respectively. Glomerulosclerosis index was found significantly higher in the CsA group in comparison with other groups (p, A-B: 0.012, B-C: 0.03, B-E: 0.022). The total damage score was 213.33±27.5 in the cyclosporine A group and had the highest value. It was found 153.5±45.15 in the untreated nephrotic syndrome group, 178±18.58 in the MMF group, 172.5±34.85 in the low dose CsA group, 165±26.22 in the combined therapy group. Total damage score was found to be significantly higher in the CsA group compared to the other groups (p: A-B: 0.012, B-C: 0.03, B-D: 0.011, B-E: 0.022). The degree of TGF-β staining was found significantly higher in the MMF treatment group compared to the CsA treatment group (B- C: 0.044). TGF-β staining was 11.18±3.72 in group A, 9.05±1.12 in group B, 10.57±1.5 in group C, 9.82±1.54 in group D, 9.6±1.14 in group E. The highest score for the interstitial fibrosis were in the MMF and no treatment group (A: 11.95±4.78, C: 11.2±1.85, respectively). The lowest value was found in the combined therapy group (9.12±1.22). The interstitial fibrosis score (IFS) was found significantly lower in the combined therapy group compared to the MMF group (p: C-E: 0.037). The lowest level in the degree of been stained with osteopontin (OPN) was 21.12±0.49 that was found in the CsA group, and it was significantly lower than the other treatment groups (p, B-C: 0.001, B-D: 0.002, B-E: 0.006). In the other groups were 22.33± 2.53, 23.04±0,97, 22.88±0.84, 23±0.33, respectively.
The fact of the rat losses in the CsA and combined treatment groups indicates that immunosuppression and toxicity are significant in these groups. Nephrotic syndrome findings, hypoalbuminemia, hypoproteinemia, and hyperlipidemia were shown in all rats at the 4th and 8th weeks, but proteinuria could not be demonstrated due to possible technical error. In this study, weight gain was found significant in the group receiving MMF and low dose CsA treatment, but weight loss was detected in the group with CsA and combined therapy, but it was not statistically significant. In addition, 5 rats died in each of these groups, and significant weight loss was observed in these rats. Similarly, in the study conducted by Baysal et al. (Effects of Cyclosporin A, Mycophenolate Mofetil, Vitamins A, D, E and N-acetylcysteine in Adriamycin-induced nephrotic syndrome. Akdeniz University Faculty of Medicine, Pediatric Nephrology Minor Thesis, Antalya 2008), no significant weight gain was observed, and weight loss was reported in the group receiving CsA treatment. Weight in the MMF group was significantly higher after treatment than in the other groups. Zoja et al.  in rats with Heyman nephritis, and Erisir et al.  with creating NS in FSGS model with adriamycin, found weight gain in rats according to weeks. However, in both studies, the treatment groups were different from our study. As mentioned in a similar study, significant weight loss was observed in the group receiving CsA treatment in our study, and it was thought to be associated with CsA toxicity. In a similar previous study, no difference was detected in kidney weights between treatment groups . In our study, it was found to be significantly higher only in the MMF group compared to the CsA group. In the experimental study by Okuda et al. , they created adriamycin nephropathy and found that rat systolic blood pressures increased after 8 weeks and then remained higher than in the control group. In our study, we found that systolic and diastolic blood pressure increased significantly.
While the significant increase did not continue after the treatment in the low dose CsA and combined treatment group, the significant increase continued in the other groups.
Serum albumin levels decreased in all groups, but there was no significant decrease in the 4th week in the combined treatment group. The best value after treatment was detected in the MMF treatment group. However, the data may not be sufficient because of the early completion of the study and short-term follow-up in observing the effectiveness of the treatments. In previous experimental studies, a re-increase in albumin level was observed in the following weeks (week 12, 16) after treatment. Serum total protein did not continue to decrease after treatment only in the combined therapy group, and the best value was detected in this group. Based on this, we can think that serum total protein can be better preserved with combined therapy. Serum total protein from high to low, respectively: combined therapy> low dose CsA> no treatment control> MMF> CsA.
In our study, serum creatinine and creatinine clearance were found to be significantly higher in the CsA group at the 4th week compared to the other treatment groups. No statistically significant difference was found between the groups. At the end of the study, the lowest value was in the control group without treatment. In the experimental study by Blume et al.  performed by creating passive Heyman nephritis in rats, when proteinuria and serum creatinine levels were compared with CsA and MMF, although proteinuria decreased in both treatment groups, serum creatinine levels were found to be higher in rats receiving CsA. In a study by Baysal et al., there was an increase in creatinine in the CsA group and it was thought to be associated with nephrotoxicity. In an experimental study conducted by Takeda et al. , a significant improvement in proteinuria was found in rats with crescentic glomerulonephritis after MMF administration. In the eighth week of our study, it was determined that urine protein/creatinine ratios were significantly decreased in the MMF and low dose CsA groups compared to the 4th week.
Serum total cholesterol values were found best in the MMF group, but it was not statistically significant. Similar to the study conducted by Baysal et al., better results were obtained in the MMF group. In addition, serum triglyceride value was best preserved in the combined group at the end of the study.
It has been shown in previous studies that cyclosporine A increases the oxidant level in the renal tissue . However, there is no such study regarding MMF. In our study, the lowest value at the end of TOS treatment was detected in the combined treatment group and was significantly lower than in the MMF group (p= 0.037). In the low-dose CsA group, it was found to be significantly lower than the untreated control, CsA, and MMF groups. With low-dose CsA and combined therapy, TOS was lower than in other treatment groups. At the 4th week, the oxidative stress index was found to be significantly lower in the low-dose CsA group compared to other treatment groups. Baysal et al. found the lowest value in the MMF group, but the dose of CsA in this study was the same as in our high dose group. The low-dose CsA and combined therapy groups were created in our study for the first time in literature. For this reason, it is not possible to compare them exactly.
TGF-β is a potent fibrogenic factor and has a predictive role in the pathogenesis of glomerulosclerosis. TGF-β is a chemoattractant for fibroblasts and stimulates fibroblast proliferation and synthesis of extracellular matrix (ECM) proteins in epithelial cells. While TGF-β directly reduces the activity of metalloproteinases, which cause ECM protein degradation, it also increases the effect of metalloproteinase tissue inhibitors and indirectly inhibits ECM degradation . Lim et al.  in their study on children with NS who received CsA treatment, as a result of the evaluation of OPN levels and renal biopsy findings before and after CsA treatment, has shown that OPN releases increased with renal microvascular damage caused by the nephrotoxic effect of CsA. Takeda et al.  demonstrated that glomerular crescent, glomerulosclerosis and glomerular OPN expression were significantly decreased in rats in which they induced crescentic glomerulonephritis with anti-GBM antibodies. Yang et al.  found that MMF was not effective on CsA toxicity in rats that used MMF treatment in interstitial fibrosis after CsA. A significant decrease in creatinine clearance was detected after 10 weeks with CsA treatment. In the experimental models, MMF has been shown to inhibit collagen storage, proliferation in renal cells and production of TGF-β1, TNF alpha, interferon-gamma [19, 20]. In this study, similar to previous experimental studies, GSI and TDS were detected in the group with the highest CsA, and this is the detection of CsA nephrotoxicity. The IFS was found to be significantly higher in the MMF group compared to the combined therapy group. TGF-β was significantly higher in the MMF group compared to the CsA group. OPN was significantly lower in the CsA group than the other treatment groups. All these results are quite different from other studies. However, it will be possible to explain the reason for this incompatibility, based on the assumption that the death of rats in the other groups and these rats were not included in the study, the results of staining with IFS, OPN and TGF-β of the dead rats could be higher.
The most important limitation of this study is the excessive rat losses, and therefore the early termination of the study before the planned time. In addition, the presence of inconsistent data in baseline values is a possible technical error that cannot be detected.
As a result, the high loss of rats in CsA and combined therapy groups can be explained by the higher toxicity in these groups. The absence of any rat loss in the MMF-only group roughly suggests that no significant toxicity was observed with MMF. According to the results obtained, it can be said that while MMF and low dose CsA show similar successful effects in protecting serum protein and creatinine, it can be said that oxidative stress can be kept lower with low dose CsA, and hyperlipidemia can be suppressed more successfully with combined therapy. Furthermore, in this study, unlike previous studies, CsA was shown to cause glomerulosclerosis and renal damage without increasing OPN and TGF-β release. It has not been shown that MMF reduces TGF-β release and fibrosis. Moreover, low-dose CsA and combined therapy were found to be more effective in maintaining systolic and diastolic blood pressure. It is thought that by keeping the doses of cyclosporine A and MMF lower, more clear results can be obtained with a long-term study.
Scientific Responsibility Statement
Animal and human rights statement
Funding: Akdeniz University Scientific Research Project.
Conflict of interest
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Ayşe Sülü, Halide Akbaş, Bahar Kılıçarslan Akkaya, Arife Uslu Gökçeoğlu, Sema Akman. Combination therapy of cyclosporine A and mycophenolate mofetil in rats with adriamycin-induced nephrotic syndrome. Ann Clin Anal Med 2021;12(8):918-923
Modified constraint-induced movement therapy versus mirror therapy on affected hand functions in hemiparetic children
Mohamed E. Madbouly 1, Khaled A. Olama 2, T.E.I. Omar 3, Mahmoud S. El Fakharany 4, 5
1 Master Physical Therapy, Cairo University, 2 Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 3 Department of Pediatrics and Pediatric Neurology, Faculty of Medicine, Alexandria University, 4 Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 5 Faculty of Physical Therapy, ELNAHDA University, Egypt
DOI: 10.4328/ACAM.20505 Received: 2021-01-26 Accepted: 2021-03-10 Published Online: 2021-05-28 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):924-928
Corresponding Author: Mahmoud S. El Fakharany, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 11816, Egypt. E-mail: Mahmoud.email@example.com P: 01067904792 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3943-4469
Aim: This study aimed to examine the efficacy of Modified Constraint-Induced Therapy versus mirror therapy for hand function in children with right hemipa- retic cerebral palsy.
Material and Methods: Forty children with hemiplegic CP participated in this study. All subjects were with right side affected, grade 1+ spasticity and level III of MACS, aged 5 to 8 years, were selected for this randomized study and randomly assigned into two equal groups. The control group (A) received mCIMT for 3 hours daily 5 days / week for consecutive 4 weeks and the other group (B) received mirror therapy for 30 minutes daily 5 days / week for consecutive 4 weeks. Both groups received regular intensive physical and occupational therapy apart from the above interventions. The data obtained from both groups pre- and post-treatment on the QUEST scale were statistically analyzed and compared.
Result: There was a significant increase in the QUEST scale for Group A compared with that for Group B post treatment (p = 0.0001). The obtained findings clearly suggest that Modified constraint induced movement therapy (MCIMT) is more effective than mirror therapy in improving functions of the affected hand in children with Hemiparetic cerebral palsy.
Discussion: Children with motor dysfunction could be improved using targeted functional training. The use of modified constraint-induced movement therapy and mirror therapy are strategies for achieving motor recovery.
Keywords: Cerebral palsy; Constraint therapy; Mirror therapy; Hand function
Cerebral Palsy (CP) describes “a group of motion and posture developmental disorders that induce functional limitations are associated with non-progressive defects that have occurred in the growing fetal or infant brain” . Hemiparetic cerebral palsy is a type of cerebral palsy that affects one arm and one leg on either the right or left side of the body and the upper limb is typically more involved than the lower limb. It is the most prevalent form of cerebral palsy disorders among full term- born infants, but is second in prevalence to spastic diplegia in premature infants . Reduction of upper extremity control can result from a sensory impairment, poor gripping, loss of fine-sequencing finger movements, loss of accuracy and speed, loss of dexterity, associated and mirror movements, preservation of grasp reflex and hypertonia . With time, these children neglect the affected arm, which can lead to additional dysfunction, such as increased muscle tone, reduced motor coordination, diminished active and passive flexibility of the limb joints, overall weakness, and slow skeletal maturation . Children with hemiparetic cerebral palsy learn tactics and methods to perform everyday activities and play with unaffected hand. Thus, the other hand, even though it is not impaired to a larger degree, is not included in practical tasks. This is called learning not to use the affected hand as if it were missing or amputated . Treatment approaches for children with hemiparetic Cerebral palsy include neurodevelopmental therapy, bilateral therapeutic exercises, constraint-induced movement therapy, sensory integration therapy, and mirror- mediated therapy . Constraint-induced movement therapy (CIMT) is defined a restriction of the less affected upper limb, with repeated task-oriented exercises for the more affected upper extremity in order to overcome the acquired non-use syndrome of the hemiplegic upper extremity and achieve functional rehabilitation . Restriction of the less affected limb can help balance hemispheric behavior. Training the more affected limb offers more advantages to ipsilesional corticospinal Tract. This might restrict the displacement of the intact Contralateral corticospinal tract projections in the affected hemisphere by enhancing more active projections in the un affected hemisphere . Intensive use of the more affected limb induces the development of the contralateral cortical area regulating the motion of the more affected limb” and recruits new ipsilateral regions, this may act as a neurological foundation for a permanent increase in the use of the affected limb post treatment . Constraint-induced movement therapy (CIMT) has been recognized as a tool for training a child to use the affected upper limb using a splint or glove restraint on the unaffected limb . Mirror therapy is another therapeutic intervention that focuses on moving the unimpaired limb. It is a procedure that is meant to enhance physical control of the affected limb in people with hemiplegia after a stroke and in children with spastic hemiparetic cerebral palsy . Therefore, this study may determine which method has a better effect on improving clinical outcomes in these children including the effect on “dissociated movement, grasps, protective extension, and weight-bearing”.
Material and Methods
This study included 40 patients with a diagnosis of Right hemiparetic cerebral palsy. Children with any other problems than right hemiparesis were excluded, such as contractures, suffering from fixed limitations in the affected upper limb, poor skin integrity or marked edema, or Any visual or auditory abnormality.
1. Mitt (Figure 1): used to constraint the unaffected hand in Group A.
2. Mirror box (Figure 2): A Mirror box is a device which allows the clinician to easily create this illusion. It is a box with one mirror in the center, where on each side, the hands are placed in a manner that the affected limb is kept covered always and the unaffected limb is kept on the other side whose reflection can be seen on the mirror .
A randomized study included forty children with right hemiparetic cerebral palsy selected from the out-patient clinic, Faculty of Physical Therapy, Cairo University (males and females, aged 5 to 8 years). Those meeting the criteria of inclusion were divided according to the type of intervention into 2 groups (A and B). Group A involved 20 children who will receive modified constraint-induced movement therapy 3 hours/ day “5 times per week” for 4 weeks. Group B involved 20 children who will receive mirror therapy, 30 minutes / day “5 times per week” using a mirror box for 4 weeks. Both groups will receive regular intensive physical and occupational therapy apart from the above interventions
This study was approved by the Cairo University Research Ethics Committee, and written informed consent was obtained from the parents of each subject to participate in this study. Participant recruitment
All children were randomly assigned equally in two groups using the closed envelopes procedure (40 children each).
• For Selection
1- Modified Ashworth Scale for selecting children (MAS):
The modified Ashworth scale is the most universally accepted clinical tool used to measure the increase of muscle tone . All subjects selected in this study were graded 1+ using MAS. 2- Manual Ability Classification System for children with cerebral palsy “4-18 yrs.” (MACS):
The Manual Ability Classification System (MACS) was developed to classify how children with cerebral palsy (CP) use their hands when handling objects in daily activities. The classification is designed to reflect the child’s typical manual performance, not the child’s maximal capacity. The MACS covers the age group between 4 and 18 years at levels ranging from I to V. The children at the level I are able to handle objects easily, those at level II handle most objects but with a little reduced quality or speed, and those at level III handle objects with difficulty and need help to prepare or change activities. At level IV, children handle a limited quantity of objects and require continuous support to partially conclude the activities, and at level V, the children do not handle objects .
All subjects selected in this study are leveled 3 using MACS.
• For assessment
The QUEST is a criterion-referenced measure that assesses upper limb movement on 34 items divided into four domains, with administration and scoring reported to take between 30 and 45 minutes. The QUEST was also constructed to be a discriminative measure of the quality of movement, measuring components of hand function, and providing information about movement and postural responses . The QUEST was developed for children aged 18 months to 8 years with muscle spasticity resulting from neurological impairment and affecting the upper extremities . The QUEST groups upper limb movement into four domains. Each domain focuses on areas of difficulty typically seen in children with spastic cerebral palsy: (a) Dissociated Movements, (the ability to voluntarily isolate movement at the shoulder, elbow, wrist and fingers); (b) Grasps (which also rates sitting postures during grasps of 1-inch cube, cereal, pencil or crayon); (c) Weight Bearing (the ability to lean on the arms in prone or 4-point kneeling, sitting and while reaching); and (d) Protective Extension (using the arms to stop oneself from falling forward, backward and to the side). QUEST was used for assessment of both groups pre-and post- treatment.
1. Modified Constraint Induced Movement Therapy
Group A Used Mitt for constraining the left hand 3 hours/ day “5 times per week” for 4 weeks, in addition to the selected physical therapy exercises (1.5 hours/ day “3 times per week”) for 4 weeks.
2. Mirror Therapy
Group B received Mirror therapy for 30 minutes / day “5 times per week” using a mirror box for 4 weeks, in addition to the selected physical therapy exercises (1.5 hours /day “3 times per week” for 4 weeks).
They were asked to perform activities with the unaffected hand while looking in the mirror. The mirror box was placed on a table of appropriate height so that she was able to see the reflection with back supported. The forearm was supported on the table. The right upper limb was placed inside the mirror box with the elbow supported. Activities performed by the right hand included grasps of cylindrical using cups, bottle, spherical using plastic balls of various diameter and hook grasp using rings and handles pattern objects. Gripping activities with Thera putty, pins board for training pincer pattern, attaching and detaching the chains using pulp-to- pulp prehension pattern. Transfer of cubes from one box to other with only left hand.
Selected physical therapy exercises include:
1- Strength exercises for weak wrist extensors, forearm supinator, and for intrinsic muscles of the affected hand.
2- Stretching exercises for wrist flexors, fingers flexors and forearm pronators.
3- Upper limb weight bearing exercises and Overhead activities. 4- Grasping and releasing small objects in a container.
5- Building a tower with cubes.
6- Balance training.
Descriptive statistics and unpaired t-test were conducted for comparison of age between groups. The Chi- squared test was used for comparison of sex distribution between groups. The normal distribution of the data was checked using the Shapiro-Wilk test. Levene’s test for homogeneity of variances was conducted to test the homogeneity between groups. The Unpaired t-test was conducted to compare the mean values of the QUEST scale between groups. Paired t-test was conducted for comparison between pre- and post-treatment in each group. Thelevelofsignificanceforallstatisticaltestswassetatp< 0.05. All statistical analyses were conducted using the statistical package for social studies (SPSS) version 25 for Windows (IBM SPSS, Chicago, IL, USA).
Forty children with hemiplegic CP participated in this study. All subjects were with right side affected, grade 1+ spasticity and level III of MACS. There was no significant difference between the groups in age and sex distribution (p > 0.05).
Effect of treatment on QUEST scale
– Within group comparison:
There was a significant increase in the QUEST scale post treatment compared with that pretreatment in groups A and B (p > 0.001). The percent of increase in the QUEST scale in group A was 10.84%, while that in the group B was 5.66% (Table 1, Figure 3).
– Between groups comparison:
There was no significant difference in the QUEST scale between both groups pre-treatment (p > 0.05). Comparison between groups post treatment revealed a significant increase in the QUEST scale for Group A compared with that for Group B (p > 0.001) (Table 1, Figure 3).
In all aspects of daily life, we carry out tasks involving the use of two hands, children with unilateral cerebral palsy, at all ages, who suffer diminished function with one hand, will continue to experience difficulties with daily occupational performance, affecting their involvement in life circumstances . As mentioned, if hemiplegic children use the upper unaffected extremity and neglect the affected upper extremity, they will lose their functional independence. This leads to theories that patients would gradually use the hemiplegic upper extremity and potentially reach functional improvement if they undergo short-term intensive rehabilitation programs such as modified constraint induced movement therapy or mirror therapy . In this study, both the mCIMT and mirror therapy groups showed improvements in the QUEST results, but the mCIMT group showed better QUEST results, and better hand function that was significantly correlated to dissociated movements, grasping, weight-bearing and protective reactions. The main difference between the mCIMT group and the mirror therapy group was that patients in the mCIMT group tried to move their affected arm, while those in the mirror therapy group did not. The intention to move the affected extremity is a notable difference between the two groups. In the Mirror therapy group, the affected limb does not engage in the task, but in the mCIMT group, there was an attempt to execute movement with the affected hand, which is necessary to reorganize the motor areas in the brain, resulting in motor skill improvement and higher performance on ADL . The reflection illusion of normal activity of the affected hand may substitute for reduced proprioceptive input, thus working to promote the premotor cortex and helping rehabilitation through a strong connection between visual input and the premotor regions. Improvements in Fugl-Meyer Assessment and fine motor movements have been recorded after a 3-to 4-week course of mirror therapy in patients with stroke. As a result, it has been shown to be successful in enhancing the range, velocity and precision of motion in the hemiplegic upper extremity . The findings of this study indicate that both mCIMT and mirror therapy improve hand function in hemiparetic cerebral palsy children, but mCIMT is significantly more effective in improving upper limb function in those children than mirror therapy. The findings of this study are in agreement with those of El-Kafy et al. who examined the effectiveness of a mCIMT protocol in improving upper extremity function in children with congenital hemiplegic cerebral palsy and reported improvement in functions of the affected hand . A study was conducted by Yumi Ju et al. to determine if therapies affect the function of the upper extremity and the ability to perform daily tasks, and they reported that mCIMT and mirror therapy significantly improves the motor function of affected hand . Further study has found that, after the implementation of CIMT, significant neuroplastic improvements in brain organization and function have occurred in people who have undergone the CIMT protocol . The modified form of restriction therapy (immobilization of the unaffected limb without intense motor training) also results in functional progress in children with cerebral palsy and contributes to cortical reorganization in children with hemiplegic cerebral palsy . Kim and Lim reported that mirror-mediated therapy conducted for 4 weeks (60 min/time, 5 days/week) had a beneficial effect on upper limb control, sensory function, and ADL in patients with chronic stroke-concomitant hemiplegia. In comparison, the experimental group demonstrated a strong recovery of hand function in more areas than the control group did in the Woo et al. study .
The Modified constraint induced movement therapy (MCIMT) is more effective than mirror therapy in improving functions of the affected hand for the children with hemiparetic cerebral palsy.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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Download attachments: 10.4328_ACAM.20505
Mohamed E. Madbouly, Khaled A. Olama, T.E.I.Omar, Mahmoud S. El Fakharany. Modified constraint-induced movement therapy versus mirror therapy on affected hand functions in hemiparetic children. Ann Clin Anal Med 2021;12(8):924-928
Effect of Helicobacter Pylori on iron deficiency anemia
Mehmet Agin 1, Yusuf Kayar 2
1 Department of Pediatric Gastroenterology, Hepatology and Nutrition, 2 Department of Gastroenterology, Van Education and Research Hospital, Van, Turkey
DOI: 10.4328/ACAM.20760 Received: 2021-06-26 Accepted: 2021-07-13 Published Online: 2021-07-24 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):929-931
Corresponding Author: Mehmet Agin, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Van Education and Research Hospital, Van, Turkey. E-mail: firstname.lastname@example.org P: +90 506-801-1083 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6177-2635
Aim: In children, although the most common causes of Iron Deficiency Anemia (IDA) are malnutrition, not consuming foods with iron, and parasitic infection, its relations with Helicobacter Pylori (HP) infection has not been clarified yet. For this reason, our purpose was to investigate the relations between HP infection and IDA in our study.
Material and Methods: A total of 111 patients, who were admitted to our Pediatric Gastroenterology Clinic due to recurrent abdominal pain and dyspeptic complaints, and whose gastric tissue biopsies were performed with upper gastrointestinal system endoscopy, were included in the study. The cases were di- vided into two groups as HP positive and HP negative. Both groups were compared in terms of hemoglobin, ferritin, serum iron, and total iron-binding capacity.
Results: 58% of the cases included in the study were HP (+), and 42% were HP (-);69% of them were females, and 31% were males. The mean age of HP (+) cases was 14.5 years, and the mean age of HP (-) cases was 15 years; no statistically significant differences were detected in this respect. No significant dif- ferences were detected between hemoglobin, iron, total iron-binding capacity, and ferritin levels between HP (+) and HP (-) cases.
Discussion: The presence of HP has no effects on iron deficiency anemia.
Keywords: Endoscopy; Helicobacter Pylori; Anemia; Children
Iron Deficiency Anemia (IDA) is the most common nutritional deficiency in the whole world, and it is reported that half of the children developing countries have IDA in . Patients infected with Helicobacter Pylori (HP) have decreased iron stores and are at risk for iron deficiency anemia [2,3]. In children, the most common causes of IDA are malnutrition, not consuming foods with iron, and parasitic infections [1,4].
It was reported that HP may affect some extraintestinal diseases, such as allergic diseases, idiopathic thrombocytopenic purpura, and anemia [5,6]. It was also reported in some previous studies that treatment of HP infection can improve IDA [7,8]. For this reason, it is still a matter of debate whether there is a relation between IDA and the presence of HP infection. The aim of this study was to investigate whether there is a relation between HP infection and IDA.
Material and Methods
A total of 111 patients, aged 2-18 years, who were admitted to the Pediatric Gastroenterology Clinic of Van Training and Research Hospital with dyspeptic complaints, and underwent upper Gastrointestinal System (GIS) endoscopy between January 2018 and January 2019 were included in the study. The data of the patients were analyzed retrospectively. Those with celiac disease, chronic or hemorrhagic disease, resistant vomiting, chronic diarrhea, oral iron therapy in the last 1 month, HP eradication treatment, those with a history of gastroduodenal surgery and antibiotic and/or Proton Pump Inhibitor (PPI) use up to one month before the study, and those who did not volunteer to participate in the study were not included in the study.
The endoscopies of the patients were performed in Van Training and Research Hospital Endoscopy Unit using Fujinon EG530WR endoscopy device. Verbal and written consent was obtained from the families before the endoscopy. All patients fasted for 6 hours before endoscopy, and the endoscopic procedure was performed after the patients were sedated. Biopsies were taken from the antrum and corpus of the stomach for pathological examinations during endoscopy and were sent to the pathology laboratory in 10% formaldehyde. The tissue samples were stained with Hematoxylin-Eosin (H-E), and evaluated under a light microscope, and then were stained with modified Giemsa to evaluate the presence of HP.
The patients were divided into two groups as HP (+) and HP (-). Age, gender, and hemoglobin, serum iron, total iron-binding capacity, and ferritin values were compared. Anemia was defined as a hemoglobin concentration < 11.5 g/dl in those aged 2-9 years, and < 12.5 g/dl in those aged 10-18 years. Iron deficiency was defined as a ferritin level < 10 ng/dl. Iron deficiency anemia (IDA) was defined as the presence of low serum iron levels (normal range: 22-184 μg/dl), high iron-binding capacity (normal range: 250-400 μg/dl), and iron deficiency . Ethical considerations
All participants provided written consents to participate in the study. Ethical approval for this study was obtained from the Ethics Committee of our hospital (Van, Turkey). All procedures were in line with the ethical standards of the human experimentation committee of our institution and the Declaration of Helsinki.
The normality of the distribution of continuous variables was tested by the Shapiro-Wilk test. The Mann- Whitney u test was used to compare 2 independent groups for non-normal data. The Chi-square test was applied to investigate the relationship between 2 categorical variables. Statistical analysis was performed with SPSS for Windows version 24.0 and a p-value < 0.05 was accepted as statistically significant.
Among the cases included in the study, 64/111 (58%) were HP (+), 47/111 (42%) were HP (-), and 76/111(69%) were females, and 35/111(31%) were males. The mean age of HP (+) cases was 14.5 years, the mean age of HP (-) cases was 15 years, and there were no statistically significant differences in this respect. No significant differences were detected in terms of hemoglobin, iron, total iron-binding capacity, and ferritin levels between HP (+) and HP (-) cases (Table 1).
Anemia is a public healthcare issue with important consequences in terms of economy and social development in the world. IDA is the cause of almost half of anemia cases. It is already known that various causes such as insufficient iron intake, chronic blood loss, chronic diseases, celiac disease, malabsorption, hemolysis, or a combination of these might cause iron deficiency [10,11]. The cause of iron deficiency cannot be identified in some of the cases with iron deficiency.
It was considered that HP may be associated with many diseases whose cause has not yet been identified, other than gastrointestinal diseases, and intensive studies wereconducted on this subject. The relations of many diseases, especially coronary diseases, immune thrombocytopenic purpura, various hematological diseases, IDA, urticaria, growth retardation, etc. with HP were intensively investigated. It was reported that HP chronic gastritis can change the physiology of the stomach, which includes reductions in gastric ascorbic acid levels and gastric acid secretion, which are necessary for the absorption of the dietary iron, resulting in iron deficiency [12- 14]. However, studies also reported conflicting results. No associations were detected between HP infection and IDA in a study conducted in Iran in the pediatric age group . In a study conducted in Estonia with children aged 7-18 years, no relations were reported between the presence of HP and IDA . In another study that was conducted in the pediatric age group in Bangladesh, it was reported that HP infection did not cause IDA . Zamani et al. reported that they detected no relations between HP antibody titer, serum ferritin levels, and IDA in their study conducted in the school-age children group in Iran . In Latin America, Santos et al. reported that there were no relations between HP and IDA in their study conducted with pediatric age groups . Contrary to these studies, there are several other studies reporting relations between HP and IDA. In a study that was conducted in Alaska by Parkinson et al. in the pediatric age group, a significant relation was detected between HP prevalence and low ferritin levels . In a study conducted by Zhang et al. in the adult age group, it was reported that HP infection affected oral iron absorption, and treatment of HP infection may have a positive effect on the treatment of iron deficiency in a positive way . In a study that was conducted in Korea with the adult age group, significant relations were detected between HP infection and low ferritin levels . Another study reported significant relations between resistant IDA and HP infection . In the present study, no significant differences were detected between HP (+) and HP (-) groups in terms of hemoglobin, ferritin, serum iron, and total iron-binding capacity. It is considered that the different results in the studies might have occurred because of geographical and cultural differences, ethnic distributions, ages of the patients, inclusion criteria, and differences in terms of study methods. Our study has limitations as well as strengths. Dietary content and iron supplement intake history could not be evaluated completely because of the retrospective nature of our study. Also, the small number of patients who were included in the study was another limitation of our study. However, investigating the presence of HP with upper GI endoscopy in all of our patients and in the pediatric group is the strength of our study. Conclusion
As a result of our study, it was found that the presence of HP did not have any negative effecton iron stores and iron deficiency anemia. However, there is a need for well-designed and long- term studies with wider participation because of the conflicting results of previous studies.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
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Mehmet Agin, Yusuf Kayar. Effect of Helicobacter Pylori on iron deficiency anemia. Ann Clin Anal Med 2021;12(8):929-931
Atherogenic indexes versus hematologic inflammatory indexes: What is the most useful predictor of coronary slow flow?
Ferhat Dindas 1, Emin Koyun 2, Idris Bugra Cerik 2, Anıl Sahin 3, Celal Kilit 1, Mustafa Dogdus 1
1 Department of Cardiology, Usak University, Training and Research Hospital, Usak, 2 Department of Cardiology, Sivas Cumhuriyet University, Faculty of Medicine, Sivas, 3 Department of Cardiology, Antalya Training and Research Hospital, Antalya, Turkey
DOI: 10.4328/ACAM.20766 Received: 2021-06-30 Accepted: 2021-07-17 Published Online: 2021-07-24 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):932-936
Corresponding Author: Ferhat Dindas, Usak Training and Research Hospital, Department of Cardiology, Usak City Center, 64200, Usak, Turkey. E-mail: email@example.com P: +90 506875 67 00 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0053-9594
Aim: Previous studies reported that inflammation and atherosclerosis are linked to coronary slow flow (CSF). The predominant pathological mechanism has not been elucidated yet. Hence, we aimed to compare hematologic inflammatory and atherogenic indexes simultaneously between patients with normal coronary flow (NCF) and CSF.
Material and Methods: In a single-center retrospective analysis, 91 consecutive NCF patients and 90 consecutive CSF patients constituted two groups ac- cording to Thrombolysis in Myocardial Infarction frame count (TFC). Hematological indexes consist of the neutrophil- lymphocyte ratio (NLR), the lymphocyte to monocyte ratio (LMR), and the platelet-lymphocyte ratio (PLR), and the atherogenic indexes consist of an atherogenic index of plasma (AIP), atherogenic coefficient (AC), and Castelli’s risk index (CRI). Baseline clinical parameters were compared beside the indexes.
Results: NLR, LMR, PLR were similar in groups. AIP, AC and CRI were significantly higher in the CSF group (p<0.05). In correlation analysis, only CRI has a significantly positive correlation with mean TFC (r: 0.419 p <0.001). In multivariate regression analysis, CRI was found as independently predictor of CSF (Odds ratio = 2.74, 95% CI= 1.21-6.207; p=0.016).
Discussion: An elevated CRI may be an independent predictor for the presence of CSF. Additionally, it can be said that the inflammatory activity in CSF is transformed into atherosclerotic structures.
Keywords: Coronary Circulation; Inflammation; Coronary Atherosclerosis; Dyslipidemias
Coronary slow flow (CSF), classified as heart syndrome Y or non-obstructive coronary artery disease (INOCA), is an angiographic phenomenon characterized by late dye transfer to the distal coronary vascular bed during angiography in patients without obstructive coronary lesions [1,2]. CSF is a considerable clinical entity because it causes acute cardiac ischemic effects as well as complaints reminiscent of myocardial ischemia in general . CSF has well-established mechanisms based on inflammation, atherosclerosis, endothelial dysfunction, and microvascular resistance . However, the proportion of this relationship between the factors involved in the pathological mechanism is still unclear.
Hematological inflammatory indexes consisting of neutrophil- to-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR), associated with inflammation in cardiovascular diseases have been previously specified [5,6]. Studies have shown that there is a significant association between decreased density lipoprotein cholesterol (HDL-c) level, increased low-density lipoprotein cholesterol (LDL-c) level, and the incidence of cardiovascular diseases and adverse events [7,8]. Recently, researchers have defined atherogenic indexes, consisting of the Atherogenic plasma index (AIP), the Atherogenic coefficient (AC), and Castelli’s risk index (CRI) to better define cardiovascular diseases based on atherosclerosis [9, 21-23].
Although many studies have been conducted on patients with CSF, as far as we know, no studies have been conducted comparing these hematologic inflammatories and atherogenic indexes in slow coronary flow. We aimed to compare the possible roles of atherogenic and hematological indexes in CSF, which includes both inflammation and atherosclerosis in its basic pathology.
Material and Methods
The present study was a retrospective and single-center study. Patients who admitted to cardiology clinic for stable angina pectoris between January 2015 and December 2018, who underwent coronary angiography and had angiographically normal or close to normal coronary arteries were retrospectively analyzed . At the beginning of our study, 129 patients with coronary slow flow (CSF) were detected. Exclusion criteria are as follows: left ventricular ejection fraction <50%, history of the previous revascularization, acute coronary syndrome, obstructive coronary lesion (>20% ), myocardial bridging, coronary ectasia, coronary spasm, infection, current anti-inflammatory and lipid- lowering medication usage, autoimmune disease, renal failure, anemia, hematological disease, and malignancy. After exclusion criteria, 181 patients were included in the final analysis, 90 consecutive patients with slow flow in either of their coronary arteries, versus 91 consecutive patients with normal coronary flow (NCF). Hypertension was defined as diastolic blood pressure ≥ 90 mm Hg or systolic blood pressure ≥ 140 mm Hg or with the use of any reported antihypertensive therapy. Diabetes mellitus (DM) was defined as the use of any antidiabetic agent. The study was in compliance with the principles in the Declaration of Helsinki and approved by the Local Institutional
Ethics Committee (Ethics committee approval code numbered 2020-16/07 was obtained on 17.06.2020).
Angiographic Data and Determination of Slow Coronary Flow Coronary angiography of all patients included in the study was performed using the Judkins technique and 6-French catheters from the femoral or radial artery. All angiographic images were recorded in Philips Allura Xper Percutaneous Coronary Intervention digital system at our cardiology clinic. Iopromide contrast (Omnipaque; GE Healthcare) was used in all study patients. Coronary flow of Angiograms was measured according to Thrombolysis in Myocardial Infarction (TFC) described by two cardiologists who were previously blinded to details of the study . The first frame count was determined as the anterograde movement of the contrast material touching both borders of the coronary lumen . The final frame count was determined as the first branch of posterolateral for right coronary artery (RCA), distal bifurcation for left anterior descending (LAD), and circumflex (CX) . The obtained frame results were doubled since the angiographic filming speed was 15 frames/second. Since the LAD artery is naturally long as described previously, the corrected TFC was obtained by dividing it by 1.7 . The mean TFC (mTFC) was calculated by summing the TFCs for the corrected LAD, CX, and RCA, and then dividing the sum by three . Patients with TFC greater than two standard deviations (SD) from the published normal range for any of the three vessels were considered patients with CSF (36.2 ± 2.6 frames for LAD, 22.2 ± 4.1 frames for CX, and 20.4 ± 3 frames for the RCA) .
Laboratory Measurements and Definition of Indexes
Blood samples were taken in the morning after 8-12 hours of overnight fast then examined within one hour of arrival at the central laboratory. Complete blood cell counts in blood samples were analyzed using a Beckman Coulter automated hematology device (Beckman Coulter Brea, CA, USA). Serum levels of total cholesterol, triglyceride (TG), and HDL-c were measured with standard enzymatic methods (Abbot GmbH Co, Germany) using a fully automated analyzer (Abbott Architect c16000) with original reagents. LDL-c concentrations were determined by the Friedewald method . Body mass index (BMI) was calculated by dividing weight by the square of the height (kg / m2). The estimated glomerular filtration rate (eGFR) was calculated by the Cockcroft Gault Calculator. Smoking was defined as one pack per day.
Hematological inflammatory indexes were calculated as follows [5,6]
Neutrophil lymphocyte ratio (NLR): Neutrophil counts/ Lymphocyte counts
Lymphocyte monocyte ratio (LMR): Lymphocyte counts/ Monocyte counts
Platelet lymphocyte ratio (PLR): Platelet counts / Lymphocyte counts
The Atherogenic indexes were calculated as follows [9,12] Atherogenic Index of Plasma (AIP) = log (TG / HDL-c) Atherogenic Coefficient (AC)=(Total cholesterol – HDL-c)/ HDL-c Castelli’s Risk Index (CRI) = LDL-c / HDL-c
All analyses were performed using SPSS for Windows version 25.0 (IBM Corp., Armonk, NY, USA). The compliance of the data to normal distribution was evaluated using the Kolmogorov- Smirnov test. Normally distributed continuous data were expressed as mean ± standard deviation, while continuous variables that were not normally distributed were specified as median with interquartile range (25–75th percentiles). Categorical variables were specified as the number with a percentage. Student’s t-tests were used to compare parametric continuous variables, and the Mann-Whitney U test was used to compare nonparametric continuous variables. Chi- square analysis was used to compare categorical variables. The correlation between CRI and mTFC was tested with the Spearman rho analysis. Logistic regression analysis was performed to assess the association of clinical and laboratory parameters with the presence of CSF. Univariate analyses were performed by including parameters that were significantly different between the groups. The Hosmer-Lemeshow test was used to determine sufficient goodness of fit for the regression model. Then, all significant parameters in univariate analysis were evaluated individually in a multivariate model with possible confounding factors (mTFC, age, gender, hypertension, smoking). All odds ratios were presented with their respective 95% confidence intervals (CI). A two-sided p<0.05 was considered significant.
The comparison of the main clinical characteristics and laboratory findings of the groups are shown in Table 1. There was no significant difference between the groups with respect to BMI, family history of premature coronary artery disease (CAD), DM, systolic blood pressure. Age (55.76 ± 12.16 years; 52.03 ± 11.94 years, p = 0.047), famele gender (n=27 [30.3%]; n=61 [67%], p <0.001), smoking (n=26 [28.9%]; n=14 [15.4%], p =0.022), hypertension (n=41 [45.6%]; n=27 [29.7 %], p =0.020) were significantly higher in patients with CSF. When the CSF and NCF groups were compared with the laboratory parameters, there was no significant difference between the CRP and glomerular filtration rate. In complete blood count, hemoglobin was significantly higher in patients with CSF (14,66 ± 1.8 g/dL, 13.91 ± 1.7 g/dL, p =0.003). On the other hand, platelet count was significantly higher in the NCF group (244.69 ± 73.52 x103/ mm3, 265.66 ± 63.57 x103/mm3, p =0.008). Neutrophil count, monocyte count and lymphocyte count were similar among groups. On a lipid scale, the TG levels were similar in the groups. Total cholesterol (134 [100.75-216] mg/dL, 123.5 [93-175.75] mg/dL, p <0.001) and LDL-c (116.98 ± 41.71 mg/dL, 90,42 ± 29.81 mg/dL, p <0.001) were higher in patients with CSF. HDL-c (40 [34-48] mg/dL, 50.5 [40.25-62] mg/dL, p <0.001) was lower in CSF group. As expected, the mTFC (31 [25-37], 14 [12-16], p <0.001) was significantly higher in the CSF group. Comparisons of the hematological inflammatory indexes and atherogenic indexes are shown in Table 1. NLR, LMR, and PLR were similar between the groups. AIP (3.4 [2.1-5.4], 2.2 [1.8- 3.8], p =0.027 ), AC (3.59 ± 1.66, 2.34 ± 1.19), p <0.001), and CRI (2.92 [1.94-3.84], 1.72 [1.17-2.53], p <0.001) were significantly higher in the CSF group. Univariate and multivariate logistic regression analyses were used to evaluate independent predictors of CSF and are shown in Table 2. In multivariate regression analysis, total cholesterol (OR = 1.946; 95% CI =1.359 – 2.787, p =0.024), LDL-c (OR = 1.032, 95% CI = 1.005- 1.059, p =0.018), CRI (OR = 2.74, 95% CI = 1.21-6.207, p =0.016) were significant independent predictors of the presence of CSF. Also, there was a moderate positive correlation between mFC and CRI (r = 0.419, p <0.001) (Figure 1).
In the present study, we found that CRI, LDL-c, and total cholesterol were independent predictors of the presence of CSF. We also found that CRI activity was moderately correlated with mTFC.
CSF is a term professionally known to interventional cardiologists that delays opacification in distal segments without >40% angiographic lesions in main epicardial coronary arteries . Previous studies have shown that CSF is a condition involving systemic inflammatory factors rather than just locally acting inflammation . Systemic inflammatory effects can alter the parameters and rates of blood count. PLR, LMR, and NLR are inexpensive systemic inflammatory markers. Considering the relationship between many cardiovascular diseases in which cardiovascular risk factors are well documented by various previous studies, these parameters can be used as markers for conditions involving an inflammatory process [5,6]. PLR, NLR, and LMR were similar between groups in our study. Inflammatory infrastructure pattern was recessive in CSF. These results may be explained by the presence of near-normal coronary arteries in our patient selection, because inflammation has been blamed in the initial stage rather than the advanced stage of the atherosclerotic process .
The benefits of increasing HDL-c level as well as lowering LDL-c level for the prevention of atherosclerotic cardiovascular disease are well known and potential benefits have been reported in patients at an early age . Besides, it has been reported that statin therapy reduces CSF and increases coronary flow reserve in patients with CSF . Decreased coronary reserve in CSF required a new definition as INOCA . The increased microvascular tone has been blamed in the CSF examined in the INOCA subgroup. In the increase of coronary microvascular tone, oxidative stress and pro-inflammatory process in which adipokines are blamed together with sympathetic hyperactivity . Recent adipokine gene studies have found significant regulatory and correlative effects of adipokines on LDL-c and total cholesterol in obese male and female patients . According to the results of our study, the increased LDL-c and total cholesterol level associated with atherosclerosis and increased microvascular tone is an independent predictor of CSF.
CSF may include diffuse atherosclerosis not only in the epicardial coronary arteries but also in the coronary microvascular circulation . The relationship of atherogenic indexes with cardiovascular diseases and cardiovascular death based on atherosclerosis has been defined [9,12]. A recent study found that the SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) score, which indicates the severity of obstructive coronary artery disease, is associated with AIP . Besides, saphenous vein graft stenosis associated with distal flow insufficiency, endothelial damage, and accelerated atherosclerosis has been associated with AIP and AC . Furthermore, in a study based on intracoronary imaging in CAD, there was a significant relationship between plaque lipid content and plaque sensitivity and CRI .
In our comparison of the CSF group with the NCF group, AIP, AC, and CRI were found to be significantly higher in the CSF group. CRI, the equivalent of LDL-c/HDL-c, was an independent predictor of CSF.
The present study has some limitations that need to be mentioned. First, this study used a retrospective study design with a relatively small sample size based on single-center experience. Second, since we used a single CRI value and a limited number of patients for our analysis, rather than a transient trend, no prognostic values were determined on cardiovascular outcomes. Third, Cohen’s kappa value was not determined to detect inter-observer and intra-observer variations in TFC measurements. Finally, we did not evaluate for endothelial dysfunction and microvascular tone.
Our findings suggested that higher total cholesterol level, LDL-c level, and CRI were independently related to the presence of CSF. In addition to that, CRI was significantly positively correlated with mTFC. The findings of our study also confirmed that CRI had a moderate positive correlation with mTFC. Studying these markers may provide more informative data about the pathogenesis of microvascular atherosclerosis in patients with CSF. Additionally, it can be said that the inflammatory activity in CSF changes into atherosclerotic structures but more studies are needed to confirm our findings in CSF.
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Animal and human rights statement
Conflict of interest
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21. Wang L, Chen F, Xiaoqi C, Yujun C, Zijie L. Atherogenic Index of Plasma Is an Independent Risk Factor for Coronary Artery Disease and a Higher SYNTAX Score. Angiology. 2021; 72(2):181-6.
22. Yavuz F, Kilic S, Kaplan M, Yıldırım A, Kucukosmanoglu M, Dogdus M. Impact of Atherogenic Indexes in Saphenous Vein Graft Stenosis. Impacto dos Índices Aterogênicos em Estenose do Enxerto de Veia Safena. Arq Bras Cardiol. 2020; 115(3):538-44.
23. Kimura T, Itoh T, Fusazaki T, Matsui H, Sugawara S, Ogino Y, et al. Low- density lipoprotein-cholesterol/high-density lipoprotein-cholesterol ratio predicts lipid-rich coronary plaque in patients with coronary artery disease–integrated- backscatter intravascular ultrasound study. Circ J. 2010; 74(7):1392-8.
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Ferhat Dindas, Emin Koyun, Idris Bugra Cerik, Anıl Sahin, Celal Kilit, Mustafa Dogdus. Atherogenic indexes versus hematologic inflammatory indexes: What is the most useful predictor of coronary slow flow? Ann Clin Anal Med 2021;12(8):932-936
Late diagnosed congenital anterior urethral diverticulum in a male teenager: A case report
Aydemir Asdemir 1, Huseyin Saygin 2, Esat Korgali 2, Resul Cicek 3
1 Urology Clinic, Suluova Public Hospital, Amasya, 2 Department of Urology, Faculty of Medicine, Cumhuriyet University, Sivas, 3 Urology Clinic, Malatya Training and Research Hospital, Malatya, Turkey
DOI: 10.4328/ACAM.20466 Received: 2021-01-05 Accepted: 2021-02-04 Published Online: 2021-02-15 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):937-939
Corresponding Author: Aydemir Asdemir, Urology Clinic, Suluova Public Hospital, 05500, Amasya, Turkey. E-mail: firstname.lastname@example.org P: +90 5068943216 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9141-6727
In this case report we present the case of an 18-year-old boy with a congenital anterior urethral diverticulum. This is a rare condition in males which can lead to obstructive lower urinary tract symptoms and urosepsis. Diagnosis is made by urethroscopy and radiological imaging. Surgical treatment can be open or endoscopic. Long-term follow up is required to check for reoccurrence of the obstruction.
Keywords: Diverticulum; Urethra; Congenital
Male urethral diverticulum is rare , and is always located in the penile urethra. This may be defined as pouch-like enlargement that is continuous with the urethral lumen. An acquired diverticulum in males may be found anywhere along the urethra. The peno-scrotal junction is the most common site for anterior urethral diverticulum. This can occur in patients who have a spinal cord injury as a result of repeated urethral trauma due to bladder catheterization . A diverticulum may be asymptomatic or lead to lower urinary tract symptoms. Rarely, the diverticulum may initially present as a scrotal mass.
An 18-year-old boy presented with a two-year history of incontinence as postmicturition dribbling and sometimes dysuria. There was no other significant history. Examination revealed no abnormalities. The urine culture was sterile. The volume of postmicturition residual urine was 103 ml. However, the average urinary flow rate was 16.7 ml/s. Rigid cystoscopy revealed an anterior urethral diverticulum (Figure 1). During the retrograde urethrogram, we were unable to obtain an image because of an error of the scopy machine. We incised the neck of the diverticulum with a cold knife (Figures 2-4). The patient’s urethral catheter was taken 5 days after the operation. In the postoperative first month the average flow rate is 19.8 ml/s and the volume of postmicturition residual urine is 33 ml. The patient’s postmicturition dribbling symptom stopped. It was planned to monitor the urinary flow rate and postmicturition residual urine at the out-patient clinic and to repeat the diverticulum neck incision if the flow rate worsens.
Urethral diverticulum belongs to a spectrum of obstructive anterior urethral conditions that include anterior urethral valves. Some authors do not distinguish between the conditions while others do . A common feature is a blind-ending outpouching of the urethra. Anterior urethral valve is completely contained within the corpus spongiosum whereas a diverticulum breaches through the corpus spongiosum into the surrounding tissue. We have not made the distinction in this paper as the management is the same for both. A flap can develop at the lip of the diverticulum which rises into the urethral lumen as the diverticulum fills with urine, causing an obstruction. Congenital urethral diverticulum in males is rare, and patients can present with poor urinary flow, postmicturition dribbling, urinary tract infections, or penile ballooning in the neonatal and infancy period [4,5], although later presentations in the teenage years have been known. The etiology is unknown but theories include a ruptured syringocele, cystic dilatation of the periurethral glands, and incomplete hypospadias.
Retrograde urethrography and voiding cystourethrography may be used to image the male urethra [5,7]. Urethroscopy will reveal an appearance of the urethral lumen splitting into the two-one passage is the true lumen while the other is the diverticulum, with the flap or distal lip of the diverticulum dividing the two. Conclusion
Management of the lesion can be endoscopic or open [3,8]. We adopted an endoscopic approach with incision of the lip of the diverticulum, although, as the diverticulum pouch still exists, it can again develop a flap, requiring repeat procedures. Subsequent scar tissue formation may result in a urethral stricture which, like the diverticulum, can cause poor urinary flow, recurrent urinary tract infections, and bladder stones. Therefore regular endoscopic surveillance and correction may be required. An open approach (patch graft urethroplasty) can also be used to excise the diverticulum permanently and reconstruct the urethra, giving it a more uniform calibre; however there is a risk of urethrocutaneous fistula formation. If the patient has urosepsis or obstructive nephropathy, temporary urinary diversion by suprapubic catheterization can be employed before surgical treatment .
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1. Parker WR, Wheat J, Montgomery JS, Latini JM. Urethral diverticulum after endoscopic urethrotomy: case report. Urology. 2007;70(1008):e5–e7.
2. Garris EM, Jolles PR, Cole TJ. Large urethral diverticulum presenting as a scrotal tracer collection on renal scintigraphy. Clin Nucl Med. 1996;21:661–2. DOI: 10.1097/00003072-199608000-00022.
3. Paulhac P, Fourcade L, Lesaux N, Alain JL, Colombeau P. Anterior urethral valves and diverticula. BJU Int. 2003;92(5):506–9.
4. Arena S, Romeo C, Borruto FA, Racchiusa S, di Benedetto V, Arena F. Anterior urethral valves in children: an uncommon multipathogenic cause of obstructive uropathy. Pediatr Surg Int. 2009;25(7):613–16.
5. Rawat J, Khan TR, Singh S, Maletha M, Kureel S. Congenital anterior urethral valves and diverticula: diagnosis and management in six cases. Afr J Paediatr Surg. 2009;6(2):102–5.
6. McLellan DL, Gaston MV, Diamond DA, Lebowitz RL, Mandell J, Atala A, et al. Anterior urethral valves and diverticula in children: a result of ruptured Cowper’s duct cyst? BJU Int. 2004;94(3):375–8.
7. Pavlica P, Barozzi L, Menchi I. Imaging of male urethra. European Radiology. 2003;13(7):1583–96.
8. Kajbafzadeh A. Congenital urethral anomalies in boys. Part II. UrolJ. 2005;2(3):125–31.
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Aydemir Asdemir, Huseyin Saygin, Esat Korgali, Resul Cicek. Late diagnosed congenital anterior urethral diverticulum in a male teenager: A case report. Ann Clin Anal Med 2021;12(8):937-939
Macro hematoma after micro percutaneous nephrolithotomy: A case report
Aydemir Asdemir 1, Huseyin Saygin 2, Esat Korgali 2, Resul Cicek 3
1 Urology Clinic, Suluova Public Hospital, Amasya, 2 Department of Urology, Faculty of Medicine, Cumhuriyet University, Sivas, 3 Urology Clinic, Malatya Training and Research Hospital, Malatya, Turkey
DOI: 10.4328/ACAM.20468 Received: 2021-01-06 Accepted: 2021-02-25 Published Online: 2021-03-09 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):940-942
Corresponding Author: Aydemir Asdemir, Urology Clinic, Suluova Public Hospital, 05500, Amasya, Turkey. E-mail: email@example.com P: +90 5068943216 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9141-6727
The micropercutaneous nephrolithotomy (mPNL, microperc) method was developed in order to prevent complications. In our clinic, we performed microperc on a 39-year-old man who expelled renal stone. During the microperc procedure, lower pole calyceal access was successfully obtained to get direct access to the stone by using 4.8Fr microperc needle. The patient’s hemoglobin dropped from 16.8 to 9.6 gr/dl about 6 hours after surgery. A new computerised tomography (CT) scan demonstrated a large retroperitoneal hematoma measuring 182x97x92 mm. When we performed retroperitoneal exploration, we saw a bleeding area due to the entrance of microperc needle. Then, we controlled the hemorrhage. The patient’s hemodynamics remained stable and he did not need any blood transfusion after exploration. Based on this case, it appears reasonable to allow open surgery after microperc to control macro hematoma.
Keywords: Macro; Hematoma; Microperc
Advances in minimally invasive endourological techniques continue to provide the urologic surgeons with excessive options for the management of symptomatic renal calculi. Reducing the size of instruments in percutaneous nephrolithotomy (PNL) is the so-called ‘microperc’, in which the procedure is carried out through a 4.8Fr all-seeing needle. Procedural steps of PNL are time-consuming and also may cause complications such as prolonged fluoroscopy times, bleeding through the access tract, infundibular rupture, and pelvic perforation. In order to prevent these complications, the microperc method was developed. But it is not clear how often and which complications occur in all microperc procedures. We reviewed the current literature and reported an index case of coexisting macro hematoma visualized on contrast-enhanced CT after microperc in this case report.
A 39-year-old man was admitted to our clinic with left renal lower anteromedial calyceal stone after 3 sessions of extracorporeal shockwave lithotripsy (ESWL) conducted in another clinic. As the patient said, the stone was 1,5cm in diameter before ESWL, and ESWL lasted 2 weeks before he applied to our clinic. We could not contact other clinic and were unable to obtain the patient’s documents before ESWL. In our clinical practice, we always talk about flexible ureteroscope, microperc or PNL after one session of ESWL failure. In our clinic, preop computerized tomography (CT) showed us that the stone was single, in lower pole anteromedial calyx, ~12,2×9,4×7,4 mm in size, and its density was 875 HU ( Hounsfield unit). After ESWL, the size of the stone decreased, but it was not enough to be subject to clearance spontaneously. We talked about watchful waiting follow-ups if there was no symptom or surgical treatment alternatives, including a flexible ureteroscope or microperc, and their probable complications if symptoms are present. The patient chose treatment because of the pain. In our clinic, we performed left microperc and left ureteral J stent was placed (because of intraoperative overbalance hemorrhage) in this patient. During the microperc procedure, lower pole calyceal access was successfully obtained to reach the stone directly using a 4.8Fr all-seeing microperc needle accompanied by visualization with scopy. No bleeding was observed during the access, and no dilatation was performed. After accessing, we observed that the stone was fragmented into several pieces due to ESWL. A large piece of stone was fragmented with [8 Hertz (6.4 Watt) 0.8 Joule] 200-micron Holmium laser fiber under direct visualization, and all of the pieces were washed out to the ureteropelvic junction. The patient’s hemoglobin dropped from 16.8 to 9.6 gr/dl about 6 hours after the operation and he was therefore re-admitted with unstable hemodynamics (heart rate: >100/min and systolic blood pressure: <100 mmHg). Contrast- enhanced CT demonstrated a large retroperitoneal hematoma measuring 182x97x92 mm. Then we consulted the patient with a radiologist if they could make selective embolization and possible drain placement to control the bleeding. But they replied to us they could not because of technical problems. Therefore, we preferred open surgery because of the patient’s unstable hemodynamics. When we performed left retroperitoneal exploration, we observed a huge hematoma and saw a nearly 3-mm bleeding area due to the insertion of a microperc needle into the lower calyceal area of the kidney. Then, we controlled the hemorrhage by suturing this area with 2/0 vicryl and using an absorbable hemostat, involving oxidized cellulose. Also, we positioned a drain here. After the exploration, the patient’s hemodynamics and hemoglobin remained stable and he did not need any blood transfusion. Three days after the exploration, patient’s drain stopped, we left out his drain and discharged him. These findings confirmed the diagnosis of a macro hematoma after microperc.
The aim of performing endoscopic procedures using smaller instruments is to reduce complications rate, morbidity and mortality with no decrease in the success rates. The main limitation of PNL is its invasiveness and accompanying morbidity. Microperc extended the concept of ‘All-seeing needle’ to perform PNL by using a 4.8-Fr tract . The optical needle helps to avoid any traversing viscera and confirms the visual cues of a correct papilla. This may provide a new standard for obtaining renal access and lithotripsy without dilatation. Complications may develop immediately after the primary puncture; therefore, establishing optimal and atraumatic access to the pelvic system is the most important initial step in a successful PNL procedure . Perinephric hematomas occur in nearly one-third of patients undergoing PNL, but are extensive in only 11% of the cases. Richstone et al., demonstrated the frequency of post-operative hemorrhage following percutaneous renal interventions  but this frequency is not clear for microperc. However, there are numerous studies on the success and complications of PNL, and there are a limited number of studies on the success and complications of using microperc. Hatipoglu et al. demonstrated that the mean drop in the hemoglobin level was 0.87±0.84 (0–4.1 g/dL) in their study of 140 patients. Bleeding requiring blood transfusion was observed in only one patient in the present series . The most important advantage of the microperc is reduced bleeding. In microperc, a single-step access under direct visualization helps prevent potential complications during access and dilatation of the tract. It also decreases the risk of intraoperative bleeding. Studies have demonstrated that the size of the nephroscope and tract affects the amount of intraoperative bleeding [5,6]. In the first microperc study, the mean decrease in hemoglobin was found to be 1.4 mg/dL  and this study did not report the need for postoperative transfusion [4,5,6].
In summary, only a few published studies have documented the efficacy and safety of microperc. Based on this case, it appears reasonable to allow selective embolization and possible drain placement or open surgery after microperc to control bleeding. It is expected that with a smaller tract, bleeding and complication decrease. However, it is not true for this case, and it is always important to remember that possible important bleeding may occur after microperc procedures ending with selective embolization or exploration.
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1. Desai MR, Sharma R, Mishra S, Sabnis RB, Stief C, Bader M. Single-step percutaneous nephrolithotomy (microperc): the initial clinical report. J Urol. 2011;186(1):140–5.
2. Chan YH, Wong KM, Kwok PC, Liu AY, Choi KS, Chau KF, et al. A veno-caliceal fistula related to ureteric stricture in a kidney allograft masquerading as renal failure.Am J Kidney Dis. 2007;49(4):547–51.
3. Chichakli R, Krause R, Voelzke B, Turk T. Incidence of perinephric hematoma after percutaneous nephrolithotomy. J Endourol. 2008;22(6):1227-32.
4. Hatipoglu NK, Tepeler A, Buldu I, Atis G, Bodakci MN, Sancaktutar AA, et al. T. Initial experience of micro-percutaneous nephrolithotomy in the treatment of renal calculi in 140 renal units. Urolithiasis. 2014;42(2):159-64.
5. Kukreja R, Desai M, Patel S, Bapat S. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol. 2004;18(8):715-22.
6. Unsal A, Resorlu B, Kara C, Bozkurt OF, Ozyuvali E. Safety and efficacy of percutaneous nephrolithotomy in infants, preschool age, and older children with different sizes of instruments. Urology. 2010;76(1):247-52.
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Aydemir Asdemir, Huseyin Saygin, Esat Korgali, Resul Cicek. Macro hematoma after micro percutaneous nephrolithotomy: A case report. Ann Clin Anal Med 2021;12(8):940-942
A rare complication of COVID-19: Pneumomediastinum
Gizem Aydınok Akçay, Saylav Ejder Bora, İsmail Eren Akçay
Department of Emergency Medicine, Izmir Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Turkey
DOI: 10.4328/ACAM.20479 Received: 2021-01-11 Accepted: 2021-02-07 Published Online: 2021-02-21 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):943-946
Corresponding Author: Ejder Saylav Bora, Department of Emergency Medicine, Izmir Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Turkey. E-mail: firstname.lastname@example.org P: +90 (532) 450 78 55 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2448-2337
COVID-19 is still common and we do not know enough about its complications. The presence of air in the mediastinum is called pneumomediastinum. Since spontaneous pneumomediastinum is rare, pneumomediastinum is started to be reported in Covid-19 patients.
A 26-year-old male patient was admitted to the emergency department with fever, shortness of breath and sore throat, and was found to have COVID-19 as a result of examinations. The treatment of the patient was started, and on the 6th day of the treatment, it was observed that the patient had an increase in shortness of breath and a new cough. Free air was seen in the mediastinum on the imaging. The patient who was diagnosed with pneumomediastinum was discharged with antibiotherapy and favipiravir treatment.
Spontaneous pneumomediastinum is a rare complication of COVID-19 infection. Here, we present a case of COVID-19 developing pneumomediastinum 6 days after the symptoms started.
Keywords: COVID-19; Pneumomediastinum; Complication
A new type of Coronavirus 2019 (COVID-19), also known as severe acute respiratory failure syndrome-coronavirus 2 (SARS-COV-2); it has not dropped from the world agenda since December 2019, when the first case appeared. As far as we know, COVID-19 is a virus with a high mortality rate, causing severe pneumonia and acute respiratory distress syndrome (ARDS) .
The presence of air in the mediastinum is called Pneumomediastinum, and pneumomediastinum is divided into spontaneous and secondary. Although spontaneous pneumomediastinum is extremely rare, it is frequently seen in healthy young men, and in its etiology, pressure-related rupture of peripheral pulmonary alveoli plays a role in the presence of various triggering factors .
Cases of pneumomediastinum rarely present with symptoms, it is usually detected incidentally, and it mostly regresses without the need for treatment .
Respiratory diseases such as asthma and respiratory tract infections can cause pneumomediastinum, especially during exacerbation periods with excessive cough .
We would like to present in this case COVID-19 disease as a factor that triggers pneumomediastinum such as asthma, interstitial lung disease, COPD, bronchiectasis, lung cysts, lung malignancy, and excessive vomiting.
A 26-year-old male patient was admitted to the emergency department with complaints of difficulty in breathing, wheezing, fever and sore throat. There was no history of trauma. There was no finding other than tachypnea on admission examination. In the patient’s history, except for 10 pack-year (active smoker) smoking, no characteristic was detected. A throat swab sample was taken and computed tomography (CT) of the thorax was taken with the suspicion of COVID-19 due to symptoms similar to upper respiratory tract disease. No pathology was found on thorax CT (Figure 1). In the patient, COVID-19 was considered, and chloroquine treatment was arranged and sent to home isolation.
The patient applied to the COVID-19 outpatient clinic again after 6 days, when his complaints did not go away, his dyspnea deepened and coughing added. When the thorax CT taken this time was compared with the thorax CT 6 days ago, there were newly emerged free air densities in the mediastinum. In addition, unlike the old CT, scattered localized ground glass densities were observed in the upper lobes in the bilateral hemithorax (Figure 2).
In laboratory tests, CRP was found to be 106.35mg / L. Ferritin, D-Dimer and other blood parameters were normal. In the physical examination, his general condition was good, he was conscious, and the patient was oriented and cooperative. Vital signs were as follows: TA: 110/70 SD: 15 SAT: 92. Fever was found to be 37.1. The patient was hospitalized in the COVID-19 service with a pre-diagnosis of COVID-19 and mediastinitis. The control Thorax Angio CT, taken on the 2nd day of the patient’s hospitalization by the radiologist, revealed the following: “In addition to the appearance compatible with COVID-19 pneumonia, the presence of free air around the vascular structures, trachea, main bronchi and esophagus in the mediastinum fat planes is noticeable. Thrombophlebitis – mediastinitis secondary to vasculitis ”(Figure 3).
Thoracic surgery specialist who evaluates the patient as a result of the desired consultation in the COVID-19 service, evaluated as “the patient’s clinic is compatible with pneumomediastinum” and made combined antibiotherapy recommendations. The patient, who was treated with moxifloxacin, Favipavir, chloroquine and oxapar, was discharged with home isolation recommendations at the end of the 7th day of his hospitalization, when his vitals were stable and no pathology requiring hospitalization was detected.
Although spontaneous Pneumomediastinum is generally a self- limiting disease, it may rarely lead to severe respiratory and circulatory disorders, but its formation mechanism is not fully known [3,5].
In COVID-19 infection, it is thought that pneumomediastinum may develop due to damage to the alveolar membrane by the virus and its explosion as a result. It is thought that this damage may be caused by the pressure gradient difference between the alveoli and the pulmonary interstitium [3,6].
The relationship between the novel coronavirus and pneumomediastinum has been discussed in many case series since December 2019, when the first case related to the novel coronavirus was announced . There are articles that argue that this relationship is a marker that will affect the prognosis of the disease negatively  and that this does not affect the prognosis . Our case is well documented for the relationship between Novel Coronavirus and Pneumomediastinum.
We think that COVID-19 infection may be associated with spontaneous air leakage, and further research is needed to delineate the mechanisms that trigger it and the impact on the course and outcome of the disease.
Pneumomediastinum can be a spontaneous condition seen in COVID-19 patients. In non-COVID-19 patients, it is commonly self-limited, but COVID-19 patients with pneumomediastinum may have more complicated results. Larger studies will show us possible correlations.
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1. Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents. 2020;55(5):105955. DOI: 10.1016/j.ijantimicag.2020.105955.
2. Kayalı A, Çakır A, Payza U, Karakaya Z, Akyol PY, Suadiye U. Frightening complication after tooth extraction: Pneumomediastinum. Ann Clin Anal Med. 2020;11(Suppl. 2): S132-4.
3. Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, et al. Pneumomediastinum. J Thorac Dis. 2015;7(S1):S44-S9. DOI: 10.3978/j.issn.2072-1439.2015.01.11
4. Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE Jr. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg. 2008;86(3):962-6. DOI: 10.1016/j.athoracsur.2008.04.067.
5. Agut A, Talavera J, Buendia A, Anson A, Santarelli G, Gomez S. Imaging Diagnosis-Spontaneous Pneumomediastinum Secondary to Primary Pulmonary Pathology in a Dalmatian Dog. Vet Radiol Ultrasound. 2015;56(5):E54-7. DOI: 10.1111/vru.12223.
6. Romano N, Fischetti A, Melani EF. Pneumomediastinum Related to Covid-19 Pneumonia. Am J Med Sci. 2020;360(6):e19-e20. DOI:10.1016/j. amjms.2020.06.003
7. Zhou C, Gao C, Xie Y, Xu M. COVID-19 with spontaneous pneumomediastinum. Lancet Infect Dis. 2020;20(4):510. DOI: 10.1016/S1473-3099(20)30156-0.
8. Wang J, Su X, Zhang T, Zheng C. Spontaneous Pneumomediastinum: A Probable Unusual Complication of Coronavirus Disease 2019 (COVID-19) Pneumonia. Korean J Radiol. 2020;21(5):627-8. DOI: 10.3348/kjr.2020.0281.
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Gizem Aydınok Akçay, Saylav Ejder Bora, İsmail Eren Akçay. A rare complication of COVID-19: Pneumomediastinum. Ann Clin Anal Med 2021;12(8):943-946
A 53-year-old female with bladder leiomyoma: A rare case and review of the literature
Aydemir Asdemir 1, Tugba Yildiz Asdemir 2, Huseyin Saygin 3, Esat Korgali 3, Resul Cicek 4
1 Urology Clinic, Suluova Public Hospital, Amasya, 2 Department of Old Care, Sabuncuoglu Serefeddin Vocational School Of Health Services , Amasya University, Amasya, 3 Department of Urology, Faculty of Medicine, Cumhuriyet University, Sivas, 4 Urology Clinic, Malatya Training And Research Hospital, Malatya, Turkey
DOI: 10.4328/ACAM.20480 Received: 2021-01-12 Accepted: 2021-02-11 Published Online: 2021-02-23 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):947-950
Corresponding Author: Aydemir Asdemir, Urology Clinic, Suluova Public Hospital, 05500, Amasya, Turkey. E-mail: email@example.com P: +90 5068943216 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9141-6727
Leiomyoma as a benign tumor of the urinary bladder, is uncommon and usually presents with obstructive voiding symptoms or irritative urinary symptoms. A 53-year-old woman was hospitalized to the general surgery clinic due to abdominal pain. During her contrast-enhanced computed tomography (CT) examina- tion, incidentally, a mass on the left anterosuperolateral side of the bladder wall was revealed. No significant finding was detected on physical examination. There was only microscopic hematuria as a result of urinalysis. Contrast-enhanced CT confirmed the presence of a mass on the left anterosuperolateral side of the bladder wall without evidence of extravesical extension and showed a well-delineated 2,6 cm x 2,4 cm endovesical bladder tumor arising from the left anterosuperolateral bladder wall and there was a thickening of the urinary bladder wall. On cystoscopy, an intraluminally protruding, rounded, smooth, ses- sile solid mass, 2,5 cm in diameter and covered by normal bladder mucosa, was seen. She underwent an uneventful transurethral resection of bladder tumor (TURBT) and histological examination revealed intersecting fascicles of smooth muscle without any evidence of malignant change, and thus diagnosis of leiomyoma was confirmed. Confirmation of the diagnosis may be difficult due to the poor yield of cold cup biopsy. In our case, transurethral resection (TUR) was diagnostic.
Keywords: Leiomyoma; Bladder; Benign
Leiomyoma, as a benign tumor of the urinary bladder, is uncommon and usually presents with obstructive voiding symptoms or irritative urinary symptoms.  But several previous cases had involved dyspareunia symptoms.  Although bladder tumors are one of the most common malignancies worldwide (Chou R, et al. Treatment of muscle-invasive bladder cancer: a systematic review. Cancer 2016) leiomyoma accounts only for <0.5% of all bladder cancers. [3, 4]
A 53-year-old female who had a history of total abdominal hysterectomy and bilateral salphingo-oopherectomy 15 years ago was hospitalized to the general surgery clinic due to abdominal pain. During her contrast-enhanced CT examination, incidentally, a mass on the left anterosuperolateral side of the bladder wall was revealed. The patient was referred to the urologist examination; however, there were no symptoms, including dysuria, urgency, nocturia, incontinence, pollakiuria, macroscopic hematuria, and obstructive complaints. No significant findings were detected on physical examination. Urinary tract infection was excluded and there was only microscopic hematuria as a result of urinalysis. The results of other laboratory tests, including renal function, liver function, complete blood cell count, and coagulation function were also within the normal range. Contrast-enhanced CT confirmed the presence of a mass on the left anterosuperolateral side of the bladder wall without evidence of extravesical extension and showed a well-delineated endovesical bladder tumor measuring 2,6 cm × 2.4 cm, arising from the left anterosuperolateral bladder wall and there was a thickening of the urinary bladder wall (Figure 1). There was no evidence of locoregional invasion. The upper urinary tract was functionally and structurally normal. On cystoscopy, an intraluminally protruding, rounded, smooth, sessile solid mass, 2,5 cm in diameter and covered by normal bladder mucosa, was seen. She underwent an uneventful TURBT, and histological examination revealed intersecting fascicles of smooth muscle (Figure 2a, b) without any evidence of malignant changes, and thus diagnosis of leiomyoma was confirmed. Microscopically, the bladder tissue covered with transitional epithelium (black arrow) was observed. Smooth muscle cells in the form of fascicles were observed under the epithelium, which formed a solid mass (white arrow) (Figure 2a). All the fragments showed the same view composed of spindle cells and fibers arranged in fascicles, separated by scant hyaline stroma (Figure 2a). The nuclei of the cells were cigar-shaped and centrally located. There was no evidence of atypia, necrosis, or mitosis (Figure 2b). The spindle cells demonstrated a smooth-muscle differentiation by positive staining with SMA (actin-smooth- muscle) (white arrow) (Figure 2c) but they are negative for Ki-67 (around 1%, black arrow) (Figure 2d). The tumor tissues were fixed in formalin, paraffin-embedded, and 5-mm-thick cut and stained with hematoxylin and eosin; immunostains for SMA, Ki67 were performed using the avidin-biotin-peroxidase complex method. The postoperative period was uneventful, the urinary catheter was removed after 3 days and the patient was discharged on postoperative day 5.
Leiomyoma is a benign smooth muscle tumor that can occur in any organ, but is most often seen in the uterus.  Leiomyomas of the bladder are rare benign tumors.  Goluboff et al.  reviewed all related literature and indicated that the most common symptoms for urinary leiomyoma were obstructive voiding symptoms (49%). Among the remaining patients, 38% presented with irritative symptoms, 11% with hematuria, and 19% were asymptomatic. However, Knoll et al. (Leiomyoma of the bladder. J Urol 1986) reviewed the literature and indicated that the most frequent clinical manifestations were irritative voiding symptoms. It was suggested that leiomyoma of the bladder is symptomatic for 2 reasons: anatomical location and size. Specifically, tumors that are present at ureteral openings or near the bladder neck tend to cause obstructive symptoms, whereas larger tumors are more likely to cause irritative symptoms. Neither of our patients had any positive findings on physical examination, although one series in the literature reported on a palpable pelvic lump in approximately 50% of patients on bimanual examination.  In the urinary system, the location is more frequent in the bladder, being the most common benign mesenchymal tumor of this organ (Tavora F, et al. Mesenchymal tumours of the bladder and prostate: an update. Pathology 2013). Nonetheless, they only represent <0.5% of all bladder cancers. [3, 4] Virchow first reported this in 1931 (JL K. Leiomyoma of the bladder with a report of a case and a review of the literature. J Urol 1931). In a review by Khater and Sakr in 2013, only 250 cases were previously reported, and since then rare cases have been reported. [3, 5, 6, 8] There is a female preponderance (70%), and this pathology affects those in their third to sixth decades, with a mean age of 44 years. [3, 7, 8 ] However, there are cases described in younger patients. These tumors can be endovesical, intramural, or extravesical. The endovesical tumors are the most common and usually present with dysuria, urinary urgency, hematuria, and sometimes with low back pain. Some tumors are pedunculated and can manifest through urinary retention. [1, 4] Regarding the diagnosis, bladder ultrasound is the imagiological examination that detects more often these tumors. In most cases, it shows a small mass with a solid aspect, homogeneous, and hypoechoic encapsulated by a hyperechogenic thin blade.  Cystoscopy shows the presence of a sessile tumor not arborescent and protruding into the bladder lumen. Computed tomography and magnetic resonance imaging (MRI) can be performed to obtain further information on the size and location.  Even though both CT and MRI offer excellent delineation of the tumor, Wong and colleagues opined that MRI should be the method of choice as it offers superior contrast and spatial resolution (Wong FK, et al. Urinary bladder leiomyoma. J HK Coll Radiol. 2002). Leiomyomas are known to show a variety of tumor-enhancement patterns after gadolinium injection but cystic degeneration always produces heterogeneous signal intensity on T2-weighted and post- gadolinium T1-weighted images (Chen M, et al. MR imaging evaluation of benign mesenchymal tumors of the urinary bladder. AJR Am J Roentgenol. 1998). MRI is the preferred method for the composition and relation to plans of the bladder wall. Despite the imaging characteristic features, the definitive diagnosis is histopathology.  The treatment of leiomyoma is surgical, and the approach depends on the location and size of the tumor. A small tumor in an asymptomatic patient may be treated conservatively with regular follow-up. An increase in size or the onset of symptoms merits surgery. In most cases, the transurethral route is preferred although some tumors, such as larger tumors involving the entire bladder wall, in a not propitious position or difficult to recognize, may require segmental resection or laparoscopic partial cystectomy. [3, 7] Enucleation via a transvaginal approach is another option, especially for tumors close to the urethra, but this is subject to anatomic constraints and a higher risk of recurrence (Knoll
LD, et al. Leiomyoma of the bladder. J Urol. 1986). Surgical complications are described almost exclusively in the larger urethral tumors. The prognosis is invariably favorable, with relief of complaints in symptomatic patients. The recurrence is rare.  Immunohistochemical and pathologic findings of bladder leiomyomas are similar to uterine leiomyomas (Jain SK, et al. Bladder leiomyoma presenting with LUTS and coexisting bladder and uterine leiomyomata: A review of two cases. Rev Urol. 2014). The precise etiology of this epidemiologic observation remains a mystery. However, it has been reported that estrogen may be associated with the growth of leiomyomas.  It was suggested that estrogen may influence the development of bladder leiomyoma. In addition, estrogen receptors have been identified in urinary leiomyomas. [1, 7] Many theories exist on the etiology of this condition and the reason for its predominance in women. It has been suggested that chromosomal abnormalities (Cornella JL, et al. Leiomyoma of the female urethra and bladder: report of twentythree patients and review of the literature. Am J Obstet Gynecol. 1997) , chronic inflammatory stimuli (Blum’s irritative theory), metaplastic reaction around the perivascular walls following inflammation of the bladder, dysontogenesis of embryonic rests (Piegel), or endocrine disorders (Lipschutz) may lead to the genesis of leiomyomas.  The latter theory is supported by observations of a higher incidence in women in the fertile period and the presence of steroidal ovarian receptors in the tumor (Furuhashi M, et al. Recurrent bladder leiomyoma with ovarian steroid hormone receptors. J Urol. 2002). Further work is needed to clarify the concrete mechanism that can lead to the initiation of bladder leiomyoma. For histologic diagnosis, tissue samples have been procured by a variety of means, including cup biopsy forceps, a resectoscope, or an ultrasound- guided transvaginal biopsy (Matsushima M, et al. Leiomyoma of the bladder presenting as acute urinary retention in a female patient: urodynamic analysis of lower urinary tract symptoms: a case report. BMC Urol. 2010). Microscopically, bladder leiomyomas are composed of interlacing and whorling bundles of smooth muscle cells. The nuclei of smooth muscle cells are oval to cigar-shaped, blunt-ended, centrally located and showing no nuclear atypia or mitotic activity.  Bladder leiomyoma usually has fewer than 2 mitotic figures per high power field.  Leiomyosarcoma, on the other hand, may also have few mitotic figures, but it is myxoid degeneration and invasion of the muscularis propria that reliably distinguishes it from the benign counterpart. Immunohistochemistry analysis of benign leiomyoma shows positive expression for smooth muscle actin and negative expression for Ki-67. The prognosis for these benign tumors is excellent and no cases of malignant degeneration have yet to be reported. 
Leiomyoma must be differentiated from other common causes of lower urinary tract symptoms (LUTS). Confirmation of diagnosis may be difficult due to the poor yield of a cold cup biopsy. In our case, TUR was diagnostic. When the bladder TUR biopsies were clinically mentioned, in the presence of a thicker muscle layer than the detrusor muscle tissue, leiomyomas should be present in the differential diagnosis.
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1. Dewaele T, D’Hooghe L, Weyers St, Visschere P De. Leiomyoma of the urinary bladder. JBR-BTR 2014; 97:263.
2. Kim IY, Sadeghi F, Slawin KM. Dyspareunia: an unusual presentation of leiomyoma of the bladder. Rev Urol 2001; 3:152–54.
3. Khater N, Sakr G. Bladder leiomyoma: Presentation, evaluation and treatment. Arab J Urol. 2013;11:54–61.
4. Pardal H, Ferronha F, Gameiro C, Vilas-Boas V, Galego P, Melo P, et al. Intramural vesical leiomyoma in a patient with a pelvic fibrous tumour – case report. Acta Urol. 2011;2:28–31.
5. Xin J, Lai HP, Lin SK, Zhang QQ, Shao CX, Jin L, et al. Bladder leiomyoma presenting as dyspareunia: Case report and literature review. Medicine (Baltimore) 2016;95:e3971.
6. Wu S. Imaging findings of atypical leiomyoma of the urinary bladder simulating bladder cancer: a case report and literature review. Med Ultrason 2013; 15:161–3.
7. Goluboff ET, O’Toole K, Sawczuk IS. Leiomyoma of bladder: report of case and review of literature. Urology 1994; 43:238–41.
8. Silva-Gutiérrez A, Martínez-Méndez ME, González-Romo MA, Nava-Jácome O, Castillo-Zurita O, Morales-Díaz J, et al. Bladder leiomyoma. Rev Mex Urol. 2013;73:43–5.
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Aydemir Asdemir, Tugba Yildiz Asdemir, Huseyin Saygin, Esat Korgali, Resul Cicek. A 53-year-old female with bladder leiomyoma: A rare case and review of the literature. Ann Clin Anal Med 2021;12(8):947-950
Relationship between COVID-19 and HDL dysfunction
Esin Eren 1, 2, Esra Akıdan 1, Mehmet Tugrul 1, Necat Yilmaz 1
1 Department of Clinical Biochemistry and LC/MS-MS Laboratory, Antalya Training and Research Hospital, 2 Department of Clinical Biochemistry, Bilim University Health Science, Antalya, Turkey
DOI: 10.4328/ACAM.20497 Received: 2021-01-21 Accepted: 2021-03-28 Published Online: 2021-04-11 Printed: 2021-08-01 Ann Clin Anal Med 2021;12(8):951-957
Corresponding Author: Necat Yilmaz, SBU-AEAH–LC-MS/MS Toxicology Laboratory, Kazim Karabekir street, Muratpasa, Antalya, Turkey. E-mail: firstname.lastname@example.org P: +90 5053578305 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3865-9156
Recent data show that no age group is excluded from the possibility of SARS-CoV-2 infection. However, it is more likely to affect the elderly with comorbidities such as cardiovascular and pulmonary diseases, diabetes, and hypertension that can lead to the progression of COVID-19. Dyslipidemia is often found with these comorbid diseases. According to recent findings, lipoproteins, and particularly high- density lipoprotein cholesterol (HDL-C), may play a role in regulating the entry of the SARS-CoV-2 virus into the host cell.
In fact, HDL-C has many beneficial properties, including anti-inflammatory, anti-oxidative, anti-thrombotic, anti-infectious, anti-apoptotic, intercellular commu- nication, and pro-vasodilator capacities. HDL-C has an affinity for binding and neutralization of the pathogen. The link between COVID-19 and lipid-dependent pathologies has not yet been fully understood. We draw attention to the molecules and functions involved in HDL-C. Because many therapeutic compounds that regulate HDL-C functions and metabolism can be used in the treatment of COVID-19 recently.
Keywords: SARS-CoV-2; COVID-19; HDL; Dsylipidemia; Pneumonia
It belongs to the beta genus of the coronavirus family, which causes COVID-19 and is called severe acute respiratory syndrome (SARS) coronavirus-2 (SARS-CoV-2). In fact, the SARS-CoV-2 virus is the 7th known member of the coronavirus family that infects humans . SARS-CoV-2 initially enters the epithelial cells of the upper respiratory tract and reproduces, on the contrary, this phenomenon is not significantly observed in SARS-CoV [1,2]. This diverse process likely explains the relatively high viral load in the upper respiratory tract, the increased levels of viral transmission, and the significantly higher contagiousness. The SARS-CoV-2 virus and its homologue, SARS-CoV, penetrate human cells through the binding of viral spike protein and human angiotensin converting enzyme II (ACE2). High fever, which is one of the symptoms of the disease, is one of the measures to reduce the ACE2 receptor binding rate due to increased body temperature .
Current evidence indicates that systemic microvascular damage and immune thrombosis play a key role in the pathogenesis of COVID-19 . Similarly, circulating megakaryocytes and microthrombi are prominent due to increased micro- thromboembolism in many organs. Of course, the ACE2 receptor is widely expressed in all vascular endothelial cells, thus providing a potential explanation for the finding that COVID-19 is associated with hypercoagulation .
In addition to the many functions of HD-C, its main task is to promote reverse cholesterol transport (RCT) from the environment to the liver. In addition to this anti-atherosclerotic RCT function of HDL-C, functions of HDL-C include modulation of the immune system and control of infectious diseases. Thus, HDL-C functions also consist of immune-modulating, anti- infectious, anti-thrombotic, anti-apoptotic and antioxidant functions . Pneumonia in general is an important public health problem worldwide with its high incidence and one of the most common infections leading to hospitalization . Dyslipidemia, which is increasing in societies today, has been defined as a marker of severe pneumonia for a long time. As a result, decreased HDL-C levels have been reported with increasing infections in clinics and especially in intensive care patients [5,7]. In fact, HDL-C particles have a great affinity for binding and neutralization of pathogen-associated lipids (e g, lipopolysaccharide, lipoteichoic acid) that mediate excessive immune activation in sepsis .
The clearance of the SARS-CoV-2 in the human body is one of the important indicators for the recovery of COVID-19 patients. A study conducted during the COVID-19 pandemic to clear this virus showed that HDL-C may be associated with disease severity and mortality [9,10]. What is well known for now is that low HDL-C and total cholesterol (TC) concentrations show an association between COVID-19 infections in patients. In contrast, an increase in triglycerides (TGs) may be seen in patients infected with SARS-CoV-2 . In conclusion, dyslipidemia, low HDL-C, and high TGs can be considered associated with the risk of developing pneumonia in the future [9, 12].
Indeed, the positive role of HDL-C in the innate immune response is now well known. Since immune modulatory molecules in
the structure of HDL-C play a role in complement activation and acute inflammatory response, a relationship between pneumoniaanddyslipidemiashouldbeexpectedinsevereform of COVID-19 . For example, there is promising literature on whether HDL-C affects virus clearance in the human body, as discussed above. This recent study found that the replication cycle time of the SARS-CoV-2 viral nucleic acid was shorter in the low HDL-C group compared to the normal group . Undoubtedly, liver cells can be damaged during COVID-19, such that HDL-C is synthesized the liver in large quantities. We cannot rule out that HDL-C may decrease quantitatively and qualitatively,oftenduetoimpairedliverfunctioninCOVID-19 disease [4, 13, 14].
Clinical data obtained from COVID-19 point to the presence of serious cardiovascular complications in addition to severe pneumonia [15, 16], because the excessive inflammatory response (cytokine storm) in COVID-19 is thought to be the primary cause of treatment failure. Whereas, although the inflammatory response represents a host defense against pathogens, this process is beneficial as long as it is limited to local infection control . When the inflammatory response in COVID-19 is excessively disproportionate, systemic inflammation may lead to diffuse intravascular coagulation, respiratory distress or septic shock, and increased morbidity mortality in COVID-19 patients (Yilmaz N, Eren E. COVID-19 iron ferroptosis parafibrin. Available at: www.researchgate.net/ publication/341055648) .
As far as is known, the SARS-CoV-2 virus can enter the cell by binding to ACE2 and some other receptors (CD147 etc.) of the pointed glycoprotein (S protein) in host cells [18,19]. In addition to these differences in tropism, the 10–20-fold higher affinity compared to SARS-CoV makes ACE-2 receptors targets for SARS-CoV-2 . Since cellular polyproteinconvertases such as (S) protein’s, furin and capesin not found in SARS-CoV could potentially increase the uptake of SARS-CoV-2 via ACE2 receptor via endocytosis [19,20]. Published data indicate that the protein of the SARS-CoV-2 virus (S) alone can damage the endothelium through increased glycolysis with impaired mitochondrial function and eNOS activity. This is due to the fact that SARS-CoV-2 virus infection triggers mitochondrial ROS production in the vascular endothelial tissue and can induce glycolysis [21-23]. However, functional HDL-C tries to protect the ACE2 receptor system in vascular tissue. But the vascular endothelial system becomes infected with SARS-CoV-2. As a result, all organs especially endothelial cells can be damaged by the qualitative and quantitative reduction of HDL-C [4, 13, 16, 17].
HDL-C has not only quantitative but qualitative laboratory measurements. Indeed, HDL-C in endothelium contributes significantly to vascular tone. Also, HDL-C contributes to the production of nitric oxides (NOs). HDL-C also has NOs independent properties on endothelial cells; these are induced proliferation, increased barrier function, suppressed inflammation and decreased apoptosis [4, 16].
But, the anti-inflammatory and antioxidant properties of HDL-C are significantly reduced during viral infections such as influenza and HIV infection. Unfortunately, after the acute onset of COVID-19, low TC levels accompanied by low HDL-C have been reported .
Also, HDL-C may mediate anti-viral effects through interaction with the scavenger receptor SR-BI, which causes a decrease in inflammatory protein production and an increase in pro- angiogenic growth factors by activating the PI3K / Akt pathway. However, the decreased ACE2 receptor functionality over time in severe COVID-19 may cause it to lose its unique protective effect on the vascular endothelial system [24,25].
Whereas HDL-C that can pass into the vascular sub-endothelial space in healthy people can preserve its endothelial structure, but unfortunately, as a result of the increased cytokine storm in COVID-19, and especially pro-inflammatory cytokines such as IL-6 may prevent the transition of HDL-C to the endothelium [26-28].
Numerous in vitro and in vivo studies have now demonstrated the anti-inflammatory and pro-angiogenic effects of HDL-C on endothelial cells . HDL-C functions may be important not only for endothelial cells, but also in the regulation of macrophage activity. In COVID-19, macrophages may show mitochondrial insufficiency as a result of increased metabolic needs after infection, and thrombotic complications may occur as a result of vascular dysfunction. In addition, macrophages can be loaded with excess free iron in the environment.
HDL-C may contribute to the reduction of mortality and morbidity in COVID-19 by reducing the inflammatory response caused by over activation of pathways in the immune system . COVID-19 can transform HDL-C into a dysfunctional, pro- inflammatory particle as a result of “cytokine storm” and severe inflammation in COVID-19 . Thus HDL-C can be damaged qualitatively and quantitatively in COVID-19 [16, 30]. HDL-SR-B1 Receptors
In the literature, a study supports the main idea of this article because the study showed that SR-B1, the major receptor of HDL-C, facilitates entry of the SARS-CoV-2 virus binding to ACE2 . Thus the activity of the (S) protein to the ACE2 receptor may be associated with the cellular uptake of HDL-C. However, as is known to date, SR-B1 is not only the HDL-C’s receptor, but also mediates the selective uptake of cholesteryl- esters and is its receptor at other lipid components . According to these findings, the presence of ACE2 and SR-B1 expression on the surface of many tissues and cells affected by COVID-19 may increase the effect of the virus. Especially, the SR-B1 receptor system in the lungs may play a role in pulmonary inflammation . It is noteworthy that SR-B1 could be a potential therapeutic target that could interfere with SARS-CoV-2 infection . In addition, according to the data obtained, cholesterol abundance in the host cell plays an important role in viral entry and fusion. Perhaps many drugs that have been used for many years to combat atherosclerosis may be effective in the treatment of COVID-19 . As is known, obesity, atherosclerotic diseases and diabetes in which the SR- B1 receptor is active are comorbid conditions that increase the risk of developing COVID-19 disease. Researchers have been increasingly successful in uncovering the possible link between the severe inflammatory response seen in COVID-19 and HDL-C dysfunction seen in COVID-19 comorbid diseases [33-35].
Lipoprotein Apo-A1 undoubtedly constitutes the largest amount of more than 200 proteins in the HDL-C structure . Apo-M, which is found in HDL-C structure like Apo-A1 but plays a very small role in HDL-C function, is associated with the Toll-like receptor and T cell receptor in macrophages [34,38].
Also, lipoproteins in the structure of HDL-C play a very important role in protecting the endothelium against infection [36, 37]. In a published study, they showed in the general population that Apo-A-1, which constitutes 70% of the HDL-C structure, decreased with the SARS-CoV-2 outbreak . This is a very important finding that COVID-19 can affect the proteins involved in HDL-C structure.
Statistically, the area Under the Characteristic Curve (diagnostic value; AUC: 0.98) of Apo-A1 was also found to be very high in the COVID-19 epidemic. In addition, intensive care attendance and survival rates were found to be associated with Apo-A1 values .
Decreased Apo-lipoprotein expression may underlie the relationship between COVID-19 and Apo-A1, because hepatic Apo-lipoprotein gene expression may be suppressed in the COVID-19 disease [36,39]. Restoration of lipoprotein function with ApoA-I enhancing agents can thus be valuable in the treatment of COVID-19 [31, 36, 38].
Recently, it has been reported that Apo-E, another lipoprotein in the HDL-C structure, and the increase in phospholipid transfer protein (PLTP) activity in the HDL structure accelerate recovery in intensive care patients [39-48].
Various findings suggest that deficiencies in Apo-E function may be important in the association of SARS – CoV – 2 with dyslipidemia and may avoid complications because Apo-E is expressed in alveolar epithelial cells as well as lung macrophages [42-44].
Supporting this knowledge, it has been reported that the Apo-E4 variant predicts the severity of COVID-19 [44,45]. Most of the Apo-E in the blood is produced by the liver, but macrophages are responsible for producing 5-10% of Apo-E in plasma [45.46]. Both the liver and macrophages are affected in COVID-19 disease, so changes in the Apo-E level in the HDL-C structure can naturally be expected. This information becomes even more important when considering COVID-19 bio-pathology . Low ApoA-I and Apo-E levels in COVID-19 patients may be partially responsible for lung inflammation [45, 46].
In addition, HDL-C prevents the oxidation of LDL-C, therefore sufficiency of Apo-AI, the activity of LCAT, lipoprotein-related phospholipase A2 (Lp-PLA2) and paraoxonase 1 (PON1) are required [4,16,36]. The HDL-C ability to prevent oxidant damage through protein and enzymes in its structure is also supported by the selective removal of lipid hydroperoxides and hydroxides by hepatocyte SR-BI [4,36]. HDL-C also participates in intercellular nucleic acids communication through transfer between tissues . Recently, HDL has been reported to carry miRNA, small non- coding RNAs that bind to complementary target regions in the 3 ‘untranslated region of mRNAs, suppressing gene expression, thereby inhibiting translation and inducing mRNA degradation. and to endothelial cells [47,48]. However, research is needed to determine the effect of HDL-C linked miRNAs in humans and animal models in the context of severe inflammatory diseases such as COVID-19.
HDL-C also contributes to innate immunity by modulating immune cell function. However, this hypothesis has not been extensively studied in the context of COVID-19 because HDL-C is also anti-infectious, anti-parasitic, and anti-viral.
Indeed, HDL-C has the unique capacity to prevent endotoxic shock, readily binds to lipopolysaccharides (LPS), and contributes to removing LPS through biliary excretion, thus aiding innate immunity [48,49].
HDL-C Anti-thrombotic activity
In addition to respiratory symptoms, abnormal coagulation with thromboembolic disease is thought to be an important factor in COVID-19 worsening and clinical outcomes. In this regard, the formation of parafibrin due to the impairment of iron metabolism may play an important role (available at: www. researchgate.net/publication/341055648). High ferritin levels seen in COVID-19 may lead to dyslipidemia [16, 50, 51]. As expected, HDL-C has anti-thrombotic activity, suppressing the coagulation cascade and inhibiting platelet activation, but also has the function of reducing platelet hyper-reactivity by limiting intra-platelet levels of cholesterol overload. Thus, HDL-C may have a limiting effect on micro-thrombi that can be seen in the pathogenesis of COVID-19 [16,52].
Lecithin cholesterol-acyl-transferase (LCAT), which is in the structure of HDL-C, is another important anti-infectious molecule. In fact, LCAT plays an important role in cholesterol metabolism as it is the only extracellular enzyme that can esterify cholesterol. LCAT activity ensures the maturation of HDL-C’s by esterifying their cholesterol. At the same time, LCAT is the strongest activator of Apo-AI, the main protein component of HDL-C. Activity of LCAT in viral infections can prevent the development of hypertriglyceridemia . Although LCAT activity has not yet been measured in COVID-19, in many viral infections, LCAT activity has been reported to decrease significantly, and thus Apo-AI levels have decreased compared to healthy controls . Perhaps decreased levels of Apo-A1 in COVID-19 patients are associated with reduced LCAT activity. Additionally, viral infections that affect LCAT enzyme functionality can result in a serious decrease in plasma HDL-C levels and significant clinical consequences. It is thought that the LCAT enzyme can stimulate the Apo-AI strands during maturation by binding and therefore affects HDL-C function [54,55]. In addition, similar to COVID-19 disease, there may be a relationship between LCAT and HDL-C functions with blood groups . This situation is similar to COVID-19 disease because studies show that individuals with non-O blood groups, which can impair HDL-C function, are at greater risk of COVID-19 .
Inflammatory factors such as SAA in the HDL-C structure may, unfortunately, increase with COVID-19 disease. In this case, HDL-C structural character may change and transform into a pro-inflammatory dysfunctional HDL-C form . Since SAA is a non-specific acute phase protein, its synthesis can be
stimulated by many cytokines (IL-1β, IL-6 and TNF-α), which may increase in COVID-19 disease . In some recent studies, the SAA molecule has been shown as a biomarker for assessing the severity and prognosis of the disease in COVID-19 patients. The increase in SAA in COVID-19 is undesired because SAA can further increase the inflammatory response by activating chemokine and inducing chemotaxis even at a very low concentration [58, 59]. Studies show that patients infected with COVID-19 have large amounts of IL-1β, IFN-γ, IP-10, MCP- 1, which in turn, stimulate liver cells to produce SAA . In addition, SAA can increase neutrophils survival and subsequently increase the inflammatory response through the P2X7 receptor, an ion channel of neutrophils. In addition, aging, which is an important risk factor in COVID-19, generally causes an increase in SAA levels, on the contrary, HDL-C levels and functions may decrease in elderly people [58, 62].
The PON1 enzyme, which is in the structure of HDL-C, is associated with the antioxidant function of HDL-C. In COVID-19 disease, due to higher inflammation and oxidative stress, there may be PON1 consumption in the structure of HDL-C. For example, it has been reported that HDL-C loses its anti-oxidant properties during infection with influenza A [63, 64]. In future clinical trials, the possible role of the PON1 enzyme in COVID-19 will be better understood. Thus, supportive applications that can increase PON1 enzyme activity in COVID-19 can be included in the treatment [4, 16, 63, 64].
Hyperferritinemia is one of the cardinal laboratory findings of COVID-19 disease. Hyperferritinemia may negatively affect HDL-C functions in COVID-19 disease [65,67]. The cellular function of ferritin is to store iron in a non-toxic and bioavailable form . Thus, at the same time, ferritin, the cellular storehouse of iron, is a key molecule in the immune system that regulates cellular defense against inflammation [65,66]. Ferritin consists of two different subunits named according to their molecular weight: H “heavy” and L “light”. The ratio of H and L subunits is tissue dependent. In particular, the ferritin H subunit participates in the catalytic oxidation of FeII to FeIII (ferroxidase), while the L-subunit provides the nucleation sites for bioavailable storage of the FeIII product [65,66]. In addition, hyperferritinemia is an important mediator of immune dysregulation [65,67].
Generally, ferritin may be higher in elderly and male patients. In addition, decreased HDL-C function is a common finding in elderly and male patients [68-72].
Possibly in COVID-19, excess iron retention in macrophages may be increased through transferrin receptors or HDL-C related SR-B1-mediated by erythro-phagocytosis.
Thus, pathway may lead to a significant increase in both mRNA and protein levels in ferritin synthesis [16, 73].
While iron-loaded macrophages can release both iron and ferritin through exocytosis, ferritin excretion from cells can be significantly reduced if there is not enough HDL-C in the environment [73, 74]. Finally, a broad neutralizing antibody response using synthetic ferritin that cheats the SARS-CoV-2 virus had been reported  because, according to the findings, iron metabolism parameters deteriorate in patients who receive outpatient and inpatient treatment in COVID-19 disease. Compared to mildly affected COVID-19 patients remaining at the outpatient level, the inpatient cohort shows a significantly more pronounced irregularity in iron metabolism parameters [75,77]. Moreover, hepcidin may increase in COVID-19 patients due to IL-6 stimulation, and elevated hepcidin levels may have adverse effects on HDL-C functionality [76,79].
According to different experimental septic models, reconstructed rHDL infusions may be a treatment option to reduce inflammation in septic patients. While a similar usage option may apply to Apo-A1 mimetics in sepsis. Nowadays although there are still few articles in the literature, functions of HDL-C can be considered a potential therapeutic target for the SARS-CoV-2 virus [56, 80, 81].
Although it may seem distant to us, studies on the origin of SARS-CoV-2 agree that the virus probably originated from the bat because analysis of mutations at contact sites in the SARS- CoV-2 virus receptor binding site reveals that human sensitivity is more likely to occur in Pangolin [19, 20]. Unfortunately, HDL-C can gain pro-inflammatory properties by losing its useful properties in severe inflammatory diseases. For example, in the case of HDL-C dysfunction, the loss of cholesterol output capacity by RCT from macrophages, in COVID-19 disease may cause an already increased macrophage load, so the activity of macrophages may be reduced. HDL-C functionality and PON1 enzyme activity are required in the face of increased inflammation and high oxidative stress in COVID-19 disease. Moreover, in COVID-19 disease, changes in the content of bioactive lipids or oxidative modifications in lipids and protein load of HDL-C can cause erythrocyte damage. Also, the reduction of erythrocytes that can be seen in COVID-19 disease may occur as a result of the reduced ability of the erythrocyte membranes’ to metabolize hydroperoxides.
The “cytokine storm” underlying COVID-19 disease, low HDL-C, high lipoprotein oxidation, and low Apo-E levels can produce immune-mediated inflammatory dyslipoproteinemia. With clinical and laboratory studies to be carried out in the upcoming period, the origin and pathophysiology of SARS-CoV-2 will be better understood and appropriate treatment strategies for COVID-19 disease will be developed. For example, futuristic use may apply to Apo-A1 mimetics in COVID-19 disease. HDL-mimetic agents could enhance the normal reverse lipid transport system (RCT). Also, ApoA-I mimetic peptides might improve endothelial cell functions [80, 81]. Finding that hepcidin is up-regulated by the inflammatory cytokine IL-6 in COVID-19 may be one of the treatment options. However, clinically used drugs that can block this relationship (Siltuximab, Tocilizumab) [77,78,81] are valuable. In addition, using drugs to down- regulate hepcidin using RNA antibodies that block ferroportin has been described .
In addition, endothelial tissue, which can be disrupted by SARS- CoV-2 viral invasion in COVID-19, can reduce vasodilation by reducing NO production. HDL-C may be required to maintain NO production in the vascular endothelial cells. In addition, pro- inflammatory HDL-C may, unfortunately, increase the greatly enhanced monocyte chemotactic activity in COVID-19 disease. In HDL-C dysfunction, its capacity to block NADPH oxidase activity and superoxide production may decrease. In general, higher membrane cholesterol may facilitate cellular entry of the SARS-CoV-2 virus. The modulated efficiency of viral entry can be explained by the presence of the SR-B1 receptor [80,81]. HDL-C itself appears to have a variety of roles from being a scavenger, an immune modulator, and a viral entry vehicle for viruses. It should also be kept in mind that HDL-C suppresses cytokine inhibition in inflammatory cells. As a result, HDL-C functions and composition can be targeted to selectively inhibit the life cycle of the virus as the basis of antiviral therapy. At the same time, HDL-C can be a potential biomarker for monitoring SARS-CoV-2 viral infection status .
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