Supplement 4 2021
Increased insulin secretion suppresses cortisol levels, exacerbates inflammation and beta-cell dysfunction
Evin Kocatürk 1, Ezgi Kar 2, Zeynep Küskü Kiraz 1, İ. Özkan Alataş 1
1 Department of Medical Biochemistry, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, 2 Department of Medical Biochemistry, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
DOI: 10.4328/ACAM.20591 Received: 2021-03-15 Accepted: 2021-05-18 Published Online: 2021-06-17 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S365-369
Corresponding Author: Ezgi Kar, Department of Medical Biochemistry, Faculty of Medicine, Çanakkale Onsekiz Mart University, 17020, Terzioğlu, Çanakkale, Turkey. E-mail: ezgikar@comu.edu.tr P: +90 5546189450 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2134-4067
Aim: The role of inflammatory mechanisms in the formation of insulin resistance (IR), diabetes and metabolic syndrome has been widely discussed in recent years. The aim of this study was to investigate the relationship between IR and pancreatic β-cell function with hematological inflammatory markers and cortisol levels.
Material and Methods: Four hundred fifteen adult patients whose samples were accepted to the laboratory between the hours of 08:00-12:00; leukocyte, neu- trophil and lymphocyte count, mean platelet volume (MPV), insulin, glucose, and cortisol levels were examined retrospectively. The neutrophil-lymphocyte ratio (NLR), the homeostasis model assessment (HOMA)-IR and HOMA-β values were calculated according to the collected data. The patients were divided into two groups: with (HOMA-IR≥2.5) and without IR (HOMA-IR<2.5). All data were statistically evaluated using the SPSS package program.
Results: A statistically significant difference was found in cortisol levels (p=0.003), leukocyte (p<0.001), neutrophil (p<0.001), lymphocyte counts (p=0.003) and NLR (p=0.011) between the groups. However, there was no significant difference between the MPV levels. Both HOMA-IR and HOMA-β showed a weak positive correlation with leukocyte, neutrophil and lymphocyte counts and showed a negative correlation with cortisol levels. There was a weak positive correlation between NLR levels and HOMA-IR. Although there was a negative correlation between cortisol with insulin and NLR levels, no significant correlation was found between cortisol and glucose, neutrophil-lymphocyte count.
Discussion: The significant increase in hematological inflammatory cells in patients with IR suggests that inflammatory mechanisms may have produced insulin resistance. The increase in insulin levels and suppression of cortisol levels may play a role in the progression of inflammation.
Keywords: Insulin Resistance; Neutrophils; Lymphocytes; Mean Platelet Volume; Hydrocortisone
Introduction
Diabetes mellitus (DM) is a chronic, broad-spectrum metabolic disorder, which requires constant medical care, and the organism cannot benefit enough carbohydrate, fat and proteins [1]. The global prevalence of DM was 9% in 2014, and in 2015 almost 1.6 million deaths were caused directly by DM in the world (available at: https://apps.who.int/iris/bitstream/ handle/10665/112736/9789240692763_eng.pdf;jsessionid=A 0D24CBF0DD2997742383515E2739EC6?sequence=1).
It is now accepted that diabetes develops through two mechanisms: insufficient insulin release and insulin resistance (IR) due to dysfunction of pancreatic β cells. The homeostasis model assessment (HOMA) model is a widely accepted method for assessing β-cell function (with HOMA-β) and IR (with HOMA- IR) from basal glucose and insulin concentrations [2-4]. Higher HOMA- β level is associated with beta-cell response or insulin secretion [5], and increased HOMA-IR and decreased HOMA-β have been shown to significantly predict type 2 diabetes [6-8]. Inflammation can affect insulin signaling, indirectly increasing the risk of DM [9], and the increase of cytokines disrupts beta cell function [10]. Many studies confirm that increased hematological inflammatory markers (especially WBC levels) are an independent risk factor for insulin resistance, diabetes, metabolic syndrome, and coronary artery disease [11-13].
The neutrophil- lymphocyte ratio (N/L ratio-NLR) is known to be related to inflammation. Both the types of malignancy and chronic diseases have been shown to be related to subclinical inflammation in various literature studies [14, 15]. However, although the relationship between IR and inflammation has been described in the literature, there is not enough information about NLR levels’ relationship.
Cortisol plays very important regulatory roles in glucose metabolism and plays an important role in the insulin signaling pathway. It disrupts insulin sensitivity in various tissues, reduces glucose uptake by inhibiting the interaction with the insulin receptor in cells, especially GLUT 4 in which adipose and muscle tissues, and contributes to IR [16, 17]. There is insufficient information about the effect of increased cortisol on pancreatic cell function and insulin secretion [17].
Cortisol is associated with inflammation and increases the number of neutrophils in the peripheral circulation by stimulating the production of neutrophils from the bone marrow in the case of inflammation. Also, it induces the production of anti- inflammatory cytokines while suppressing the proinflammatory cytokines.
In this study, we aimed to investigate the relationship between IR and pancreatic β cell function with hematological inflammatory markers (leukocyte, neutrophil and lymphocyte counts, neutrophil/lymphocyte ratio, mean platelet volume) and cortisol levels.
Material and Methods
Subjects, inclusion and exclusion criteria
For this cohort study, the necessary permission was obtained from the local ethics committee (Decision number: 30.04.2019/34). Four hundred fifteen adult patients (18-60 years) who applied to the Biochemistry Laboratory of Eskişehir Osmangazi University Hospital for checkup between the hours of 08:00-12:00 from January 2017 to 2019 were included the study. Individuals with defined any chronic, (rheumatoid arthritis, thyroid dysfunction, etc.) or malignancy disease, Diabetes Mellitus or obesity disease, pituitary gland diseases (including Cushing syndrome), irregular menstrual cycle disease, post-surgical patients and pregnant women were excluded from the study.
Data collection and calculations
In the early hours of the morning, fasting blood was collected from the participants into one red-capped hemogram tube (for serum samples) and two purple-capped EDTA-containing tube (for plasma and whole blood samples). Fasting insulin, and glucose levels were observed in serum samples, leukocyte (WBC), mean platelet volume (MPV), neutrophil and lymphocyte counts were observed in whole blood samples, and cortisol levels were observed in plasma samples. According to the electrochemiluminescence immunoassay (ECLIA, Elecsys system), sandwich method, insulin levels were measured with appropriate commercial reagents on Roche Cobas e 801 auto- analyzer device (Roche Diagnostic GmbH, Mannheim, Germany). Participants’ glucose values were measured on a Roche Cobas c 702 auto-analyzer device using commercial kits, including the reference spectrophotometric hexokinase method. According to the ECLIA competitive method, cortisol levels were measured with appropriate commercial reagents on a Roche Cobas e 601 auto-analyzer device. Sysmex XN-9000 (Sysmex Co., Kobe, Japan) automatic analyzer was used for hematological inflammatory markers. HOMA-IR and HOMA-β values of the participants were calculated by the following equations in the literature, respectively:
HOMA-IR = [fasting plasma glucose (mg/dL) × fasting insulin level (mIU/L)] / 405,
HOMA-β = [360 ×fasting insulin level (mIU/L)] / [fasting plasma glucose (mg/dL) – 63] [2, 4].
IR was defined as a HOMA-IR value equal or greater than 2.5 [18], and patients were divided into two groups according to the absence (HOMA-IR <2.5 – Group I) or presence (HOMA-IR ≥2.5 – Group II) of IR. In addition, the neutrophil/lymphocyte ratio (NLR) levels of patients were calculated by proportioning the obtained neutrophil and lymphocyte count.
Statistical Analysis
All parameters were analyzed using the Kolmogorov-Smirnov and Shapiro-Wilk normality tests. The Mann-Whitney U statistic test was used for the parameters that did not show normal distribution. Correlations of parameters were examined with the Spearman correlation test. All statistical evaluations were performed with the SPSS package programs. Significance value (p) < 0.05 was considered statistically significant.
Results
The baseline characteristics of the participant are summarized in Table 1. According to the HOMA-IR values, 148 of the participants were included in Group I (absence of IR) and 267 in Group II (presence of IR). The average age of the groups was 37.5 (27.0-48.75) and 42.0 (28.0-50.0) years, respectively ((Median (25-75%), Table 1). Females were dominant than males in both groups. As expected, there was a significant difference between insulin and glucose concentrations between Groups I and II (Figure 1).
When Group I and Group II were compared, a statistically significant difference was found between cortisol levels (p=0.003), leukocyte (p<0.001), neutrophil (p<0.001), lymphocyte count (p=0.003) and NLR (p=0.011). In Group II, cortisol levels were significantly lower and other parameters were significantly higher than in Group I. MPV levels were higher in Group II, but there was no significant difference between Group I (Table 2). Both HOMA-IR and HOMA-β showed a positive correlation with hematological inflammatory markers and showed a negative correlation with cortisol levels (Table 3). There was a weak positive correlation between NLR levels and HOMA-IR (p =0.007, r =0.132). Although there was a negative correlation between cortisol with insulin and NLR levels (p <0.001, r = -0.182; p =0.008, r = -0.129, respectively), no significant correlation was found between cortisol and glucose, neutrophil and lymphocyte count (Table 3).
Discussion
Many studies in the literature have shown that diabetes is associated with inflammation [19, 20]. Although the molecular mechanisms leading to IR formation are still unclear, epidemiological studies have demonstrated that systemic inflammation and IR coexistence play a role in the pathogenesis of diabetes [20]. Increased neutrophil and decreased lymphocyte count indicate the immune system’s response to different physiological diseases, and the neutrophil/lymphocyte ratio (NLR) is now considered an important inflammatory marker for evaluating the degree of disease [19, 21, 22]. In our study, hematological inflammatory markers were found to be high in patients with IR. Although both neutrophil and lymphocyte count was higher, the NLR was also found to be significantly higher in patients with IR, as the increase in neutrophil counts was higher (p = 0.011). The positive correlation of these hematological inflammatory markers with both HOMA-IR and HOMA-β suggested that inflammation was associated with IR and β cell dysfunction.
Glucocorticoids (GC) are a main group of endocrine regulating hormones that are released in our body in cases of stress. GCs and especially cortisol increase serum glucose levels by increasing gluconeogenic gene expression and gluconeogenesis in the liver, as well as inhibiting the entry of glucose into muscle and adipose tissue by inhibition of GLUT 4 receptor translocation [23, 24]. These mechanisms may lead to impaired glucose tolerance, development of IR and excessive cortisol release leading to diabetes. However, there is no precise information about the development of IR or whether it causes pancreatic β cell dysfunction. In our study, cortisol levels were lower in patients with IR and cortisol levels were negatively correlated with HOMA-IR, HOMA-β and insulin levels (r = -0.17 p =0.001, r = -0.157 p =0.001, r = -0.182 p <0.001, respectively). This shows us that cortisol causes β cell dysfunction rather than IR. Our results suggest that cortisol may directly suppress β-cell function, and in this case, higher cortisol levels may increase the risk of impaired glucose metabolism independent of induction of insulin resistance. At the same time, the negative correlation of cortisol with NLR (r = -0.129, p=0.008) indicates that inflammation may be exacerbated by decreasing cortisol levels. In our study, fasting glucose and insulin levels of the participants were studied in order to determine insulin resistance in a healthy way. In addition, the hours when the cortisol level is the highest in healthy people between 8:00 and 12:00 hours were preferred [24].
MPV is one of the hemogram parameters measured as a marker of blood platelets. MPV values are the subject of recent studies that may be evaluated as early markers of inflammatory diseases such as Type I Diabetes Mellitus and atherosclerosis [25]. Hyperglycemia induces non-enzymatic glycosylation of some proteins present on the platelet surface. Therefore, platelet reactivity is reduced because the glycation of the membrane proteins changes membrane fluidity [25]. Our study aimed to investigate insulin resistance and cortisol levels with MPV levels as potential hematological inflammatory markers. However, we did not observe significant difference or correlation with MPV levels.
The limitations of our study can be summarized as follows: due to the retrospective nature of the study, all the data of the participants were obtained through our laboratory data system, and although it was examined and excluded from the study whether they had chronic diseases, their regular drug use that may affect the parameters could not be determined. Conclusion
In conclusion, a significant increase in hematological inflammatory markers in patients with IR suggests that inflammatory mechanisms may have produced IR. The increase in insulin levels and suppressing cortisol levels may have played a role in making inflammation more pronounced.
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.
Funding: None
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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Evin Kocatürk, Ezgi Kar, Zeynep Küskü Kiraz, İ. Özkan Alataş. Increased insulin secretion suppresses cortisol levels, exacerbates inflammation and beta-cell dysfunction. Ann Clin Anal Med 2021;12(Suppl 4): S365-369
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Thiol/Disulphide homeostasis in children with acute pyelonephritis and cystitis
Hatice S. Yalçın-Cömert 1, Elif Bahat-Özdoğan 2, Mustafa İmamoğlu 1, Rezzan Sümeli 3, Haluk Sarıhan 1, Mehmet A. Bildirici 4, Süleyman C. Karahan 5, Özcan Erel 6, Cemile Biçer 6
1 Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, 2 Department of Pediatric Nephrology, Karadeniz Technical University, Faculty of Medicine, Trabzon, 3 Department of Pediatric Surgery, Kartal Dr. Lutfi Kırdar Education and Research Hospital, İstanbul, 4 Department of Medical Biochemistry, Doğu Beyazıt Hospital, Ağrı, 5 Department of Medical Biochemistry, Karadeniz Technical University, Faculty of Medicine, Trabzon, 6 Department of Medical Biochemistry, Ankara Yıldırım Beyazıt University, School of Medicine, Ankara, Turkey
DOI: 10.4328/ACAM.20593 Received: 2021-03-16 Accepted: 2021-05-12 Published Online: 2021-05-29 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S370-373
Corresponding Author: Hatice Sonay Yalcin Comert, Karadeniz Technical University, Faculty of Medicine, Department of Pediatric Surgery, Trabzon, Turkey. E-mail: sonayyalcin@hotmail.com P: +90 5327419246 F: +90 462 3250518 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5281-4933
Aim: Urinary tract infection is frequently seen in children, and in recurrent cases, invasive methods such as scintigraphy may be required for prognosis. We aimed to investigate whether the thiol/disulfide homeostasis has any role or effect on acute pyelonephritis and cystitis in pediatric patients.
Material and Methods: This case-control study was collected between June 2016 and June 2019. A total of 80 children (aged between 6 months and 17 years) participated in the study. Patient (80 children) demographics, serum and urine analyzes were collected.
Results: A significant difference was found when ages, heights, weights, body temperature, diastolic blood pressure, hemoglobin, leukocyte, C reactive protein (CRP), urine analysis and albumin values were compared. No significant difference was observed in systolic blood pressure, platelets and in thiol, disulfide and ischemia modified albumin (IMA) values and thiol/disulfide related ratios when all groups were compared. We also could not found any correlations results between thiol/disulfide and other parameters.
Discussion: Although there are meaningful results in many studies about thiol/disulfide homeostasis, we could not achieve the same results for urinary tract infection in our study. The pathophysiology of acute pyelonephritis and cystitis might not be related to the thiol/disulfide mechanism or does not cause enough change in the values of these parameters in the blood.
Keywords: Thiol/Disulfide; Pyelonephritis; Cystitis
Introduction
Urinary tract infection is one of the most common bacterial infections in children. When the infection is in the upper urinary tract, it is defined as pyelonephritis; in the lower urinary system, it is called cystitis if appropriate and adequate treatment is not performed [1-3]. Although acute pyelonephritis is common in children nowadays, Technetium-99m-dimercaptosuccinic acid (DMSA), which is an invasive examination for the child, is used to determine the prognosis and renal scar, diagnosis can lead to serious consequences, such as chronic pyelonephritis, hypertension and renal failure [4].
Oxidative stress plays an important role in the etiopathogenesis of this disease, and there are experimental studies in the literature about the protective properties of some antioxidants [5]. Oxidative stress is caused by the deterioration of the balance between antioxidant molecules and reactive oxygen species (ROS) [6]. ROS above the physiological level causes oxidation of many molecules, such as radical-based cysteine residues. As a result of this reaction, the sulfur atom present in the cysteine side chain is oxidized to disulfide [7]. In this case, the dynamic thiol/disulfide balance shifts to the disulfide form. Thiol/disulfide homeostasis plays a very important role in maintaining physiological processes such as antioxidant defense, apoptosis and protection of protein structures necessary for the organism [8]. In degenerative diseases such as diabetes, cardiovascular diseases, and rheumatic diseases, this balance is thought to shift in favor of disulfide [9]. It is not known how the balance of thiol/disulfide changes in acute pyelonephritis with high morbidity.
A simple, reliable and precise measurement method was developed by Erel et al. in 2014 to measure thiol/disulfide homeostasis, native thiol and total thiol levels for the first time [9]. In this study, we aimed to investigate the oxidative thiol/ disulfide homeostasis in pediatric patients with pyelonephritis and cystitis attacks compared to healthy controls. We foresee that thiol/disulfide homeostasis may be a predictor of oxidative stress in the near future and may indicate the severity of the disease and the degree of recovery after treatment. We anticipate that our study may contribute to fill the gap in the literature on this subject.
Material and Methods
Study population
This case-control study was collected between June 2016 and June 2019. A total of 80 children (aged between 6 months and 17 years) participated in the study. The control group consisted of 40 healthy children without any disease who were to undergo circumcision, inguinal hernia or frenilum linguale operations in the Department of Pediatric Surgery, Trabzon, Turkey. Twenty pediatric patients with pyelonephritis and 20 pediatric patients with cystitis in the Department of Pediatric Nephrology, Trabzon, Turkey were included as the patient groups. The study was approved by the Local Ethics Committee and informed consent was obtained from the parents/caregivers of the patients. Procedures
Patient demographics, sex, age, height, weight, body temperature and systolic/diastolic blood pressures were collected.
Laboratory method
Urine samples for urinalysis and urine culture were obtained using catheterization from non- continent patients, and clean middle-flow urine was obtained from continent children. Urine samples were taken for analysis (leukocyte, nitrite and protein) with a Beckman Coulter autoanalyzer. In the urinary culture, ≥10,000 colonies of a single pathogen were considered significant from non-continent patients; ≥100,000 colonies of a single pathogen were considered significant from continent patients.
Venous blood samples were taken to measure hemoglobin, leukocyte, platelets and determined with a Sysmex autoanalyzer. C reactive protein (CRP) was determined with a Beckman Coulter autoanalyzer. Additional 2-3 cc blood samples were taken to measure total thiol, native thiol, disulphide levels, disulphide/native thiol, disulphide/total thiol, native thiol/total thiol ratios, ischemia modified albumin (IMA) and albumin at Ankara Ataturk Education and Research Hospital using the method described by Erel et al [9]. Sera were separated after centrifugation at 1600 g for 10 minutes, and samples were transferred to Eppendorf tubes and stored at -80oC.
Thiol- disulphides homeostasis parameters measurement:
Thiol/Disulphide Homeostasis tests were measured by an automated spectrophotometric method described by Erel & Neselioglu [9]. For short, the disulphide bonds were first reduced to form free functional thiol groups with sodium borohydride. Unused reductant sodium borohydride was consumed and removed with formaldehyde to prevent reduction of DTNB (5,5’-dithiobis-(2-nitrobenzoic) acid), and all of the thiol groups, including reduced and native thiol groups, were determined after the reaction with DTNB. Half of the difference between total thiols and native thiols provides a dynamic disulphide amount. After the determination of native and total thiols, and disulphide amounts, the disulphide/total thiol (SS/SH+SS), disulfide/native thiol ratio (SS/SH) and native thiol/total thiol ratio (SH/SH+SS) were calculated [9]. The amounts were expressed as g/dL (albumin), absorbance unit- ABSU (IMA) and umol/L (native and total thiol ratios).
Measurement of the IMA
Albumin Cobalt Binding Test was used to detect the presence of Ischemia Modified Albumin (IMA). This test was performed by adding 50 mL 0.1% cobalt (II) chloride (CoCl2,6H2O) (Sigma- Aldrich Chemie GmbH Riedstrasse 2, Steinheim, Germany) to the patient serum. After mixing, followed by 10 minutes of incubation, 50 mL 1,5 mg/mL dithiothreitol was added to allow for albumin cobalt binding,. After mixing, followed by 2 minutes of incubation, 1.0 mL of a 0.9% sodium chloride solution was added in order to reduce the binding capacity. The blank was prepared similarly with distilled water instead of dithiothreitol. The absorbance of samples was measured at 470 nm using a spectrophotometer. The results were expressed as absorbance units (ABSU) [10].
Statistical analysis
The Kolmogorov- Smirnov test was used to test the conformity of the measurement data to normal distribution. We applied One way ANOVA test for normally distributed parameters and the Bonferroni test for posthoc values. The results of the tests for normal distribution are given as mean ± standard
derivation (SD). The Kruskal-Wallis test was used to compare the parameters without normal distribution and the Chi- Square test for posthoc values. The results are given as median inter quartile range (IQR). A p<0.05 was considered significant for statistical analyses.
Results
A total of 80 children were evaluated in our study. A significant difference was found when the age, height and weight of the patients in the cystitis group (CG) were compared with the control and pyelonephritis groups (PG). When comparing the body temperature of the PG with the control and the CG, significant differences were found. No significant difference was observed between all groups with systolic blood pressure; however, there was a significant difference between control and both PG and CG with diastolic blood pressure. The demographics parameters of the groups are summarized in Table 1.
In our study, significant differences were found between hemoglobin and leukocyte analysis between the control group and pyelonephritis and between the pyelonephritis and cystitis group. There was no significant difference between the groups in terms of platelet values.
Significant differences were obtained in CRP results, between the PG and CG groups and between control and patients groups. In our urine analysis results, there were significant differences in both leukocyte and protein values, when the control group was compared to both groups separately. A significant difference in urine nitrite values when comparing the control group with both groups separately. Table 2 shows the laboratory findings of the groups of our study.
Table 3 shows the analysis between thiol/disulfide homeostasis parameters, other characteristic properties, albumin and IMA results of our study population. No statistically significant differences were found in thiol, disulfide and thiol/disulfide ratios and IMA values when comparing all groups. A significant difference was found only with the albumin values when the control group was compared with PG.
We determined a positive correlation of albumin with native thiol, total thiol and disulphide while we determined no correlation of IMA with other parameters in the PG. We determined a positive correlation of both native thiol and total thiol with hemoglobin and albumin, while we determined a negative correlation of disulfide with leukocyte in the CG. We did not determine any correlation of IMA with other parameters in the CG. There was no correlation of CRP with native thiol, total thiol and disulfide ratio in the PG.
Discussion
Here we aimed to determine demographic and laboratory parameters and also the status of dynamic thiol/disulfide homeostasis and correlations using this novel method in pyelonephritis and cystitis in pediatric patients.
In our study, we found significant differences in body temperature, leukocyte, CRP and urine leukocyte values that were significant, especially in pyelonephritis. When we look at the thiol/disulfide homeostasis parameters, we could only obtain positive results in albumin values. When we examine our results in more detail, correlations that were positive in terms of correlation were found in values associated with albumin. Thiols are mostly found in albumin (the more the albumin, the more the thiol group). We think that we can say that the meaningful results we found in albumin value are indirectly present in thiols. In addition, we were sensitive about the gender, age, height and weight of the patients to be close to each other, so as not to affect the results in our study.
In clinical practice, cystitis and pyelonephritis patients come to the hospital with fever, vomiting, irritability, jaundice and failure to thrive in newborns. Young children (not-toilet-trained) apply with complaints such as irritability, foul-smelling urine, abdominal pain, hematuria and suprapubic tenderness and older children (toilet-trained) apply with dysuria, foul-smelling or cloudy urine, voiding dysfunction, incontinence, frequency, fever and abdominal or flank pain [2]. DMSA is thought that the most sensitive test for detecting renal scarring and for diagnosis of acute pyelonephritis [2,4]. Previous studies have shown that antioxidants can reduce tissue damage and renal scarring of acute pyelonephritis and dynamic thiol /disulphide balance has an important roles in antioxidant protection [4, 9]. Based on the fact that DMSA is an invasive method, looking at the thiol/disulfide balance, we thought that it might help us in the diagnosis of cystitis or pyelonephritis.
However, we did not detect any changes in this thiol/disulfide hemostasis in our study.
We attributed this to the absence of any evidence of diffuse blood from oxidative stress markers in acute pyelonephritis, or by the fact that these markers were not distinctive parameters in pyelonephritis in the early stages.
In both cystitis and pyelonephritis, the pathology depends on the tissues (bladder/kidney), and the diseases are not systemic. Thiol is an organic compound containing a sulfhydryl (-SH) group, which plays a critical role in preventing the occurrence of any oxidative stress in cells [9, 11, 12]. Dynamic thiol/disulfide balance status plays critical roles in antioxidant defense, detoxification apoptosis, regulation of enzyme activities, transcription and cellular signal transduction mechanisms [9, 11]. In the literature, some groups of diseases in which thiol/ disulfide homeostasis is affected have been described. These are diabetes, cardiovascular diseases, cancer, rheumatoid arthritis, chronic kidney disease, acquired immunodeficiency syndrome, Parkinson’s disease, Alzheimer’s disease, Friedreich’s ataxia, multiple sclerosis, and amyotrophic lateral sclerosis, liver disorder [9].
Thiol/disulfide balance can be measured by a method developed by Erel et al [9] and after them, Elmas et al showed that this method could be easily performed in a pediatric group of patient studies [13]. They found an association with thiol/ disulfide homeostasis and inflammation in obese pediatric patients. Ozyazici et al indicated that dynamic thiol/disulfide balance is shifted towards disulphide formation in patients with acute appendicitis [11]. Kurt et al have found a change in the thiol/disulfide homeostasis with febrile seizure pathogenesis in children [14]. Both acute appendicitis and sepsis are systemic diseases. Ayar et al showed that hemodialysis had a positive effect on thiol/disulfide homeostasis [12]. Again Ayar et al. showed in another study the efficiency of the thiol/disulfide balance with sepsis in children [15].
Both infection and inflammation occur in acute pyelonephritis. Inflammation causes tissue damage. This damage results in released acute phase proteins, cytokines and migration of granulocyte to the affected tissue [16]. Vysakh et al. claimed that the main pathophysiological cause was oxidative stress in acute pyelonephritis [17]. Also, Caliskan et al. found an increase in oxidative stress parameters and antioxidant enzyme activities in a rat model of acute pyelonephritis [18]. Based on the results obtained from these studies, we investigated how the balance of thiol /disulfide homeostasis will be affected in acute pyelonephritis.
This study demonstrated no effective results regarding thiol/disulfide homeostasis in acute pyelonephritis and cystitis diseases. Prospective and randomized controlled trials are needed to confirm the pathological role of thiol/disulfide balance in pyelonephritis and cystitis.
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.
Funding: None
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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3. Becknell B, Schober M, Korbel L, Spencer JD. The Diagnosis, Evaluation and Treatment of Acute and Recurrent Pediatric Urinary Tract Infections. Expert Rev Anti Infect Ther. 2015; 13(1):81–90.
4. Ozdogan EB, Ozdemir T, Çamlar SA, Imamoğlu M, Cobanoğlu Ü, Sönmez B, et al. Could pyelonephritic scarring be prevented by anti-inflammatory treatment? An experimental model of acute pyelonephritis. BioMed Research International. 2014; DOI: 10.1155/2014/134940.
5. Imamoglu M, Cay A, Cobanoglu U, Bahat E, Karahan C, Tosun I, et al. Effects of melatonin on suppressıon of renal scarring in experimental model of pyelonephritis. Urology. 2006; 67:1315–9.
6. Ates I, Ozkayar N, Topcuoğlu C, Dede F. Relationship between oxidative stress parameters and asymptomatic organ damage in hypertensive patients without diabetes mellitus. Scand Cardiovasc J. 2015; 49(5):249-56.
7. Cremers C.M, Jakob U. Oxidant sensing by reversible disulfide bond formation. J Biol Chem. 2013; 288(37):26489-96.
8. Schafer F.Q, Buettner G.R. Redox envoirenment of the cell as viewed through the redox state of the glutathione disulfide/ glutathione couple. Free Radic Biol Med. 2001; 30(11):1191-212.
9. Erel O, Neselioglu S. A novel and automated assay for thiol/disulphide homeostasis. Clin Biochem. 2014; 47(18):326-32.
10. Bar-Or D, Lau E, Winkler JV. A novel assay for cobalt albumin binding and its potential as a marker for myocardial ischemia—a preliminary report. Journal of Emergency Medicine. 2000; 19(4):311–15.
11. Ozyazıcı S, Karateke F, Turan U, Kuvvetli A, Kilavuz H, Karakaya B, et al. A Novel Oxidative Stress Mediator in Acute Appendicitis: Thiol/Disulphide Homeostasis. Hindawi Publishing Corporation Mediators of Inflammation. 2016; DOI: 10.1155/2016/6761050
12. Ayar G, Sahin S, Yazici MU, Neselioglu S, Erel O, Bayrakcı US. Effects of Hemodialysis on Thiol-Disulphide Homeostasis in Critically Ill Pediatric Patients with Acute Kidney Injury. BioMed Research International. 2018; DOI: 10.1155/2018/1898671
13. Elmas B, Karacan M, Dervişoğlu P, Kösecik M, İşgüven ŞP, Bal C. Dynamic thiol/disulphide homeostasis as a novel indicatorof oxidative stress in obese children and its relationship with inflammatory-cardiovascular markers. Anatol J Cardiol. 2017; 18(5):361-9.
14. Kurt ANC, Demir H, Aydin A, Erel Ö. Dynamic thiol/disulphide homeostasis in children with febrile seizure. Seizure. 2018; 59:34–37.
15. Ayar G, Sahin SD, Atmaca YM, Yazici MU, Neselioglu S, Erel O. Thiol-disulphide homeostasis is an oxidative stres indicator in critically ill children with sepsis. Arch Argent Pediatr. 2019; 117(3):143-8.
16. Vysakh A, Raji NR, Suma D, Jayesh K, Jyothis M, Latha MS. Role of Antioxidant Defence, Renal Toxicity Markers and Inflammatory Cascade in Disease Progression of Acute Pyelonephritis in Experimental Rat Model. Microb Pathog. 2017; 109:189-94.
17. Vysakh A, Jayesh K, Jisha N, Vijeesh V, Midhun SJ, Jyothis M, et al. Rotula aquatica Lour. Mitigates Oxidative Stress and Inflammation in Acute Pyelonephritic Rats. Arch Physiol Biochem. 2019; 27:1-9.
18. Caliskan B, Guven A, Ozler M, Cayci T, Ozcan A, Bedir O, et al. Ozone Therapy Prevents Renal Inflammation and Fibrosis in a Rat Model of Acute Pyelonephritis. Scand J Clin Lab Invest. 2011; 71(6):473-80.
Download attachments: 10.4328:ACAM.20593
Hatice S. Yalçın-Cömert, Elif Bahat- Özdoğan, Mustafa İmamoğlu, Rezzan Sümeli, Haluk Sarıhan, Mehmet A. Bildirici, Süleyman C. Karahan, Özcan Erel, Cemile Biçer. Thiol /Disulphide homeostasis in children with acute pyelonephritis and cystitis. Ann Clin Anal Med 2021;12(Suppl 4): S370-373
Citations in Google Scholar: Google Scholar
Impact of Covid-19 pandemic on eating habits of the Turkish population
Nazan Erenoğlu Son
Department Nutrition and Dietetic, Faculty of Health Sciences, Afyonkarahisar Health Sciences University / Department History of Medicine and Ethics, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyon, Turkey
DOI: 10.4328/ACAM.20594 Received: 2021-03-16 Accepted: 2021-05-29 Published Online: 2021-06-10 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S374-378
Corresponding Author: Nazan Erenoğlu SON, Afyonkarahisar Health Sciences University, Faculty of Health Sciences, Head of Department Nutrition and Dietetic, Faculty of Medicine, Department History of Medicine and Ethics, Afyon, Turkey. E-mail: nazan.son@afsu.edu.tr, nazanson@gmail.com P: +90 505 4481441 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3614-3604
Aim: This study was planned in order to reveal how the quarantine process applied in Turkey due to the pandemic has affected the eating habits of our society.
Material and Methods: This is a cross-sectional comparative survey study. The study was carried out using the Attitude Scale for Healthy Nutrition and socio- demographic data in the cities located in the west of Turkey: Eskisehir, Ankara, and Afyonkarahisar. The survey was applied twice to measure pre-quarantine and post-quarantine information, and completed by reaching 306 people via social media.
Results: The majority of the participants in the study were women. The educational and socio-economic levels of the participants were found to be high. The body mass index of the majority of the participants in the study was in the normal or healthy weight status before quarantine, while it shifted to the over- weight status after quarantine. The total score of the Attitude Scale for Healthy Nutrition and the knowledge level scores about nutrition were found to be higher than before quarantine.
Discussions: Although the knowledge level of the individuals participating in the study about nutrition increased, it was found that this was not implemented much in practice. Due to the quarantine, individuals began to gain weight. During the quarantine process, ready-to-eat food consumption has decreased significantly. We can say that even though the consumption of ready-to-eat food increased a little after quarantine, it did not return to the previous levels.
Keywords: COVID-19; Pandemic; Nutrition; Pandemic Nutrition; Physical Activity
Introduction
Coronavirus infection is a viral disease that emerged in Wuhan, China in late 2019 [1]. Later, it quickly affected the whole world and was declared a global pandemic by the World Health Organization (WHO) [2]. The disease, named “COVID-19” by WHO, has infected 99,638,508 people worldwide so far and caused 2,141,568 deaths (available online: https://covid19.who. int/?gclid=CjwKCAiAu8SABhAxEiwAsodSZFelStWTgXz4J6kME ORsKSptmQRoPS-E0k97PjmCAhW7VmFtbGH71xoC2TcQAvD_ BwE, Accessed 27.01.2021). The situation is not any different in our country. As of now, 2,435,247 people have been infected in our country due to the COVID-19 outbreak, and 25,210 people have died (available online: https://covid19.who.int/region/ euro/country/tr, Accessed 27.01.2021). Due to the COVID-19 pandemic, the whole world has faced an unknown disease and has made an effort to take a series of measures to slow its spread. On the other hand, efforts and studies to develop a vaccine against COVID-19 have started all over the world. In order to prevent the spread of the virus, wearing a mask, frequently washing or disinfecting the hands, and maintaining the distance between individuals were among the first measures taken [3-5]. However, these measures were not enough to slow the spread of the virus. Immediately afterward, additional measures were taken and education was interrupted differently in each country, working conditions were transformed into home-office systems, and international flights were stopped [6]. When these measures did not bring enough success in the fight against the virus, more aggressive practices were initiated and different measures were taken, such as lockdown processes, curfews, and the virus-infected people not contacting anyone for 14 days [6,7]. While the measures taken against COVID-19 have reduced the spread of the virus to some extent, this has led to a number of different issues. Although COVID-19 caused great damage to the economies of the countries, many businesses were closed and many people lost their jobs [8]. People forced to stay in their homes became isolated from social life, and a great change of lifestyle emerged. People have done their food and beverage shopping as if there was a famine, and an inactive process was started. Along with the pandemic, the eating habits and lifestyles of societies have changed [9]. Every country, through the media and the press, emphasized that the measures should be followed and the immune resistance should be kept high in order to be protected from COVID-19 [10]. There is a strong relationship between diseases and nutrition [1,5,6]. Nutrition is as important as medical treatment in the prevention and treatment process of diseases [1,5,6,9,10]. People with chronic diseases had to be especially much more careful. In quarantine periods, people tend to eat healthier and in a way that strengthens immune resistance. However, an inactive life led them to gain weight rapidly [9,12]. This study was planned in order to reveal how the quarantine process applied in our country due to the pandemic affected the eating habits of our society.
Material and Methods
Study Design and Determination of the Participants
This study is a cross-sectional comparative survey study designed to determine the changing eating habits of society with the effect of the pandemic. Long-term quarantine in our country started in March 2020 and was partially ended in July 2020. However, the inability to prevent the spread of the virus and the arrival of a 2nd wave with a heavier picture led the quarantine to be returned with more severe sanctions. Currently, several vaccines for the virus have been developed, but partial restrictions are ongoing due to the issues with the management of access to the vaccine and the vaccination process in communities. The survey of the study was carried out after the first long quarantine period, by delivering it to the people involving friends and neighbors via Whatsapp and mail between 1 July 2020 and 1 September 2020. A total of 378 people participated in the study, however, 306 questionnaires were evaluated, after the questionnaires thought to be incomplete or inaccurate were removed. All the participants of the study are of Turkish descent. The regions reached by the study are the cities of Eskisehir, Ankara, and Afyonkarahisar and their environs in the west of Turkey. The study covers individuals aged 18 and above. The data of the study were obtained from survey questions that consist of two parts. The first part of the survey included questions on the presence of any disease, weight before and after quarantine, number of people at home during the quarantine periods, the physical activity level of the people before, during, and after the quarantine, the consumption status of ready-to-eat food of the people before, during and after the quarantine, and whether they made their bread during the quarantine periods as well as questions on sociodemographic data such as gender, age, height, education level. The participants’ height and weight were used to calculate their Body Mass Index (BMI). BMI’s were calculated with the use of the formula “weight (kg)/height (m)2. In the second part, the Attitude Scale for Healthy Nutrition (ASHN) consisting of 21 items was used to evaluate the nutritional knowledge and behaviors of the participants before and after quarantine. The ASHN was used twice to measure eating habits of the participants before and after the pandemic. Changing eating habits, physical changes, and physical activity levels of the individuals before and after the pandemic were compared. ASHN is a scale developed in Turkish by Tekkurşun Demir and Cicioğlu in 2019 to measure attitudes towards healthy nutrition, and its validity and reliability study was conducted [13]. The ASHN has a structure consisting of 21 items and 4 factors. These factors are called Information on Nutrition (IN), Emotion for Nutrition (EN), Positive Nutrition (PN), and Malnutrition (MN). The scale consists of 10 positive (1. I know the benefits of a healthy diet, 2. I know which foods contain protein, 3. I know which foods contain carbohydrates, 4. I know which foods contain vitamins/minerals. 5. I know what healthy foods are, 12. I have main meals (breakfast, lunch, and dinner) regularly, 13. I drink at least 1.5 liters of water a day, 14. I consume at least 3 meals a week of vegetables, 15. I eat fruit regularly, 16. I eat protein-containing foods (meat, milk, eggs, etc.) every day.) and 11 negative items (6. I get happy when I consume foods with sugar (chocolate, cake, biscuit, etc.), 7. I enjoy eating fast food products (hamburgers, pizza, etc.), 8. I enjoy eating delicatessen products (salami, sausage, soudjouk, etc.), 9 I like to eat fried foods, 10. I don’t like to eat fruit, 11. I get happy when I consume desserts with syrup (baklava, kunafah, etc.), 17.
I skip main meals, 18. I eat junk food (chips, chocolate, biscuits, etc.) every day, 19. I drink at least 1 glass of acidic/carbonated beverage every day, 20. I eat fast, 21. I usually have foods such as cake and biscuits for my main meal.). The ratings for the positive items in the scale are “Strongly Disagree”, “Disagree”, “Neither agree nor disagree”, “Agree”, and “Strongly Agree”. On the scale, positive items were scored as 1. 2. 3. 4 and 5, and negative items as 5. 4. 3. 2 and 1. The lowest score on the scale is 21 and the highest score is 105. The participants are considered to have a very low level of attitude towards healthy eating with a score of 21 on the scale, low level with a score of 22-42, medium level with a score of 43-63, high level with a score of 64-84 and ideally high level with a score of 85-110. The IN score was obtained from the items 1., 2., 3., 4., 5. while EN score from 6., 7., 8., 9., 10., 11, PN score from 12., 13., 14., 15., 16., and MN score from 17., 18., 19., 20., 21.) [13].
The internal consistency coefficients of the scale were calculated as 0.90 for the IN factor, 0.84 for the EN factor, 0.75 for the PN factor, and 0.83 for the MN factor [13].
Ethical Consideration
The Clinical Research Ethics Committee of Afyonkarahisar Health Sciences University was consulted and the written statement, dated 05.06.2020 and numbered 2020/6, explaining that this study does not require an Ethics Committee approval since it is a survey study, was obtained.
Statistical Analysis
The data were entered and analyzed in SPSS 22 version for statistical analysis. The data were evaluated using descriptive statistics (mean, median, standard deviation, percentage distributions). When comparing the means between the groups, firstly, the suitability of normal distribution was evaluated using the Kolmogorov-Smirnov and Shapiro-Wilk tests. When comparing the mean of the two dependent groups, the t-test and the chi-square test were used when parametric conditions were met, and the Wilcoxon test was used in cases where parametric conditions were not met. When comparing the mean of two independent groups, the t-test was used when parametric conditions were met, and the Mann-Whitney U test was used in cases where parametric conditions were not met. One-Way Analysis of Variance and Mean ± Standard Deviation were used to compare multiple groups.
Results
The study was conducted with 306 participants, of which 241 were women, 65 were men. The mean age of the participants was 39.64 ± 10.04 years; 84.3% of the participants were university graduates. The income level of 45.1% of the participants was between 5000-10000 Turkish Lira per month. While 5.6% of the participants were alone during quarantine, 14% were with another 1 person, 38% with 2 people, 34.6% with 3 people, and 7.6% of them were with 4 or more people. While 81.7% of the participants did not have a chronic disease, 4.6% had diabetes, 3.6% respiratory disease, 1.6% blood pressure, 2.9% cardiovascular disease, and 5.6% had other diseases. While the mean BMI value of the participants before the quarantine was 24.83 ± 4.48 kg/m2, the mean BMI value after the quarantine was found to be 25.79 ± 4.48 kg/m2, and a statistically significant difference was found between them (p<0.001) (Table 1).
Looking at the individual BMI values of the participant before the quarantine, 4.6% of them had a BMI value equal to or less than 18.5, 50.3% of them had a BMI value between 18.5-25.0 and 45.1% of them had a BMI value equal to or more than 25. After the quarantine, 4.9% of them were found to have a BMI value equal to or less than 18.5, 44.4% with a value between 18.5-25.0, and 50.7% with a value equal to or more than 25. While the total score of the ASHN before the quarantine was 83.22 ± 10.69, it was 83.76 ± 9.74 after the quarantine, and there was a statistically significant difference between them (p<0.001) (Table 2). Among the four factors of the scale, a statistically significant difference was found in the pre- quarantine and post-quarantine nutritional knowledge levels only in IN (p<0.001) (Table 2).
Participants were asked about their weekly ready-to-eat food (ordered from outside) consumption frequency before, during, and after quarantine and were found to be 2.01 ± 1.67, 0.31 ± 0.93, 0.73 ± 0.92/week, respectively. A statistically significant difference was found between these values (p<0.001) (Table 3). Multiple comparisons showing where the statistical difference comes from are shown in Table 3. Participants’ exercise status before, during, and after quarantine (at least 3 days a week over 50 minutes of exercise, walking=150 minutes and more per week) was found to be 56.2%, 24.2%, 55.2%, respectively. Among the participants, 43.5% reported making their bread at home during the quarantine period.
Discussion
The results of our study show that the measures taken in response to the COVID-19 outbreak affect the eating habits of the society [14-17]. The majority of the participants in our study were women [11,15,17,18]. This situation has been interpreted as women are more interested in issues related to nutrition on social media. Besides, in Turkish society, mostly women are involved in cooking. The fact that they had a high level of education [11,15,17,18] and were in the middle age group, shows that they could use more social media and participate in the study. It has also shown that 92.4% of the participants spent the quarantine process with at most 4 people in the same house. The results are similar to other studies related to quarantine processes [15-19]. Most of the participants in our study were seen not to have a chronic disease.
Among all the measures taken due to the COVID-19 pandemic all over the world, the best protection was achieved with quarantine processes [8-10]. Quarantine processes have led to the emergence of different problems in society, as well as to a decrease in the spread of the virus [12-20]. Prolonged quarantine processes negatively affected the mental health of people and caused an increase in depression and body weight, and a decrease in physical activity in many societies [11,16,20,21]. Distance education and online working systems have played an important role in the emergence of a sedentary life in quarantine processes [14-21]. In our study, 56.2% of the participants before the quarantine stated that they performed regular physical activity, exercise, and sports, while this decreased to 24.2% during the quarantine process. With the easing of quarantine restrictions, the rate of performing sports has returned to similar numbers as before the quarantine. The results of our study are similar to the results in the literature [15-17]. Although there were so many exercise programs on social media during the pandemic process, these programs were understood not to attract enough attention of people due to low levels of morale and motivation in the societies [9-12]. The results of our study show how much the quarantine process leads to a sedentary lifestyle. Studies have emphasized that quarantine processes enforced due to the COVID-19 pandemic and the resulting sedentary life cause an increase in body weight [9-11,15-17]. As a matter of fact, in our study, the body weight of the participants increased after quarantine compared to before quarantine. In our study, while the mean BMI value of the participants before the quarantine was 24.83 ± 4.48 kg/m2, the mean BMI value after the quarantine was found to be 25.79 ± 4.48 kg/m2, and a statistically significant difference was found in terms of weight gain. Using the classification of WHO on BMI, while 45.1% of the participants, before the quarantine had a BMI value equal to or more than 25, i.e. overweight, this rate increased to 50.7% after quarantine. While the BMI of 50.3% of the participants before the quarantine was between 18.5-25.0, after quarantine, there was a negative movement towards a rate of 44.4%.
Another pandemic that threatens humanity in the world in terms of health is obesity. Unfortunately, the COVID-19 pandemic seems to have triggered the obesity pandemic. One of the most important ways of protection from viral diseases is the determination and application of correct nutritional rules that will keep immune resistance high [22-24]. In our study, the eating habits of the participants were found to change after the quarantine compared to pre-quarantine habits, and also, the knowledge of the participants on nutrition improved. However, the fact that the emotion for nutrition, positive nutrition, and malnutrition scores did not change before and after quarantine shows that the knowledge improvement on nutrition is not put into practice. While the results of our study show similarities with some literature information, they show differences with some others [9-10,15,16]. In a study conducted in Italy, those with low BMI were reported to lose weight due to decreased appetite, and those who were overweight gained weight due to increased appetite [9]. In a study conducted in Poland, it was stated that the appetite of obese people increased and negative eating behaviors were adopted [10].
Conclusion
The results of our study showed that pre-quarantine ready- to-eat food consumption decreased to almost non-existent levels during the quarantine process, while at the end of the quarantine it increased slightly again. The data obtained show that the consumption of ready-to-eat food has decreased. As a result of our study, the knowledge improvement on nutrition and the decrease in ready-to-eat food consumption is seen as a return to healthy nutrition in the long term. The fact that almost half of the participants were making their bread at home in the quarantine process supports this idea.
The results also revealed that the quarantine process applied due to the COVID-19 pandemic triggered weight gain. Data reveal that the consumption of ready-to-eat food decreased during the quarantine periods, and even though this habit was relatively relaxed to some extent, it continued permanently after the quarantine period. In our study, it was found that there was an increased level of knowledge about nutrition to eat healthily and protect against COVID-19.
The weight of the individuals participating in our study has increased even though the tendency to healthy eating has increased. This situation might be explained by the excessive amount of food consumption and/or the decrease in physical activity. It is extremely important to raise awareness of the communities about healthy nutrition, so that pandemics that may occur in the future will not trigger the obesity pandemic.
Limitations
This study, which is a cross-sectional comparative survey, was conducted at a time when the first full quarantine ended. In connection with the measures taken due to COVID-19, the study was carried out through social media. The weight and height measurements of the individuals participating in the study were recorded according to their self-report, and BMI values were calculated accordingly. This study may not reflect the general population as it was carried out in the region where the author has been living.
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.
Funding: None
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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Antiinflammatory and antioxidant activities of different hemostatics and pulp capping materials applied on rat teeth
Ayşegül Göze Saygın 1, Murat Ünal 2, Nazlı Ercan 3, Pınar Demir 4
1 Department of Prosthodontics, Sivas Cumhuriyet University, Faculty of Dentistry, Sivas, 2 Department of Pediatric Dentistry, Sivas Cumhuriyet University, Faculty of Dentistry, Sivas, 3 Department of Biochemistry, Sivas Cumhuriyet University, Faculty of Veterinary Medicine, Sivas, 4 Pediatric Dentistry, İnönü University, Faculty of Dentistry, Malatya, Turkey
DOI: 10.4328/ACAM.20595 Received: 2021-03-16 Accepted: 2021-06-01 Published Online: 2021-06-16 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S379-384
Corresponding Author: Ayşegül Göze Saygin, Department of Prosthodontics, Sivas Cumhuriyet University, 58140, Turkey. E-mail: aysegulgoze@hotmail.com P: +90 507 706 97 60 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2826-5011
Aim: This study aimed to investigate the anti-inflammatory and antioxidant activities of different hemostatic agents and pulp capping materials.
Material and Methods: Ninety-six Wistar albino male rats were divided into the following groups: Sterile Saline (SS), Sodium Hypochlorite (NaOCl), Mecsina Hemostopper (MHS). Occlusal cavities were prepared in the first molar teeth. Hemostatic agents were used to control bleeding and different pulp capping materials were applied on the exposed pulp area. Subgroups were created according to pulp capping materials (Dycal, Biodentine Theracal, MTA RepairHP). Half of the groups were left to wait for sacrifice on the 7th day and the others on the 28th day. Cardiac blood was taken to determine of antiinflammatory and antioxidant serum markers.
Results: The use of different hemostatic agents in terms of antioxidant (CAT, GPX) and anti-inflammatory (IL1-β, TNF-α, IL-6) activity was statistically signifi- cant (p <0.05). There was no statistical significance between groups for SOD (p> 0.05). IL-6 was significantly higher on the 7th day than on the 28th day (p <0.05). The anti-inflammatory activity reduced from the 7th to the 28th day, in contrast, antioxidant activity induced.
Discussion: The inflammation process was related to the hemostatic agents and the capping materials used in DPC treatment. MHS may be an alternative for DPC treatment for bleeding control.
Keywords: Anti-Inflammatory Effect; Antioxidants; Dentistry; Direct Pulp Capping; Mecsina Hemostopper
Introduction
Direct pulp capping (DPC) is a treatment method involving the application of dental materials on the exposed pulp tissue for the survival of the pulp and the formation of reparative dentin. Cytokines are important markers in the repair process, in which immune cells come into play along with hard tissue formation. This process results in either a pulp repair with or without the dentine bridge, or in fibrosis or necrosis [1]. For this reason, the success of DPC treatment is still controversial for clinicians due to its unpredictable results [2].
Cytokines, which are released after exposure to pulp tissue, are polypeptide products that act as mediators of the immune response. IL-1β, which induces acute and chronic inflammation, is a cytokine that activates the natural and acquired immune system IL-6, an important cytokine in the formation of an acute phase response to tissue damage, works synergistically with IL-1β and TNF-α, which is known to have a significant effect in acute inflammation [3]. It has been reported that titers of IL-1β and TNF-α significantly increase in irreversible damage of pulpal tissue [4].
Antioxidant enzymes (Superoxide dismutase, Catalase, Glutathione Peroxidase) act as protection against oxidative damage that is caused by free radicals released during inflammation (such as H2O2). Superoxide dismutase (SOD) is the strongest antioxidant and the first detoxification enzyme [5]. Catalase, known as H2O2 oxidoreductase, is an antioxidant enzyme necessary for the the proper functioning of the organism [6]. Glutathione peroxidase, an intracellular antioxidant enzyme, plays a vital role in protecting the organism against free radicals [5]. Antioxidants can be natural and synthetic. Plant extracts contain some components with antioxidant properties [7]. Pulpal bleeding control is an important step in DPC treatment. For this purpose, sterile saline (SS), sodium hypochlorite (NaOCl) are used in traditional applications. SS, which can cause pulpal inflammation as a result of reactivation of hemorrhage and causing dislocation of the clot, has been shown as the material with the least cytotoxicity in the studies conducted [8]. NaOCl has been shown to have negative effects on stem cell survival and differentiation as a result of clinical studies and research [9]. It is also known to increase acute inflammation of vital cells [9.10]. Mecsina hemostopper (MHS) is a herbal extract made from herbal agents such as Glycyrrhiza glabra extract, Alpinia officinarum, Thymus serpyllum, Syzygium aromaticum, Hypericum perforatum, Vitis vinifera, Urtica angustifolia, Mentha arvensis. This leads to an erythrocyte aggregation by creating a protein network in the bleeding area and enables bleeding control [11].
Research was carried out to investigate and use new materials to predict and achieve desired success in dental practice [12]. Bioactive endodontic materials (BEM) should prevent pulpal inflammation and provide tissue healing. Calcium hydroxide, which is used as the gold standard in DPC treatment, has properties such as adhesion deficiency, deterioration after acid etching, dissolution against oral fluids [13]. Theracal resin-based material, which leads to repair dentine formation by increasing the pH on the pulp surface, and polymerizes with light, may cause pulpal inflammation due to its cytotoxic feature [14]. The issue of how MTA Repair HP, a new bioactive material, acts in the pulpal healing process has not yet been adequately clarified.
Due to the fact that the pulp tissue, which has a low amount of antioxidant activity, can give an inadequate recovery response to any injury, in this study, it was planned to investigate the anti-inflammatory and antioxidant response, MHS, which is provided with hemostasis and different bioactive materials, which is a new hemostatic agent with an herbal content. The first null hypothesis of this study is that different hemostatic agents will not affect anti-inflammatory markers on the 7th and 28th days. The second null hypothesis of this study is that the effectiveness of hemostatic agents will not differ in terms of antioxidant activity at different times.
Material and Methods
For the study, approval was obtained from the Ethics Committee of Sivas Cumhuriyet University (ID: 65202830- 050.04.04-179). Wistar albino male rats, 4-6 months old, with a total weight of 200-250 g were divided into 3 main groups in order to carry out the application procedure of anti-bleeding agents. All experiments were conducted in compliance with the National Institute of Health’s Guidelines for the Care and Use of Laboratory Animals. The subjects were kept in standard test cages at 22-24 ° C, 55-70% humidity, 1 atm. pressure for 12 hours in a light/dark room and their health status was checked. The animals were anesthetized with intramuscular injection of ketamine HCl (25 mg/kg) and xylazine (10 mg/kg). Maxillary first molar teeth were cleaned with a small brush with %5 sodium hypochlorite and %0.1 chlorhexidine gluconate before cavity preparation. Class I cavities opened with dental burs under water cooling, approximately 1 mm perforation areas were created with a sterile probe tip. In Group SS, 0.09% Sterile Saline (Osel Drug Company), in Group NaOCl, 5% Sodium Hypochlorite Imicryl, Konya, Turkey and in Group MHS, Mecsina Hemostopper [Gesmir Company, Ankara, Turkey] were applied with sterile cotton pellets. The application times of the agents for hemostasis were determined as 5 minutes, 20 seconds and 20 seconds, respectively. Then the main groups were divided into 4 different subgroups according to the DPC application procedure (n = 8), and then, perforation areas were filled in with Calcium Hydroxide (C) [Dycal Dentsply, Caulk Milford, DE, USA]; Biodentine (B) [Septodont, Saint Maur des Faussés, France], Theracal (Th) [Bisco Inc, Schamburg, IL, USA] and MTA Repair Hp (MTA) [Angelus, Londrina, PR, Brazil] prepared in line with the manufacturing firm’s instructions and the cavities were filled with glass ionomer cement (GC Fuji IXGP EXTRA, GC Corporation, Tokyo, Japan) to prevent microleakage.
Half of the rats were sacrificed on the 7th day and the rest on the 28th day. Cardiac blood was collected under anesthesia. It was centrifuged in a cooled centrifuge (Hermle Z326) to obtain serum from the collected blood. Enzyme-linked immunosorbent assay (ELISA) test was performed to compare antioxidant enzymes (Catalase, Glutathione Peroxidase, Superoxide Dismutase) and anti-inflammatory (IL-1β, IL-6, TNF-α) activities.
ELISA Test Procedure Blood serums were obtained after centrifugation and collected in Eppendorf tubes. IL-1β, IL-6, TNF-α, Cat, GPX, SOD were analyzed spectroscopically using an ELISA device (Thermo Multiskan) according to kit procedures using the Bioassay Technology Laboratory commercial test kits. The respective reagent and antibody were added to each well. Streptavidin-HRP (50μl) was added to each standard and sample. After incubation, the wells were washed 5 times at 37 °C and 60 minutes in the dark environment. Finally, the absorbance of the standard and samples was measured in the ELISA device at 450 nm wavelength.
Statistical analysis was performed in the SPSS 22.0 program used to evaluate the data, and the significance value was taken as p <0.05. The normality of data distributions was analyzed with the Kolmogorov-Smirnov test. The Kruskal-Wallis for nonparametric testing and One-way ANOVA for parametric testing were used for variables to compare the studied parameters for the statistical difference. Differences were considered significant at p <0.05.
Results
When the serum levels of rats sacrificed on the 7th day were evaluated, after the normality tests were applied, non- parametric tests were conducted since the Cat, SOD, IL1β and IL-6 parameters did not show normal distribution. The Kruskal- Wallis test was used to compare these values. Since GPX and TNF-α parameters had normal distribution, One-Way ANOVA test was applied (Table 1).
When comparing Cat, GPX, IL1-β, TNF-α, IL-6 values between groups using different haemostatic agents in terms of antioxidant and anti-inflammatory efficacy, a statistically significant difference was obtained (p<0.05). There was no statistical difference between the groups in terms of SOD enzymes (p>0.05). Cat value was found to be higher in hemostasis with MHS coated with Biodentine and MTA Repair Hp groups than hemostasis SS capped by MTA Repair Hp groups. Average GPX parameter for MHS-Cal, SS-MTA, NaOCl-B groups is higher than for the other groups. The mean IL-1β cytokine is lower in the SS-MTA group than the MHS-B, MHS-MTA, SS-B, NaOCl-C and NaOCl-The averages.
The mean value of the IL-1β cytokine of the SS-Cal group is lower than those of the NaOCl-C, NaOCl-The groups. The average TNF-α enzyme is higher in the groups MHS-The, SS- MTA, SS-C, NaOCl (C, B, MTA) than in the others. The mean of IL-6 was higher in the groups that were covered with Theracal and MTA material by ensuring hemostasis with NaOCl.
When the serum markers of the rats sacrificed on the 28th day were evaluated, Cat, SOD, IL1-β and IL-6 parameters did not show normality, although the Kruskal-Wallis test was applied. One-way ANOVA test was applied because GPX and TNF-α parameters, belonging to the same group, showed normality (Table 2).
The average SS-MTA Cat parameter was lower than other groups. NaOCl-The Cat parameter average was higher than in the other groups. SOD averages did not show statistical differences according to the applied materials (p> 0.05).
When blood serum markers were evaluated on the 7th and 28th day, the mean IL-6 parameter was significantly higher on the 7th day than on the 28th day (p > 0.05) ( Table 3 ).
Cat, GPX, IL-1β and SOD levels in the MHS group were not statistically significant on the 7th day than on the 28th day (p> 0.05). However, the difference between TNF-α and IL-6 levels was found to be statistically significant (p >0.05).
When comparing the variability of blood serum markers on the7th and 28th days of different materials used in the study, there were statistical differences in IL-6 and TNF-α levels (p<0.05). IL-6 levels comparison between days 7 and 28 was statistically significant between 7th and 28th day (p<0.05). The levels of IL-6 and Cat showed a statistically significant difference on the 7th and 28th days (p<0.05).
Discussion
This study aimed to investigate the anti-inflammatory and antioxidant activities of different hemostatic agents and capping materials in the early and late periods. The first null hypothesis, which states that the data obtained from the study did not have any effect on different days of inflammatory markers, was rejected. The response of pulp tissue to different hemostatic agents and capping materials was statistically significant at different times and the difference in the inflammatory response to MHS plant extract and other haemostatics was statistically significant. The 2nd null hypothesis, which states that different haemostatics did not affect antioxidant markers on days 7 and 28, was also rejected. Antioxidant markers showed a difference with responses given to different hemostatic agents on days 7 and 28.
Many experimental animals are used in the creation of pulpal injury in the literature. In the current study, rats were used because of the similarity of the oral microflora and the fact that pulp and periodontal tissues are similar to to those of humans [15]. An inflammatory response and inflammatory cells similar to that of human are seen in rat pulp tissue [15,16]. The expected pulpal healing process following the application of DPC materials on damaged pulp tissue depends on the response of the inflammatory process to the material. This process is related to the cytotoxicity of these materials used in capping. The resulting inflammatory response is also related to the induction of cytokine production of capping materials. Cytokines used in studies in order to understand the mechanisms of pulpal diseases in the literature involve the investigation levels of IL-1, IL-6 and TNF-α [17,18]. In this study, the in vivo method was preferred because observing the clinical success of the DPC procedure is difficult with in-vitro. The ELISA test is considered one of the most reliable methods to detect cytokine antigen [19].
SS, formed as a control group, is the most commonly used hemostatic agent in the clinic, although the success and effectiveness of pulpal treatments are limited [8]. It is observed that the inflammatory response is generally higher in groups that have hemostasis with SS.
NaOCl has a disadvantage due to its cytotoxicity to pulp cells, although it is recommended as an alternative hemostatic agent due to its bacterial activity [20]. However, it is emphasized that its use in concentrations between 2% and 5% is not cytotoxic to pulp cells [21]. For this reason, it was observed that
the 5% concentration of NaOCl inflammation was preferred and increased the release of cytokines in the acute period. Inflammatory reaction starts immediately in a healthy pulp tissue as a result of pulpal injury [22].
In the MHS group, which is completely obtained from plant extract, it was observed that while TNF-α levels on the 28th day were higher compared the 7th day ; on the contrary, IL-6 levels appear to decrease. It is thought that this may be due to the fact that IL-6 is more pronounced in acute inflammation or that the anti-inflammatory activities of the hemostatic agent used are different.
IL-1, IL-6 and TNF-α are cytokines that occur in the management of pulpal inflammation. TNF-α values, which are an important mediator in the creation of host response in the early period of injury, have lower averages in the groups that achieved haemostasis with MHS. Acute inflammation turns into chronic inflammation, which is characterized by the production of more diverse pro-inflammatory cytokines and antioxidant activity over time. In oral diseases, IL-6 is a cytokine involved in trauma, infection response and inflammation, and can be found at high levels in isolated from blood serum when irreversible pulpitis is seen compared to healthy pulp tissue [23]. The lower levels of IL-6 levels in groups with hemorrhage with MHS compared to the hemostatic used on day 7 is an important finding in terms of the fastest control of the anti-inflammatory response. However, the statistically insignificant increases observed in some groups suggest that this may be due to the different chemical properties of the capping materials. When the groups in this study are evaluated, there was a general decrease in IL-6 levels on day 28th. This indicates that pulpal inflammation slowed down in the following days. When these findings are examined in terms of the response of the organism on different days, a decrease of IL-6 levels while an increase in the value of IL-1β and TNF-α, which show synergistic effect, corresponds to the literature [4]. This finding shows that the cellular response given in the following period changed from an acute phase to a chronic phase.
It is possible that the capping materials modulate the inflammatory response. Cavalcanti et al. examined cytokine release in their study using a healthy human donor and found a high level of IL1-β release in the MTA group [23]. The probable reason for our results that do not match with the data of their study can be explained by the fact that the MTA Repair Hp material is different from the conventional MTA; it is treated with a hemostatic agent before the capping materials are applied, and the experimental procedure performed in the rat pulp is different. In vitro studies show that non-resin containing Biodentine and MTA material increase proinflammatory cytokine secretion compared to the resin-containing Theracal material [10,14,23]. In 2017, Jeanneau et al. ‘s study on immunofluorescence reported that Biodentine material reduced proinflammatory cytokine (IL-8) released from pulpal cells, but this release was high in the resin-containing Theracal material [14]. It is thought that the cytokine studied in the forementioned study is different from this study and the interaction of fibroblasts obtained from human pulp with the capping materials is not parallel with the data of this study. These data confirm that inflammation is suppressed on the 28th day.
Antioxidants have been used for many purposes (pulp capping, dentin hypersensitivity, remineralization, bond strength after bleaching) in the field of dentistry [5,11]. The response to pulpal damage is a rather complex process. Antioxidant enzymes are present in the healthy dental pulp [16,23]. In their study, Tulunoğlu et al. examined SOD levels in healthy and pilpulistic pulp tissues and found difference between these two tissues in terms of enzyme activity [24]. In the current study, it was observed that SOD levels generally increased, but in some groups, there were statistically insignificant decreases. This variability can be expressed as the difference in components of the capping materials used in combination with hemostatic agents. There are study findings showing that SOD enzyme activity increases with inflammation [19,23,24]. Supporting the literature, there was an increase in the amount of SOD on the 7th and 28th days. Decreased SOD activity in the MHS group can be explained as suppression of inflammation. The literature has reported effectiveness against free radicals formed after pulp capping antioxidants such as N-acetylcysteine Ankaferd hemostopper, propolis, and catalase applied as local antioxidants, have been reported to delay pulpal inflammation [6]. The marked decrease in IL-6 levels on the 28th day was that the acute infection response of IL-6 cytokine was stronger and decreased in the following period; it can also be explained by the effectiveness of the shot at antioxidant enzyme levels although it has no statistically any differences.
The clinical study in healthy humans, with reversible and irreversible pulpitis has revealed that catalase activity is an important defense against free radicals and is statistically significant [25]. It is not surprising that the results of this clinical study carried out by Esposito et al. do not correspond with the results of the current study. It is thought that differences in experimental models, materials, and treatment methods used are reflected in the results. Within the limitations of the present study, it was concluded that the course of inflammation was related to the hemostatic and the coating material used on the 7th day and 28th day. The results indicate that the changes in the rate of inflammatory cytokines on the 7th day and on the 28th day are important for the control of inflammation and that early inflammation is controlled by MHS in an early period, and can be used as an alternative to SS and NaOCl in clinical practice. However, more research is needed to observe the results that may occur with clinical use.
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.
Funding: This work was supported by the Scientific Research Project Fund of Cumhuriyet University under project number DIS-220 and Mecsina Hemostooper® company.
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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Ayşegül Göze Saygın, Murat Ünal, Pınar Demir, Nazlı Ercan. Antiinflammatory and antioxidant activities of different hemostatics and pulp capping materials applied on rat teeth. Ann Clin Anal Med 2021;12(Suppl 4): S379-384
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Gender differences in 24-hour pH meter results for gastroesophageal reflux
Aydin Ulaş 1, Durdu Mehmet Kos 2
1 Department of Critical Care Medicine, University of Health Sciences, Bursa City Hospital, Bursa, 2 Department of Internal Medicine, Ankara Beytepe Murat Erdi Eker Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20597 Received: 2021-03-17 Accepted: 2021-05-18 Published Online: 2021-06-08 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S385-389
Corresponding Author: Aydin Ulas, Department of Critical Care Medicine, University of Health Sciences, Bursa City Hospital, Dogankoy, 16110 Nilüfer, Bursa, Turkey. E-mail: draydinulas@yahoo.com P: +90 505 6800056 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8130-9901
Aim: The pH meter, which records the 24-hour esophageal acidity, is accepted as the best standard method for understanding the physiology of gastroesopha- geal reflux disease (GERD) and making the diagnosis. In this study, we investigated gender differences in our patients who were diagnosed with GERD using this method.
Material and Methods: Outpatient pH monitoring was applied to patients with reflux symptoms. The results were evaluated according to the De-Meester scoring.
Results: In our study, we found the rate of GERD as 79.4% (83.3% of women and 70.0% of men). It was found that the number of reflux episodes, total reflux time, and mean values of reflux episodes lasting longer than 5 minutes, which are among the De-Meester criteria indicating GERD were higher in women than in men. Among the GERD parameters, only the mean duration of the longest reflux episode was found to be higher in male cases.
Discussion: We found that the 24-hour pH monitoring method was a reliable method for detecting GERD without the need for any other radiological or endo- scopic intervention in patients with significant reflux symptoms, and the results differed according to gender.
Keywords: Gastroesophageal Reflux; pH Meter; Gender
Introduction
Gastroesophageal reflux is defined as the retrograde passage of stomach contents or sometimes duodenal contents into the esophagus [1]. Under standard conditions, although the intragastric pressure is positive and the intraesophageal pressure is negative, gastric contents do not pass into the esophagus, even in a person standing upside down. Although the mechanisms regulating this are not known exactly, it is accepted that lower esophageal sphincter tone is the leading factor that prevents GERD [1].
The data show that gastroesophageal reflux occurs through 3 main mechanisms [2]: First, reflux resulting from temporary lower esophageal sphincter relaxation that is not associated with swallowing (Spontaneous Reflux). Second, stress reflux was caused by the temporary increase in intra-abdominal pressure due to contraction of the abdominal muscles. Third, it is free reflux. Although spontaneous reflux can occur at normal or low lower esophageal sphincter pressures, stress or free reflux always occurs at low or no lower esophageal sphincter pressures. Reflux in normal persons is always due to temporary lower esophageal sphincter relaxation. This mechanism is also valid in 2/3 of the esophagitis. Therefore, the differentiation of gastroesophageal reflux in normals and esophagitis is quantitative rather than qualitative. However, the reflux mechanism prevailing in patients is heterogeneous. In some patients, reflux may be due to only temporary lower esophageal sphincter relaxation, while in others it may be due to stress or free reflux. In some other patients, it may participate equally in all three mechanisms.
In the last 20 years, there has been a consensus that factors such as the effectiveness of the antireflux mechanism, the corrosive potential of the refluxing material and the ability of the stomach to empty, as well as the resistance of the esophageal mucosa and the “clearing” ability of the esophagus play important roles in the development of gastroesophageal reflux disease (GERD) [3]. Since esophagitis may not develop in some cases with lower esophageal sphincter insufficiency and sufficient number of GERD episodes, a disorder that may occur in one or more of the mechanisms for the protection of the esophageal mucosa may cause esophagitis. Therefore, GERD is a multifactorial disease.
Various methods have been used in the diagnosis of GERD. These include the standard acid reflux test [4], acid perfusion test (Bernstein test), mano-metric examination of the lower esophageal sphincter, radiological examination of the esophagus, endoscopy, biopsy and isotope studies. With the development of sensitive devices that record 24-hour esophageal acidity, significant advances have been made in understanding esophageal physiology, and the investigation of the reflux event and the definition of physiological and pathological reflux margins have been achieved. A 24-hour intraesophageal pH meter is currently considered the best standard method for the evaluation of GERD [5].
The ambulatory pH technique was introduced in 1985 because of the limited benefit of esophagography and endoscopy in the diagnosis of GERD disease. This method plays an important role in understanding the pathophysiology of GERD. Although pH monitoring is not required in most patients with GERD, there are various situations that require this test. Although endoscopy is normal, pH monitoring is helpful in diagnosis in patients with atypical pharyngeal or pulmonary symptoms such as cough, wheezing, asthma and recurrent pneumonia. PH monitoring should be performed in all patients with esophageal spasms even in the absence of GERD symptoms. Ambulatory pH monitoring is the method of choice in patients who have typical GERD symptoms but do not respond to standard medical treatment, when the effectiveness of medical or surgical treatment needs to be followed, and in patients who are considered to undergo anti-reflux surgery and whose diagnosis needs to be confirmed [6].
Ambulatory pH monitoring is applied over a period of 18-24 hours. The use of H2 receptor blockers and prokinetic agents is discontinued 48 hours before the procedure. Proton pump inhibitors (PPIs) should be stopped 2 weeks in advance. The pH monitoring system consists of three parts as follows: The pH probe placed 5 cm proximal to the lower esophageal sphincter, whose level was previously determined by the manometric method, a reference electrode placed on the skin and a portable data logger that can be carried by wearing a belt or hanging on the shoulder, the pH distal to the esophagus is continuously recorded in a 24-hour period. During pH monitoring, patients are asked to continue their routine daily activities and diets, avoid activities that require great effort, avoid alcohol and smoking, start and end times of meals and sleep periods, and the time of occurrence of reflux symptoms on the device. In addition, the patient is advised to document the relationship between pain or reflux symptoms occurring during the follow- up with the type of food taken, body activity and changes in position [7].
At the end of the recording period, the pH area scale is created as a result of the analysis of the information recorded during the monitoring period. The symptoms recorded by the patient are documented on a radiograph. The parameters obtained from the data are calculated. The specificity and sensitivity of ambulatory pH monitoring, which is the gold standard method in detecting GERD patients, is around 90% and 85%, respectively. There are several factors that limit the use of the method; firstly, this technique is the longest running test among esophagus tests. As a result of discomfort and displacement of the probe with body movements, erroneous results may be obtained. Secondly, bending of the probe in the esophagus or embedding in the mucous fold leads to incorrect data collection. As for the third, acid reflux can vary from day to day. pH monitoring cannot distinguish between weak reflux and reflux reduction caused by the use of drugs that block acid release [3]. With this study, we aimed to show the presence of GERD by applying the 24-hour pH meter monitoring method in patients who presented to our outpatient clinic with reflux complaints, and to evaluate whether these results differ according to gender.
Material and Methods
Patients with reflux symptoms and suspected GERD were evaluated in the outpatient clinic of the Department of General Surgery of our hospital. Patients with previous endoscopically or radiologically detected gastric ulcer, duodenal ulcer history, gastric surgery, esophageal surgery history, Nissen fundoplication, pre-intervention H2 receptor blocker or PPI intake were excluded from the study.
Care was taken to keep the monitor on for 24 hours. During this test, patients were asked to continue their daily activities normally during the examination. However, due to the social status of the patients, they remained under observation in the hospital. The use of H2 receptor blockers and prokinetic agents was discontinued 48 hours before the procedure. PPIs were discontinued 2 weeks ago. Flexible probes with a length of 180 cm, a width of 2.1 mm and a distance of 15 cm between two probes were used with a medical measurement system brand monitor (version 7.3). First, the probe was inserted through the nasopharynx to patients who were not hungry. The sensor at the distal end of the probe with two ends was placed in the stomach, and the sensor at the proximal end was placed distal to the esophagus. The location of the catheter (medical measurement system catheter) was confirmed by monitoring the pH of the distal and proximal ends on the monitor. The catheter was fixed to the nasal skin. The patients were called again 24 hours later, the recording was ended, and the catheters were removed. The results were documented using the Medical Measurement System program. The results obtained during the 24-hour ambulatory esophageal pH monitoring were evaluated according to the DeMeester Scoring [8]. Reflux time lasting more than 4% of the total duration, reflux of more than 50, the number of reflux lasting longer than 5 minutes, and reflux lasting longer than 10 minutes were considered significant. Ethics committee approval and practice approval was obtained from the ethics committee of our university to conduct our study (Decision no: 2005-26 / 06). The study was explained in detail to the patients participating in the study, and their verbal and written informed consent was obtained.
Statistical analysis
Statistical analyzes were performed using SPSS Statistics version 24.0 (IBM Corp., Chicago). Numerical variables were given as median (range) and mean ± SD. Categorical variables were expressed as numbers and percentages. For the correlation between parameters, the Chi-square test or Fisher’s tests was applied by selecting the appropriate one. A value of P <0.05 was considered statistically significant.
Results
Thirty-four evaluated patients were included in the study. Twenty-four (70.6%) of the patients were female and 10 (29.4%) were male. The mean age of all patients was 44.2 (range: 19-73) years. While the mean age of female patients was 40.8 (19-72) years, it was 52.4 (31-74) years for men. According to 24-hour pH measurements; We found the rate of GERD as 79.4% (83.3% of women and 70.0% of men). While the number of reflux episodes and the number of reflux lasting longer than 5 minutes were significantly higher in women, the longest reflux episodes were found to be significantly higher in men (Table 1).
Considering the DeMeester scoring criteria, since the total reflux time in 24 hours was more than 4%, the presence of reflux was detected in 20 (83.3%) women and 7 (70.0%) men. The rate of GERD in the total reflux time in women was statistically significantly higher than in men (p = 0.04). According to the number of reflux lasting more than 5 minutes, the presence of reflux was detected in 20 (83.3%) of women and 5 (50.0%) of men. According to the number of reflux lasting longer than 5 minutes in women, the rate of GERD was found to be statistically significantly higher than in men (p = 0.01). According to whether reflux lasts longer than 10 minutes, GERD was detected in 16 (66.6%) women and 6 (60.0%) men. When the distribution of reflux lasting longer than 10 minutes by gender was compared, no significant difference was found between the groups (p = 0.38). More than 50 refluxes were detected in 15 (62.5%) women and 4 (40.0%) men, and the difference was statistically significant (p = 0.03). The age, gender and 24-hour pH monitoring results of the patients are shown in Table 2.
Discussion
GERD is the retrograde passage of stomach contents or sometimes duodenal contents into the esophagus. Reflux is a physiological situation, but it is named “Reflux disease” when it causes esophageal tissue damage or symptoms [1]. Various methods have been used in the diagnosis of GERD. Methods used to contribute to the diagnosis have not been able to demonstrate the condition of GERD objectively. For example, although the acid perfusion test is 100% positive in reflux cases [9], it only shows the acid sensitivity of the distal esophagus and does not determine endogenous reflux. Although the esophageal manometer is a good method for detecting both lower esophageal sphincter insufficiency and esophageal motility disorders, it is not sensitive in detecting reflux. Likewise, although endoscopic examination is valuable in the diagnosis of esophagitis and its complications, radiological examination is valuable in the diagnosis of hiatus hernia, they are not sensitive in detecting GERD [9]. However, it is certain that a method that will reveal GERD status objectively will make great contributions to the evaluation of GERD.
Over the last 20 years, with the development of sensitive devices that measure intraesophageal pH for 24 hours, it has been possible to detect intraesophageal pH changes in accordance with physiological conditions as much as possible. Thus, the limits of normal and abnormal reflux were determined, the relationship of symptoms with reflux was revealed, thus new dimensions were reached in the diagnosis of GERD.
There have been many studies investigating the reliability of this method and comparing it with other methods. De Meester and Johnson, who contributed greatly to the development of this direction, reported the sensitivity of the test as 90.3% and the specificity as 90% (5,8,10). In their study, the researchers endoscopically evaluated 199 patients with typical reflux symptoms, and found that 96 of the cases were normal and 103 of them have esophagitis. With a 24-hour intra-oesophageal pH meter performed in both groups, GERD was detected in 55% of cases evaluated as endoscopically normal and in 90% of the cases evaluated as esophagitis. At the end of this study, the researchers suggested that endoscopy is not a sensitive method in recognizing GERD, and in cases with typical reflux symptoms, even if the endoscopic examination is evaluated as normal, a 24-hour intraesophageal pH measurement should be performed [11].
Pujol et al., investigated 15 controls and 47 patients with typical reflux symptoms. They determined the sensitivity of the 24-hour intraesophageal pH meter test as 94% and the specificity as 100% [12]. The investigators also found GERD on a 24-hour intraesophageal pH meter test, as in the DeMees sweat and Johnson’s studies, in more than half of the patients with reflux symptoms that were endoscopically normal.
Fuchs et al., found that the results of 24-hour intraesophageal pH meter had higher sensitivity and specificity compared to standard acid reflux test, manometry and endoscopy results in their study in 45 cases with reflux symptoms and 45 cases of controls [13]. DeVault and Castell reported that the most sensitive and specific test in the diagnosis of GERD is the 24- hour intraesophageal pH meter [14]. In the light of these data, it has been shown that the 24-hour intraesophageal pH meter is the most sensitive and specific method in the diagnosis of GERD, which is the most objective way of presenting GERD.
In our study, we investigated the diagnosis of GERD by 24-hour pH monitoring, which is the gold standard in the diagnosis of GERD. We found the rate of GERD as 79.4% in the patients we evaluated (83.3% of women and 70.0% of men). The high rate of GERD in our study compared to the rates stated in the literature can be explained by the presence of severe GERD symptoms in the patients included in the study. It was observed that the majority of the patients presenting with dyspeptic complaints were women aged 35-45. However, no etiological reason could be found to explain its prevalence in female patients. It was found that the mean values of the number of reflux episodes, total reflux time, and the number of reflux episodes lasting longer than 5 minutes, which are among the DeMeester criteria indicating GERD in female cases, were higher than that of men. Among GERD parameters, only the mean duration of the longest reflux episode was found to be higher in male cases. We can think that the high number of female cases in our study may affect these results. The number of reflux lasting longer than 5 minutes was higher in women. However, reflux lasting longer than 10 minutes did not differ between men and women. In the literature, epidemiological studies on GERD have shown that there is a gender difference depending on geographical location. There was no difference in North America and Europe, while women in South America and Asia had more symptoms [15-18]. However, in a study on the prevalence of GERD, it was reported that male gender is an independent risk factor, especially for erosive reflux disease [19]. Non-erosive GERD is frequently observed in women. It has been suggested that the sex effect may be due to differences in parietal cell mass between men and women, and even female sex hormones may play a protective role.
The small number of patients in our study is a serious limitation. However, considering that 24-hour pH monitoring provides reliable results, this technique is not easy to apply and takes a long time, and we can show this as a reason for the number of patients. In addition, the numbers of men and women were not equal in our study. This is seen as another limitation. We explain this by the fact that the majority of our patients who applied to the polyclinic with reflux complaints are women.
In this study, we thought that the 24-hour pH monitoring method is a reliable method for detecting GERD without the need for any other radiological or endoscopic intervention in patients with significant reflux symptoms. Despite all these limitations, our study is one of the few studies comparing male and female data in the literature. If all the data in the study are discussed with a larger number of randomized groups, it will help explain these gender differences.
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.
Funding: None
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.
References
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3. Yorulmaz İ, Özlügedik S, Küçük TB. Gastroesophageal reflux disease: symptoms versus pH monitoring results. Otolaryngol Head Neck Surg. 2003; 129:582-6.
4. Schowengerd CG. Standard acid reflux testing revisited. Dig Dis Sci. 2001;46(3):603-5.
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8. Stein HJ, DeMeester TR. Indications, technique, and clinical use of ambulatory 24-hour esophageal motility monitoring in a surgical practice. Ann Surg. 1993; 217(2):128–37.
9. Emerenziani S, Sifrim D. New developments in detection of gastroesophageal reflux. Review. Curr Opin Gastroenterol. 2005; 21(4):450-3.
10. Johnson LF, DeMeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974; 62(4):325-32.
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Aydin Ulaş, Durdu Mehmet Kos. Gender differences in 24-hour pH meter results for gastroesophageal reflux. Ann Clin Anal Med 2021;12(Suppl 4): S385-389
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Validation of the Turkish version of the obsession with Covid-19 scale (OCS)
Mehmet Emin Kurt 1, Cuma Çakmak 1, İsmail Biçer 2
1 Department of Healthcare Management, Dicle University, Diyarbakır, 2 Healthcare Management Program, Çivril Atasay Kamer Vocational School, Pamukkale University, Denizli, Turkey
DOI: 10.4328/ACAM.20598 Received: 2021-03-17 Accepted: 2021-06-02 Published Online: 2021-06-16 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S390-394
Corresponding Author: İsmail Biçer, Healthcare Management Program, Çivril Atasay Kamer Vocational School, Pamukkale University, Kızılcasöğüt, Atatürk Cd., 20680, Çivril, Denizli, Turkey. E-mail: ismailbiceer@gmail.com P: +90 507 416 51 75 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1878-0546
Aim: The validity and reliability of the obsession with the COVID-19 scale developed by Lee (2020) were tested in the USA, but there is no research on this matter in Turkey. Within this scope, the aim of the study is to determine the validity and reliability of the scale in Turkish.
Material and Methods: The Obsession with COVID-19 Scale (OCS) has been tested in Turkish individuals. Descriptive statistical analysis, t-tests and one-way analysis of variance (ANOVA) were used. Exploratory factor analysis (EFA) was performed to validate the OCS. Maximum likelihood method and confirmatory factor analysis were applied to the model obtained from EFA.
Results: The Turkish version of OCS was found to have consistent psychometric properties and construct validity.
Discussion: Developing valid screening tools across different cultures is vital for health practitioners and scientists during global infectious disease outbreaks.
Keywords: Coronavirus; Mental health; Obsession With COVID-19 Scale
Introduction
Humanity is in the middle of a pandemic causing instability in all areas of life. The World Health Organization announced the pandemic, which first emerged in Wuhan, China, in the final days of 2019. In the 13 months, since it was first announced, the pandemic has proven to have the deadliest power of the 21st century. The first case was announced in Turkey on March 11, 2020, and the total number of infected people was 4.820.591, with the number of the deceased reported to be 40.131 (available at: https://covid19.saglik.gov.tr/; 30.04.2021). In addition to increasing mortality rates worldwide, the unpredictable nature of the virus creates stressful environments that increase the risks of psychological disorders [1]. Countries worldwide apply full or partial lockdowns with practices such as social isolation, mask-wearing, social distancing and quarantine throughout the country to reduce the spread of the virus. Quarantine practices designed to decrease the spread of infectious diseases can cause feelings of loneliness, boredom, physical inactivity, and insecurity about food and finance in many individuals [2]. In other words, it is indicated that in the event of an infectious disease epidemic, a large proportion of people tend to experience clinically significant levels of fear and anxiety [3]. The high infection and mortality rates associated with COVID-19 have been reported to cause widespread fear and anxiety [4].
As the number of deaths and problems due to COVID-19 increases, the number of people experiencing long-term fear and anxiety also increases. While anxiety caused by COVID-19 was observed in 69.8% of Americans, there was a 37.7% increase in the number of prescribed anxiety medications, and a 75-fold increase was determined in the number of calls to the suicide helpline. Also, similar numbers related to the worry-fear- anxiety cases due to COVID- 19 have been reported outside the USA [5].
In the light of the data mentioned above, psychological conditions originating from COVID-19 have increased, one of which is the obsession with COVID-19. Obsession is characterized by unwanted and unpleasant thoughts, images, or impulses. Obsessive-compulsive individuals have fear of cleaning, contamination, and getting a disease. Thus, they now become the main theme of news and social media [6].
The determination of COVID-19 obsession level is vital to health care professionals. As a result, measurement tools are needed that will strengthen clinicians’ and researchers’ hands. Therefore, studies whose validity and reliability are tested in various cultures are significant. To close this gap in the literature, this study aims to verify the validity and reliability of the Turkish translation of the Obsession with COVID-19 Scale (OCS) using a large sample.
Material and Methods
Participants
The population of this research consists of people who are above 18 years old and live in Turkey. The questionnaire was distributed via google form and WhatsApp and expanded via snowball sampling. Data were collected for ten days. A total of 419 people participated in the study.
The Aim and Importance of the Study
Although there are many studies on the global pandemic, the number of studies conducted on obsessive-compulsive disorder caused by COVID-19 is limited. This study aimed to provide a valid and reliable scale to the national literature by conducting the Turkish validity and reliability study of the OCS.
Data Collection Tools
Obsession with the COVID-19 scale developed by Lee (2020) was used in the study [7]. The OCS is a 5-point Likert-type scale, consisting of 4 questions and one dimension. The scoring of the scale was as follows: 0=never;1=rare (less than a day or two); 2=a few days (3-5 days); 3=more than 7 days; and 4=almost every day in the last two weeks, where a total OCS score of ≥7 shows a relationship between coronavirus and dysfunctional obsession. High scores of a certain item or a high total scale score (≥7) show that the individual might have symptoms that require further evaluation and/or treatment. The original author stated that “no official permission is required for reproduction and use by others, beyond the proper citation of the COVID-19 and Obsession Scale in order to encourage its use in clinical evaluations and research”, the author of the current study felt free to use the scale in this context. The study was approved by the Ministry of Health Scientific Research Platform on January 16, 2021. Finally, ethics committee permission was taken from the Social Sciences and Humanities, Ethics Committee of Dicle University with the number 66756. The data used in the study were collected via an online questionnaire between 17-22 January.
Results
Descriptive Findings
Two hundred twenty (52.5%) participants were female and 199 (47.5%) were male. The mean age was 29.9±8.82 years (range 18-69). Marital status of the participants was as follows: 37.5% (157) were married, 59.2% (248) were single, and 3.3% (14) were divorced. The average total household income was 72730±4872.7 Turkish Lira. The total household income ranged between 2.000-30.000 TL. Education levels were as follows: 21% (88) high school, 24.8% (104) vocational school or associate’s degree, 31% (130) undergraduate, and 23.2% (97) graduate. Among the survey participants, 50.1% (210) lived in the Marmara Region, 12.2% (51) in the Central Anatolia Region, and 37.7% (158) in other regions. Among the participants, 80.9% did not contract coronavirus disease. In addition, 19.1% of the participants tested positive for COVID-19. Within the scope of the study, only whether the test result was positive or negative was examined. It was not checked whether the patients with positive tests were treated in the hospital or at home. However, 27.4% have lost a relative due to the coronavirus.
Findings Regarding Validity
Language Validity
The OCS English original was translated into Turkish by three different academics independently. Later, in line with the suggestions of an expert faculty member, the expressions that best explained each question in the questionnaire were adopted, and a single Turkish version was created, ensuring that translators paid attention to cultural, psychological, and grammar differences in both languages. [8]. The Turkish draft was then translated back into English by a sworn translator to be compared with its English original. The expressions were found to be quite consistent. Finally, the Turkish version of the questionnaire was revised so that the Turkish expressions would match better with the original.
Structural Validity
To identify the structural validity of the OCS, first explanatory factor analysis and then confirmatory factor analysis were performed. Explanatory factor analysis is a method that aims to identify fewer factors using the relationships of variables in a data matrix [9]. SPSS 23 statistics program was used to perform explanatory factor analysis. In order to apply explanatory factor analysis, data must be collected at least five times the number of items in the scale [10]. As the number of items in OCS was 4, the total number of participants was (419) adequate. Within the study’s scope, the KMO value found within the framework of EFA results assumptions was determined as 0.749 and is above the recommended value (0.60).[11]. According to the results of the factor analysis using principal components and Varimax factor rotation methods, a total of 4 questions in the scale were collected under one factor. One component explained 56.6% of the total variance. The OCS displayed a single-factor structure similar to the study by Lee (2020), who developed the scale. The factor loadings of the items of the scale, which consisted of a single factor and 4 items, varied between 0.671 and 0.834 (Table 1). Generally, load values of 0.60 and above are considered high [12].
The structural validity of the OCS was also tested with confirmatory factor analysis, which is a factor analysis used to test the compatibility of the factors determined by explanatory factor analysis with the factor structures determined by a hypothesis [9]. SPSS Amos 26 program was used for the confirmatory factor analysis. One factor and 4 items were included in the confirmatory factor analysis. The goodness of fit of the model obtained in the confirmatory factor analysis showed a significant x2 value (x2/df = .022; p <0.001) (Table 2). Other goodness indexes were as follows: RMSEA=0.000; GFI=1.000; AGFI=1.000; CFI=1.000; NFI= 1.000; TLI=1.016, and IFI=1.005.
All fit indexes were had acceptable values, showing that the single-factor model fit well. The single-factor structure was also supported by the confirmatory factor analysis. Path diagram of the confirmatory factor analysis and factor loads for the model are shown in Figure 1.
Findings Regarding Reliability
Cronbach alpha coefficient was calculated as 0.740. Since the alpha value should be at least 0.70 in social sciences, [13] our finding of 0.74 is within the range of reliability.
T-Tests, ANOVAs, and Correlations
In the independent samples t-test, there was a significant difference between females (M = 1.02; SD = 0.87) and males (M = 0.73; SD = 0.70) in the OCS scores (t = 3.638; p <0.05). There was also a statistically significant difference (t = 3.371; p <0.05) between participants diagnosed with COVID-19 (M = 1.19; SD = 1.02) and those without COVID-19 (M = 0.81; SD = 0.73). There was no significant difference between those who lost an acquaintance due to COVID-19 and those who did not in OCS scores (t = 0.699; p> 0.05). In Tukey’s HSD test, no significant difference was found in OCS scores in terms of age (F = 0.887; p> 0.05). Similarly, OCS scores did not differ significantly with regard to educational status, total household income and marital status. However, OCS scores differed significantly with respect to the region of residence of the participants (F = 3.029; p <0.05). Moreover, there was a significant difference between the participants residing in the Marmara Region and the Eastern Anatolia Region (p = 0.017). In correlation analysis, OCS scores were not correlated with gender (r = -.175, p <0.01), education status (r = .108, p <0.05) and contracting COVID-19 (r = -.158, p <0.05).
Discussion
Anxiety, fear, and obsession caused by COVID-19 show an upward trend worldwide. For this reason, the effect of these conditions on mental health should be studied. In addition, it is important to investigate the effects of these conditions on the burden of mental illnesses. Thus, the validity and reliability of the Obsession with the COVID-19 Scale should be tested across cultures. The results of this study are considerably similar to the findings obtained in other studies. For example, our findings of validity and reliability are consistent with those reported by Ashraf et al. in the Urdu language (2020) [14], and by Choi et al. (2020) in the Korean language [15]. In the current study, obsession levels were high in 14.3% (n=60, ≥7) of the participants. Srivastava et al. (2020) [16] found that %13.47) of participants (n=270) had high levels of obsession with COVID-19. While the reliability coefficient of the items in the scale was 0.84-0.85 according to the results obtained by Lee (2020), it was calculated as 0.74 in this study.
Wang et al. (2020) found that people with high levels of psychological distress had more dreams about COVID-19 [17]. Moreover, high levels of obsession and anxiety about COVID-19 have been reported to have negative impacts on psychological dysfunction [18]. Some studies have also found increased obsessive-compulsive symptoms after COVID-19 [19-20]. Another study showed higher prevalence of depression, obsessive-compulsive disorder (OCD), panic, and general anxiety disorder during the COVID-19 pandemic than before the COVID-19 pandemic [21]. Similarly, Tanir et al. (2020) found that the severity of OCS symptoms increased in more than half of the participants during the pandemic [22].
In the current study, the Obsession with the COVID-19 Scale was found to reliably describe dysfunctional obsession associated with the pandemic in the Turkish adult population. This study has some limitations. Participants were reached through online questionnaires, which was the only method due to the pandemic. Another limitation is the number of participants, it could have been larger. Nevertheless, the OCS was found to be a valid and reliable scale.
In conclusion, the OCS-Turkish showed good psychometric properties and construct validity. Developing such valid screening tools across different cultures is vital for health practitioners and scholars during similar global infectious disease outbreaks. It also helps in clinical studies and can be used as a reference by researchers in future studies.
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.
Funding: None
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.
References
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Mehmet Emin Kurt, Cuma Çakmak, İsmail Biçer. Validation of the Turkish version of the obsession with Covid-19 scale (OCS). Ann Clin Anal Med 2021;12(Suppl 4): S390-394
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Evaluation of early and late percutaneous tracheostomy in geriatric patients in the intensive care unit
Eralp Çevikkalp
Department of Anaesthesiology and Reanimation, Private Medicabil Hospital, Bursa, Turkey
DOI: 10.4328/ACAM.20602 Received: 2021-03-18 Accepted: 2021-06-09 Published Online: 2021-06-19 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S395-398
Corresponding Author: Eralp Çevikkalp, Department of Anaesthesiology and Reanimation, Private Medicabil Hospital, Bursa, Fethiye mahallesi Küre sokak no:1 Nilüfer\Bursa, Turkey. E-mail: eralpcevikkalp@hotmail.com P: +90 5054554875 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6027-624X
Aim: Percutaneous tracheostomy is a method frequently used in intensive care because of ease of implementation, can be open at the beside and has a low complication rate. Early tracheostomy was defined in 3-10 days of mechanical ventilation, late tracheostomy was defined at any time except the early period. Mortality risk rises with prolonged ventilation in the geriatric population. The first aim of this study is to search for the duration of hospital stay for the geri- atric patients who underwent early and late percutaneous tracheostomy in the intensive care unit and its effect on 30-day mortality; and the second aim is to evaluate the complications of early and late tracheostomy.
Material and Methods: Forty-six patients over 65 years of age who underwent percutaneous tracheostomy in the intensive care unit divided into two groups: within 3-10 days were grouped as “early tracheostomy”, and after 10 days as “late tracheostomy”. APACHE II scores, demographical data, indications, length of stay, discharge, 30-day mortality and complications during the procedure were recorded.
Results: In late tracheostomies, the incidence of minor bleeding was less than in early tracheostomies, but the incidence of major complications such as subcutaneous emphysema, pneumothorax, and hypotension was higher. Hospital stay and intensive care durations were found to be shorter in patients who underwent early tracheostomy.
Discussion: An early tracheostomy reduces the duration of hospital stay and has no effect on mortality and complications. Major complications after early tracheostomies were less common than in the late period. However, we think that this result should be investigated using randomized controlled studies with higher patient numbers.
Keywords: Percutaneous Tracheostomy; Early; Late; Length of Stay; Complication
Introduction
Percutaneous tracheostomy is a method frequently used in intensive care because of ease of implementation, can be open at the beside and has a low complication rate [1,2]. The tracheostomy procedure is performed for prolonged intubation, failure in extubating attempts, the need for a long- term mechanical ventilator, protection of the respiratory tract and prevention of aspiration in patients with severe brain damage, facial and neck traumas, and to by-pass upper airway obstruction [3].
Geriatric patients who are followed up in the intensive care have prolonged adherence to a mechanical ventilator, and an unsuccessful weaning process occurs [4]. Mortality risk rises with prolonged ventilation in the geriatric population [5]. Despite the advantages of tracheostomy in prolonged mechanical ventilation, optimal timing for tracheostomy remains controversial. In the articles published in the last years, while early tracheostomy was defined in 3-10 days of mechanical ventilation, late tracheostomy was defined at any time except the early period [6]. However, tracheostomy opening time does not depend on the physician’s choice only, and the time for family decision and hesitation also affects the time for opening the tracheostomy. Airway safety, improved patient comfort, easier and more efficient secretion clearance are among the advantages of ventilation with a tracheostomy tube [7]. However, complications such as minor/major bleeding, wound infection, subcutaneous emphysema, pneumothorax/ mediastinum, tracheal stenosis, tracheoesophageal fistula occurrence, tracheomalacia, cardiac arrest can be seen also [8]. The first aim of this study is to search for the duration of hospital stay for the geriatric patients who underwent early and late percutaneous tracheostomy in the intensive care unit and its effect on 30-day mortality; and the second aim is to evaluate the complications of early and late tracheostomy.
Material and Methods
The patients over 65 years age who underwent percutaneous tracheostomy between January 2015 and April 2020 were included in the study. After the ethical committee approval obtained from Uludag University Ethical Committee (no: 2021- 5/2, date: 03.03.2021), patients over 65 years of age who underwent percutaneous tracheostomy in the intensive care unit of our hospital between January 2015 and April 2020 were evaluated retrospectively. The patients were divided into two groups according to the time from intubation to the opening of tracheostomy. Patients who underwent tracheostomy within 3-10 days were grouped as “early tracheostomy”, and patients who underwent tracheostomy after 10 days as “late tracheostomy”. Percutaneous dilatational tracheostomy has not been performed in patients without the permission of themselves and/or their families, and patients who have bleeding diathesis presence (thrombocyte count <60,000 mm3/L, international normalized ratio > 1.5), requiring high oxygenation support (positive expiratory pressure > 10 mmHg; fiO2>%80) and presence of cervical trauma.
The patients were given fentanyl 1–2 mg kg−1, midazolam 0.2 mg kg−1 and rocuronium 0.5–1 mg kg−1 for sedation and muscle relaxation. Thereafter, for the position, the armpit support was placed with the head in extension while the patient was in the supine position. After cleaning the mouth with antiseptic solutions, the endotracheal tube balloon was lowered and retracted to the vocal cord level and inflated. Percutaneous tracheostomy was opened via the Griggs technique. After the neck area was sterilized by povidone iodine in the surgical area, a local anesthetic was applied to the incision area. Skin and subcutaneous incisions were made over 2-3 tracheal rings, after the neck area was sterilized by povidone iodine in the surgical area, a local anesthetic was applied to the incision area. A guidewire was inserted into the lumen of the trachea through the needle. The area was enlarged with the help of an 8F dilatator passed over the guidewire. After removing the dilatator, expanding the skin, subcutaneous and trachea with the help of forceps and guiding the guide wire to the tracheal lumen, the appropriate tracheostomy cannula was inserted, the cuff was inflated. After the endotracheal tube was removed, ventilation of both lungs was controlled by listening. It was evaluated with chest radiography after the procedure. Close observation and monitoring were performed for 24 hours for early complications.
Patients’ Acute Physiology, Assessment and Chronic Health Evaluation II (APACHE II) scores, age, gender, additional diseases, intensive care hospitalization indications, time of opening of tracheostomy, intensive care stay, intensive care discharge, 30-day mortality, and complications during the procedure (bleeding, pneumothorax, subcutaneous emphysema, hypotension, hypoxia, mortality) were recorded. The bleeding was classified as minor bleeding (bleeding that stops for a short time with the sponge wrapped around the stoma), moderate bleeding (continuation of bleeding from the trachea with stoma/aspiration despite compression) and abundant bleeding (bleeding that was taken to the operating room and intervened).
Statistical analysis
Data were analyzed using Statistical Package for the Social Sciences software for Windows (version 22.0; SPSS Inc., Chicago, IL, USA). Whether continuous variables were normally distributed was determined using the Kolmogorov-Smirnov test. The Levene test was used to evaluate the variance homogeneity. Continuous data are presented as mean ± standard deviation (sd). Median (range) was used for skewed distributions. Categorical data were previously sent as the number of cases (%).
Results
Forty-six patients were included in the study. There were 20 patients in the early tracheostomy group and 26 patients in the late tracheostomy group. There was no statistically significant difference between the groups in terms of age, comorbidity, hospitalization indications, APACHE II scores, discharge, and 30- day mortality (Tables 1 and 2). The time to open tracheostomy in the early tracheostomy group was 6.2 ± 2.6 days, and in the late tracheostomy group it was 21.42 ± 10.02 days. The hospitalization duration of patients who underwent early tracheostomy was 20.35 ± 5.14 days, and for patients who underwent late tracheostomy was 43.11 ± 15.18 days (Table 2). The hospital stay after tracheostomy was shorter in early tracheostomies than in late tracheostomies (p<0.05, Table 2). Minor bleeding was observed in 10% (n = 5) of the patients, subcutaneous emphysema in 2% (n = 1), pneumothorax in 2% (n = 1), hypotension in 2% (n = 1). In early tracheostomies, minor bleeding was observed in 4 patients, and in addition to minor bleeding in late tracheostomies, subcutaneous emphysema, pneumothorax and hypotension were observed.
Discussion
In late tracheostomies, the incidence of minor bleeding was less than in early tracheostomies, but the incidence of major complications such as subcutaneous emphysema, pneumothorax, and hypotension was higher. Hospital stay and intensive care durations were found to be shorter in patients who underwent early tracheostomy.
In meta-analyzes comparing early tracheostomy and late tracheostomies in intensive care, it has been shown that the duration of hospital stay and in-hospital mortality are less with early tracheostomies [9, 10]. Jeon et al.’s study in the neurological intensive care unit showed that early tracheostomies shorten the length of hospital stay and do not affect mortality in the intensive care unit [11]. Chen et al.’s study on patients followed up for hemorrhagic stroke showed that early tracheostomies reduce the length of hospital stay and have no effect on mortality in intensive care [12]. In the monocenter study by Affronti et al. comparing early and late tracheostomies after cardiac surgery, showed that early tracheostomy decreases the duration of hospital stay and does not affect mortality in intensive care [13]. In the study by Schneider et al. on elderly patients hospitalized in the intensive care unit, it was shown that the duration of intensive care stay was short in patients who underwent early tracheostomy [14]. In our study, it was also observed that the duration of hospital stay was less in early tracheostomies, but there was no difference in terms of mortality in the intensive care unit.
In addition to studies showing that early tracheostomy is short in intensive care, there are also studies showing that it does not affect the duration of hospital stay [15,16]. In the randomized controlled study by Bösel et al., it was shown that early tracheostomy did not reduce the length of stay in the hospital [17]. Day 3 was taken as the limit for early tracheostomy in this study. In the late tracheostomy group, the mean time to open tracheostomy is 10.5 days. In our study, the time to open tracheostomy in the late tracheostomy group was found to be 21.42 ± 10.02 days. We think that the reason for the discrepancy with the literature cited is the difference between the average tracheostomy opening days. Berguist et al.’s study showed that early tracheostomy does not reduce the duration of hospital stay [18]. The patients included in the study were over the age of 15, and the average age was below 65. We think this is the reason why it differs from our study.
In addition, many studies do not specify whether the total length of hospital stay or only the duration after tracheotomy is calculated. In the study by Young et al., it was shown that there was no correlation between the intubation time before tracheostomy and the duration of hospital stay. In the study by Türkovic et al., it was shown that there was no difference between the duration of hospital stay after tracheostomy between early and late tracheostomy [19,20]. In our study, the duration of hospital stay was found to be shorter in patients who underwent early tracheostomy. We think that this difference from the literature is due to the fact that there are patients who underwent surgical operations in our patient population. Compared with surgical tracheostomy, less complications have been reported in percutaneous tracheostomy [6]. In patients who underwent percutaneous tracheostomy, minor bleeding was 1.4%, 5.5%, 28%, and major bleeding was 4.2%, 2.7% [7, 21,22]. In our study, the rate of minor bleeding was measured as 10%, and it was seen in accordance with the given literature. Post-procedure incidence of hypotension was reported as 3.8%, pneumothorax 0.5% and subcutaneous emphysema 1.1% [1, 2, 21, 22]. In our study, the incidence of hypotension, pneumothorax, and subcutaneous emphysema was found to be 2% and in accordance with the literature. Complications of early and late tracheostomy application have not been compared much in the literature. In the study by Ülkümen et al., comparing post-procedural complications of early and late tracheostomies, no difference was observed [1]. In the same study, it was stated that minor bleeding was more common with early tracheostomies, but it was not statistically significant. In our study, there was no statistically significant difference between early and late tracheostomies, but in the early period, minor bleeding was seen more often, and the incidence of pneumothorax hypotension and subcutaneous emphysema in the late period was found to be higher than in the early period. As a result, we think that early tracheostomy reduces the duration of hospital stay and has no effect on mortality and complications. Major complications after early tracheostomies were less common than in the late period. However, we think that this result should be investigated in randomized controlled studies with higher patient numbers.
The most important limitation of our study is that it had a retrospective design and that late complications after tracheostomy were not examined.
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.
Funding: None
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.
References
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13. Affronti A, Casali F, Eusebi P, Todisco C, Volpi F, Beato V, et al. Early Versus Late Tracheostomy in Cardiac Surgical Patients: A 12-Year Single Center Experience. J Cardiothorac Vasc Anesth. 2019;33(1):82-90. DOI: 10.1053/j.jvca.2018.05.041.
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Eralp Çevikkalp. Evaluation of early and late percutaneous tracheostomy in geriatric patients in the intensive care unit. Ann Clin Anal Med 2021;12(Suppl 4): S395-398
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Knowledge and attitude towards contact lenses among female students of Northern Border University, Saudi Arabia
Mujeeb Ur Rehman Parrey 1, Farhan Khashim Alswailmi 2, Maram Khalf A Alenzi 3, Mariam ayiad J Alshammari 3, Deema Faleh Alanazi 3, Reema Faleh Alanazi 3
1 Department of Surgery, Faculty of Medicine; Northern Border University, Arar, 2 Department of Pharmacy Practice, College of Pharmacy, University of Hafr Al-Batin; Hafar Al Batin, 3 College of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
DOI: 10.4328/ACAM.20606 Received: 2021-03-19 Accepted: 2021-05-18 Published Online: 2021-06-06 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S399-403
Corresponding Author: Mujeeb Ur Rehman Parrey, Department of Surgery, Faculty of Medicine, 1321, Northern Border University, Arar, KSA. E-mail: drparrey@gmail.com P: 00966504127126 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2731-5438
Aim: In this study, we aimed to assess attitudes and knowledge of contact lenses (CL) among female students from Northern Border University (NBU) of Saudi Arabia.
Material and Methods: This questionnaire-based survey was conducted on 392 undergraduate female students from five colleges of NBU. Their ages ranged from 18 to 27 years, with a mean age of 23.7±5.3 years. Participants who did not provide a completely filled questionnaire were excluded from this study.
Results: In our study, a positive attitude towards CL was found in 72.7% of participants, and sufficient knowledge about CL was shown by 64% of participants. The faculties, personal history of refractive error (RE), or personal history of CL wearing had significantly influenced both the knowledge and the attitude of the participants towards CL. Only 254 (64.7%) of all participants reported that they had tried CL at least once during their life. Among the participants with a history of CL wearing, 72.4% had used CL for both RE and cosmetic purposes, and 71.2% revealed that they were satisfied with their CL use. Comfort was cited by 64.5% of CL wearers to be the main reason for their CL choice. Soft and monthly disposable CLs were the most popular among our participants. The most common CL- related complication in our study was red eyes in 39% of cases. To overcome the complications caused by CL, 62.6% of CL wearers reported that they discontinued using CL without further treatment, 28% had opted for self-medication after removal of CL, while only 16.9% reported that they preferred to consult an ophthalmologist for any CL- related complication. CL sellers were the main source (32.9% of participants) with a limited role of ophthalmologists and optometrists (13.5% of participants) in the source of their CL- related knowledge.
Discussion: Despite the positive attitude and overall good knowledge demonstrated by the majority of the NBU female undergraduates, knowledge related to particular aspects like cleaning of CL and the use of CL in active inflammation/infection was found to be unsatisfactory. More ocular health education sessions with the active role of ophthalmologists and optometrists need to be focused on to increase awareness in these areas.
Keywords: Contact Lens; Complication; Knowledge; Northern Border University; Saudi Arabia
Introduction
Contact lenses (CL) are optical devices in immediate contact with the cornea of the eye. The quality of the optical image provided by CL is superior to the image viewed through the eye glasses, and they also eliminate the cosmetic disadvantage of thick eyeglasses in severe ametropia [1]. CL can be aimed at improving the visual acuity when this cannot be achieved by spectacles in conditions like irregular astigmatism associated with keratoconus, corneal irregularities and anisometropia [2- 5].
The use of CL is gaining more popularity in view of the availability of a wide range of choices, not only in terms of the lens type and materials alone, but also the increased availability at a large number of locations in the country at a much lower cost compared to the past [3]. Many studies have confirmed that CL usage is becoming more popular, especially among young females [4-6].
Although CL offer many advantages over spectacles, such as more natural appearance and unrestricted field of vision, they need extra care in their handling and maintenance. CL can cause mild complications like redness, ocular discomfort, etc., but some complications, such as microbial keratitis caused by CL, may be potentially vision-threatening [7-8]. Complications may be associated with the knowledge and attitude of the CL wearer.
Knowledge and careful practice of CL wearing can help in preventing complications that may arise from inappropriate use of CL. Although some studies pertaining to the behavior of CL users have been conducted in parts of Saudi Arabia [9-10], there is no such data available from the Northern Border Region of this country. Therefore, this study was taken up to assess the attitude and knowledge of CL among female students from Northern Border University through a predesigned questionnaire.
Material and Methods
Study design
This non-funded research project was approved by the Local Committee of Bioethics, Northern Border University on 05/05/2019 under decision No: 37/40/H. The current study was a cross-sectional, questionnaire-based study on the attitude and knowledge of CL among female students of NBU, Saudi Arabia. The questionnaire papers were distributed randomly to the female students of the different faculties of the university. The predesigned questionnaire contained five parts. The first part covered the demographic data of the participants, including age, marital status, college name, academic year, family and personal history of RE, and the use of CL. The second part included 6 questions regarding the attitudes of the participants towards CL, while the third part was composed of ten true and false awareness questions about CL. The fourth part was designed to evaluate the personal experience of CL users among the participants. The last section of the questionnaire was aimed at knowing the main source of knowledge about CL among all participants. The questionnaire was validated by the staff members of the Ophthalmology department of NBU. Only those forms that were completed in all respects were included in the current study.
Data Analysis
The demographic and perception data were collected and analyzed as numbers and percentages. For the attitude question, “yes” answers were scored as 1, while “no” answers were recorded as zero. Participants who scored more than three were considered to have a positive attitude towards CL. While the participants who scored below three were considered to have a negative attitude towards CL. For knowledge questions, correct answers were scored as one, while the wrong answers were scored as zero. The participants who had scored five or more were considered to have sufficient knowledge, while the participants with scores below five were considered to have insufficient knowledge about the CL. The effect of the different variables of the demographic data on the overall scores was analyzed using the Mann-Whitney test. Significance was considered with a P-value of less than 0.05.
Results
After receiving informed consent, 392 female students from NBU returned completely filled forms to the data collectors. Their ages ranged from 18 to 27 years, with a mean age of 23.7±5.3 years. The whole collected demographic data of the studied participants are shown in Table 1.
Regarding the participants’ attitude towards the CL, 285 (72.7%) showed a positive attitude with an overall score geometric mean of 4.8 (95% confidence interval: 4.4-5.3) ranging from 3 to 6 points. Answers of the participants to the attitude questions according to their own beliefs are shown in Table 2. The faculties, personal history of RE, or personal history of CL use significantly affected the attitude of the participants towards CL (P-value=0.034, 0.012, and 0.008, respectively) (Figure 1).
Sufficient knowledge about CL was shown by 251 (64%) participants with an overall score geometric mean of 7.7 (95% confidence interval: 7.1-8.3) ranging from 4 to 10 points. The summary of the right answers is shown in Table 3. The faculties, personal history of RE, or personal history of CL wearing significantly affected the attitude of the participants towards CL (P-value=0.034, 0.025, and 0.018, respectively) (Figure 2). Only 254 of the participants (64.7%) reported that they had used CL at least once during their life. Regarding the personal experience about CL among the participants with a history of CL wearing (at least once during their life), 184/254 (72.4%) used CL for both RE and cosmetic purpose, while only 30 and 40 users reported that they have used CL for RE or cosmetic reasons, respectively. Among CL wearers, 181 (71.2%) revealed that they were satisfied with their CL and felt comfortable with the CL use. The main reason for their choice for CL was a comfort as reported by 164 (64.5%) CL users, which is more prioritized for them than the brands or ease of maintenance. Soft CL was the most common type used by 154 (60.6%) CL users. The semisoft, hard and rigid gas permeable lenses were used by 44 (17.3%), 42 (16.5%) and 14 (5.5%) CL users, respectively. The most popular modality was the monthly disposable contact lens, used by 87 (34.3%) CL users. Daily, weekly, bi-weekly and quarterly disposable were used by 64 (25.2%), 46 (18.1%), and 21 (8.3%) CL users, respectively. Only 15 (5.9%) CL users opted for the bi-annual replacement modality.
Regarding CL complications among participants, the red eye was the commonest [99 (39%)], while 15% of CL users did not report any complications for CL. (Fig. 3a). The response of the participants to CL complications was variable; 159 (62.6%) reported that they would just remove CL without further treatment, 71 (28%) reported that they may use self-medications after removal of CL, while only 43 (16.9%) reported that they opted to consult an ophthalmologist for any CL complication. The majority of the participants reported the CL sellers as the main source of knowledge about CL, with limited role of ophthalmologists and optometrists in the source of their knowledge (Figure 3b).
Discussion
The contact lens (CL)-related attitude and knowledge among 392 undergraduate female students from five colleges of NBU of Saudi Arabia was assessed through a structured questionnaire.
In our study, a positive attitude towards CL was found in 72.7% of participants. This is in line with a study conducted in Thailand in which 75% of the participants had a moderate attitude level about contact lens use and good practice level about the proper contact lens use and care [11].
Regarding the knowledge related to CL, 64% of our participants showed that they have sufficient knowledge about CL. Similarly, 54.7% of Saudi urban CL users were found to have an excellent level of knowledge regarding CL [9].
The faculties, personal history of RE, or personal history of CL wearing had significantly influenced the attitude and as well as the CL-related knowledge of the participants. This is because the students from health sciences are expected to have more awareness about contact lenses than other faculties.
Although the participants of this study demonstrated generally sufficient knowledge about the CL, 51.3% of the participants thought that CL can be cleaned with water, and 47.7% participants thought that the use of CL during active inflammation/infection was acceptable. These are some serious concerns which need to be addressed through educational sessions. These percentages are lower than the results of a recent study conducted on female university students in eastern Saudi Arabia [12]. In their study, 59.1% of the participants knew that any active inflammation/infection was a contraindication for the CL use, and 54.6% of the participants were aware that cleaning of CL with water would cause infection. These variations maybe because of the differences in the sources of knowledge for CL, as in their study, the main source was a doctor or optometrist, while as in our study, it was mainly the CL sellers.
In our study, 64.7% of the participants reported that they had used CL at least once during their life. This is higher than the rate (50.2%) reported among medical students from King Abdulaziz University, Jeddah, Saudi Arabia [10]. This difference may be because all colleges of the university were included in our study.
The current study revealed that 72.4% of the participants used CL for both RE and cosmetic purposes. Soft and monthly disposable CL were the most popular among our participants. Among CL wearers, 71.2% revealed that they were satisfied with their CL and the main reason for their CL choice was comfort, as cited by 64.5% of CL users. The same is noted in a study conducted in India, where the majority of medical college students were using soft contact lenses as they are more comfortable and better tolerated [13].
Red eyes were the most common reported CL complications, [99 participants (39%)]. Likewise, the acute red eye was the commonest CL complication reported in another study conducted in Jeddah Saudi Arabia [10].
To overcome the complications caused by CL, 62.6% reported that they just removed CL without further treatment, 28% reported that they could use self-medications after removal of CL, while only 16.9% reported that they opted to consult an ophthalmologist for any CL complication. This is slightly lower than what is indicated in a study at King Abdulaziz University, Jeddah, Saudi Arabia. In their study 55.5% of the female medical college students would discontinue their CL until symptoms resolved, and only 23.2% would seek medical help and consulted a doctor for treatment [14]. These small differences may be due to the fact that only university medical students were included in their study.
CL sellers were the main source of knowledge about CL with the limited role of ophthalmologists and optometrists in the source of their knowledge. This is supported by a study conducted in Madinah Saudi Arabia in which 75.9% of the participants mentioned that they buy contact lenses at optical shops, 19.8 % at cosmetic centers and only 4.3% at hospitals [15]. Similarly, another study from Riyadh, Saudi Arabia also reported that the main purchasing locations for CL were optical shops (51%), beauty salons (38%) and pharmacies (11%) [16]. However, this in contradiction to other study conducted in Turkey, where the most common source of CL use education was ophthalmologists (55.5% of the participants), followed by opticians (28.2%) [17]. This may be due to different health care systems in different countries.
Conclusion
Although a positive attitude towards contact lenses and overall good knowledge was demonstrated by the majority of female undergraduates, there is still insufficiency in the knowledge when particular aspects, such as cleaning of CL and the use of CL in active inflammation/infection are taken into consideration. Therefore, more ocular health education sessions with the active role of ophthalmologists and optometrists need to be focused to increase awareness in these areas.
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.
Funding: None
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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3. Bowden T, Harknett A. What the patient wore, and why. Cont Lens Anterior Eye. 2006;29(1):5-15. DOI:10.1016/j.clae.2005.12.002
4. Ahmed II, Breslin CW. Role of the bandage soft contact lens in the postoperative laser in situ keratomileusis patient. J Cataract Refract Surg. 2001;27(12):1932-6. DOI:10.1016/s0886-3350(01)01183-x
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6. Aasuri MK, Venkata N, Preetam P, Rao NT. Management of pediatric aphakia with silsoft contact lenses. CLAO J. 1999;25(4):209-12.
7. Acharya M, Farooqui JH, Jain S, Mathur U. Pearls and paradigms in Infective Keratitis. Rom J Ophthalmol. 2019;63(2):119-27.
8. Alipour F, Khaheshi S, Soleimanzadeh M, Heidarzadeh S, Heydarzadeh S. Contact Lens-related Complications: A Review. J Ophthalmic Vis Res. 2017;12(2):193-204. DOI: 10.4103/jovr.jovr_159_16
9. Alobaidan OS, Alkhalifah MK, AlSayegh AA, Alhumaid FA, Ashammery AS, Alghamdi K, et al. Knowledge and practice regarding contact lens among Saudi urban contact lens users. Saudi J Ophthalmol. 2018;32(2):93-6. DOI:10.1016/j. sjopt.2017.09.008
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16. Abahussin M, AlAnazi M, Ogbuehi KC, Osuagwu UL. Prevalence, use and sale of contact lenses in Saudi Arabia: survey on university women and non- ophthalmic stores. Cont Lens Anterior Eye. 2014;37(3):185-90. DOI:10.1016/j. clae.2013.10.001
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Mujeeb Ur Rehman Parrey, Farhan Khashim Alswailmi, Maram Khalf A Alenzi, Mariam ayiad J Alshammari, Deema Faleh Alanazi, Reema Faleh Alanazi. Knowledge and attitude towards contact lenses among female students of Northern Border University, Saudi Arabia. Ann Clin Anal Med 2021;12(Suppl 4): S399-403
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Factors affecting midwifery students’ perceptions of spiritual care: A cross-sectional study of the Eastern Region of Turkey
Evrim Çelebi 1, Hafize Öztürk Can 2
1 Department of Nursing, Fırat University Faculty of Health Sciences, Elazığ, 2 Department of Midwifery, Ege University Faculty of Health Sciences, Izmir, Turkey
DOI: 10.4328/ACAM.20612 Received: 2021-03-23 Accepted: 2021-07-05 Published Online: 2021-08-10 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S404-409
Corresponding Author: Hafize Öztürk Can, Department of Midwifery, Ege University Faculty of Health Sciences, Izmir, Turkey. E-mail: hafizeztrk@gmail.com P: +90 (232) 311 83 00/8304 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8213-3330
Aim: The aim of this study was to determine the factors affecting midwifery students’ perceptions of spiritual care in a particular region.
Material and Methods: This descriptive and cross-sectional study included 179 midwifery students. The tools used for data collection were the personal infor- mation form and the Turkish version of the “Spiritual Care-Giving Scale”.
Results: Among the students participating in the study, 73.2% had heard of spiritual care, one-third received information about spiritual care, 78.2% did not have enough knowledge about spiritual care, and 17.9% were able to adequately meet the spiritual care needs of the individuals/patients to whom they gave a care. The spiritual care method, which was most commonly used by 82.7% of the participating students, was an empathic approach. According to midwifery students, the most serious barrier to giving spiritual care is the lack of knowledge. The mean score obtained on the Spiritual Care-Giving Scale by the partici- pating midwifery students was 108.50 ± 12.46.
Discussion: The mean scale scores obtained by the students who had previously received information about spiritual care, who wanted to get more information about spiritual care, and who considered that spiritual care was important in midwifery care were found high.
Keywords: Midwifery Student; Midwifery Education; Spirituality; Spiritual Care
Introduction
The most comprehensive approach in the provision of health care is the holistic approach. According to the holistic approach, a person is a whole with physical, mental, emotional, sociocultural and spiritual dimensions. This definition of holistic care is complementary to the definition of health given by the World Health Organization (WHO) [1]. With the provision of health care to individuals with a holistic approach, the spiritual dimension of healthcare has gained importance, and when care is given, not only the physical, emotional and psychosocial dimensions of care have been taken into account, but also its spiritual dimension [2]. All these dimensions that make up a human being are in constant interaction. While a problem that occurs in the physical field affects other dimensions, problems that occur in the spiritual, social and emotional dimensions can cause problems in the physical field. Therefore, in the field of health, human health should not be evaluated only from a medical point of view; all the aspects of health should be taken into account in order for the person to maintain his/her health [1,3-5]. Despite the increasing importance of spiritual care in recent years [1], the perception and definition of spiritual care vary from one health professional to another [6].
Spiritual care, which is a component of healthcare to meet the spiritual needs of patients, is also an important part of holistic health care and the provision of multi-disciplinary interventions, which assess and address the spiritual needs of patients [7]. Spiritual needs arise in situations of crisis, when an individual experiences a life-threatening illness, stress, fear of death, questions the meaning of life, and loses hope [8]. Studies show that health care providers do not know how to provide spiritual care and that they receive little training on the spiritual dimension of care, which suggests that they are poorly aware of their patients’ mental needs and that their education does not provide them with sufficient information on how to give spiritual care [6]. In this respect, it is important to evaluate students’ perceptions of spirituality and to determine their perspectives on related interventions so that midwives/student midwives t evaluate the patients they care for to determine their spiritual needs correctly.
During midwifery applications, in particular in cases of death, pregnancy losses, termination of pregnancy, preterm birth, birth of a child with anomalies, birth and postpartum problems etc., it is important to provide care related to spiritual needs professionally. Midwives are present at moments of birth and death, as well as at other significant moments of a person’s life. It is at those times, in particular, when the care provided may leave a lasting impressions on people, and this is the reason why midwives need to have the required skills and competencies to provide individual-centered, reliable and respectful holistic care [9]. In particular, Lewinson et al. (2015) have reported in a systematic review of international studies that they suggest that training programs can increase spiritual awareness and enhance nurses and midwives’ confidence in their ability to provide spiritual care [10].
In midwifery education in Turkey, the concept of spiritual care and holistic care is addressed as a human need. Including spiritual care into curriculum and practices within the frame of a holistic view of health, and drawing graduated health personnel’s attention to the issue through in-service training programs are of great importance in the provision of holistic healthcare services [3].
Therefore, the present study was mainly aimed at investigating the factors affecting the midwifery students’ perceptions of spirituality and spiritual care. While this cross-sectional study was performed, it was aimed to determine student midwives’ awareness and perspectives of spiritual care, and the effect of midwifery education on students’ perception of spiritual care. It is expected that the results of the study will guide the basic midwifery education on spiritual care.
Material and Methods
Participants
The study population included 198 midwifery students having an undergraduate education at a state university located in the eastern part of Turkey. Turkey is made up of seven geographical regions, each with its own geographical, political and cultural structure. Studies on this issue were mostly conducted with students in the western part of Turkey. Therefore, we wanted to perform our study in a region with a different cultural structure, and decided to do it in the Eastern Anatolia Region of Turkey. Students studying in a large and old university in this region comprised the study population.
Considering the possibility of accessing the entire study population, no sampling method was implemented. Instead, it was aimed to reach the entire study population. The study was completed with 179 of 198 midwifery students. The participation rate was 90.4%. Inclusion criteria were as follows: being a second, third and fourth year student, and volunteering to participate in the study.
The mean age of the participants was 20.77±2.92 (min 18; max 28) years; 35.8% of them were second year students, 34.1% were third year students, 30.2% were fourth year students, 98.3% were single and 62.6% stayed in the dormitory.
Data Collection Tool
A two-part questionnaire was used to collect the study data. The first part of the questionnaire included closed-ended questions on the participants’ demographic characteristics, such as age, marital status, year at school, and their previous experiences of spiritual care and implementation of spiritual care in educational and practical activities [11,12].
The second part included the Spiritual Care- Giving Scale (SCGS), which was developed by Tiew and Creedy [13], and whose Turkish validity and reliability study was performed by Çoban et al. [14]. While the Cronbach’s alpha coefficient of the original scale was 0.86, it was 0.96 in the Turkish validity and reliability study of the scale. The scale consists of 35 items and five sub-dimensions: perceptions of spirituality, definitions of spiritual care, spiritual care practices, spiritual care attitudes and general features of spiritual care. Responses given to the items of the scale are rated on a 5-point Likert scale ranging from 1 to 5 ( 1=strongly disagree, 2=disagree, 3=somewhat agree, 4=agree, 5=strongly agree). The minimum and maximum possible scores to be obtained on the scale were 35 and 175, respectively. The higher the score obtained on the overall scale, the higher the participant’s perception of spirituality and spiritual care is [13,14]. In the present study, Cronbach’s alpha coefficient of the scale was 0,938
Procedures
The study data were collected between March 01 and April 15, 2019 on days during classroom hours. Participants were first informed about the purpose of the study in the classroom. Then the participants who accepted to participate in the study were asked to fill out a questionnaire and they were given 10-15 minutes to answer the questions. If there were any unclear points about the items, the researcher clarified them. Finally, they were asked to hand in the questionnaires to the researcher after answering the items.
Dependent and independent variables
The dependent variables of the study are the Spiritual Care- Giving Scale and its subscales.
The independent variables in the study are age, the year at school, having heard of spiritual care, awareness of spiritual care, source of knowledge about spiritual care, considering that spiritual care education is necessary, willingness to learn more about spiritual care, meeting the needs of patients for spiritual care and considering that spiritual care is necessary in midwifery care.
Statistical analysis
Statistical analysis was performed using the SPSS (version 22). The study data were presented as numbers, percentages, arithmetic mean and standard deviation. In the statistical analysis of the dependent and independent variables, the independent sample t-test and ANOVA were used. P-values less than 0.05 were considered statistically significant.
Ethical issues
Before the study was conducted, approval from the ethics committee of the university (07/03 / 2019-20- Decision No:11) and permission from the Dean of the Faculty were obtained. The questionnaires included information about the study. Participants were also informed verbally in the classroom. To protect their privacy, the participants were asked not to write any personally identifiable information on the questionnaire.
Results
The findings of this cross-sectional descriptive study are presented in three tables in this section.
The distribution of the mean scores obtained on the SCGS and its subscales by the participating midwifery students is shown in Table 1. The mean score they obtained from the overall SCGS was 108.50±12.46 (Min= 79, Max=130) for the overall Spiritual Care-Giving Scale, 39.11±4.28 perceptions of spirituality subscale, 19.18±3.10 for the definitions of spiritual care subscale and 25.57±3.41 for the spiritual care practices subscale. In order to better interpret these mean values, the lowest and highest scores were determined for all the subscales, and the score range was divided by three. The reason for doing this was to interpret the scores obtained from each dimension as low, moderate and high.
A comparison of the mean scores of participating midwifery students obtained from SCGS in terms of the independent variables is shown in Table 2. As can be seen in Table 2, 86.6% of the participants think that spiritual care is very important and necessary in midwifery care. While there were no differences between the participants’ SCGS scores in terms of variables such as year at school, hearing of spiritual care before, the opinion that spiritual care education is necessary, and meeting the needs of patients for spiritual care (p>0.05), there were differences between the participants’ SCGS scores in terms of the variables such as the source of knowledge about spiritual care and the opinion that spiritual care is necessary in midwifery care (p<0.05).
As can be seen from Table 3, of the spiritual care methods, the participants mostly used ‘displaying empathic approach’ and ‘listening to the patient’. According to the participants, the most important barriers to giving spiritual care were lack of knowledge, communication problems with the patient and lack of a comfortable environment. Comparison of the spiritual care methods applied by the participants with their mean SCGS scores demonstrated that there was a statistically significant difference between the mean SCGS scores obtained by the participants who used the ‘displaying empathic approach’ method and those of the participants who did not use the same method.
Discussion
It is important that for health professionals to provide patients with holistic care, to understand and evaluate spirituality and spiritual care well [15]. The participants’ scores were moderate for the overall SCGS and the definitions of spiritual care subscale, and high for the perceptions of spirituality and spiritual care practices subscales. In a study conducted with nursing and midwifery senior students to whom the Spirituality and Spiritual Care Rating Scale (SSCRS) was administered, the students’ spirituality and spiritual care levels were high [11]. In a study conducted with midwifery students assigned the same scale, students’ spirituality and spiritual care scores were high too. However, there are studies in which the participants’ spirituality and spiritual care scores were low [16]. The mean scores the participating students obtained on the SCGS subscales were high in our study, indicating that they are aware of spiritual care. However, the SCGS scores vary from study to study. This is probably due to the fact that the studies have different samples and that measurements are performed with different measurement tools.
Three out of every four midwifery students participating in the study had heard about spiritual care, and about one-third stated that they did not have enough knowledge about spiritual care. In the studies by Mermer et al. [11] and Karadag Arli et al. [17], the rate of the participants who received information about spiritual care prior to their education was lower than in the present study. A review of the literature demonstrated that findings varied from one study to another. For instance, the rate of the midwifery students who had heard of spiritual care was 77.1% in Mermer et al.’s study [11] and 60% in Gönenç et al.’s study [18].
Almost all of the midwifery students who participated in the study stated that education on spiritual care was necessary and that they wanted to be more knowledgeable about spiritual care. This finding reveals the need for information about spiritual care in the vocational education process, and shows that the course content should involve spirituality and spiritual care more. In Daghan et al.’study [12], the majority of nursing students stated that the concepts of spirituality and spiritual care should be included in the course content more. In Lewinson et al.’s study [10], nurses and midwives stated that they were ready to provide spiritual care and that they were eager to receive further education. Research has shown that nurses/midwives experience spiritual awareness more and feel more competent in providing spiritual care after participating in training programs on spiritual care [19].
Awareness of midwifery students about the spiritual care needs will improve the quality of holistic and individual midwifery care. Within this context, Callister et al. reported that many nurses hesitate to assess patients’ spiritual needs and to encourage patients to pay more attention to their spiritual health and spirituality because they lack the knowledge and experience to do so [20]. Within this context, only 17.9% of the participants stated that they met the spiritual needs of the patients to whom they gave care, but 59.2% stated that they were unsure whether they met their patients’ spiritual care needs. Spiritual care is more complex than physical care. This is due to the broad, abstract, value-laden and multidimensional structure of spirituality. Therefore, it is not easy for students to understand spirituality, and thus they are not competent enough to meet the spiritual needs of patients. In Eğlence et al.’s study [4], 40.6% of the participating nurses stated that they were able to meet the spiritual care needs of the patients they gave care. In the present study, according to the participants’ statements, the methods they mostly tried to use to meet the the patients’ spiritual care needs were ‘displaying an empathic approach, listening to the patient/pregnant woman and providing a peaceful environment. In the study, it was determined that the students tried to fulfill such components of the SCGS as empathic approach, active listening, creating an appropriate environment, and interacting with the individuals to whom they cared for during their training. These behaviors of the students are consistent with the mean scores they obtained from the subscales of the SCGS. In a literature review, it has been observed that similar applications have been performed, and that the results of those studies reviewed were consistent with our findings [4,11]. In another literature review, it was reported that the use of spiritual interventions yielded positive results in terms of promoting health status and minimizing disease symptoms among Muslim patients [21].
As stated by the participants in the present study, the most important barrier to giving spiritual care was the lack of knowledge. Other barriers were communication problems with the patient, lack of comfortable environments, and prioritization of physical care. These results were similar to those of other studies [4,13,15]. These results suggest that training programs should include more courses on spiritual care to eliminate the lack of education among students, and educational activities aimed at eliminating communication barriers should be organized more.
Most patients have a spiritual life and regard their spiritual health and physical health as equally important. Furthermore, people may have greater spiritual needs while they are sick [22]. The participants’ scores obtained from the SCGS were compared in terms of the variables: “willing to get more information” and “considering that spiritual care is necessary in midwifery care”, and the result was statistically significant (p<0.05). The scores obtained from the SCGS by the participants who wanted to learn more about spiritual care and considered that spiritual care was very important in midwifery care were significantly higher.
Limitations of Study
The results of the present study cannot generalized to all midwifery students in Turkey. The data were collected based on the participants’ self-reports. Another limitation is that although several scales have been developed to investigate topics such as spiritual care, spiritual care perceptions, etc., in addition, it has also not been questioned whether the participants have encountered a situation/event requiring spiritual care before midwifery education, and whether they needed spiritual care.
Conclusion
The mean scores the participants obtained from the SCGS were compared in terms of the factors affecting their perceptions of spiritual care such as the year at school, receiving information about spiritual care, considering that spiritual care education is necessary, meeting the spiritual care needs of patients to whom they give care, but no significant correlation was determined. However, the mean scores obtained by the students who had previously received information about spiritual care, who wanted to get more information about spiritual care and who considered that spiritual care was important in midwifery care were significantly higher. Since they are always in close relationship with pregnant women, midwives can maintain those women’s integrity. Therefore, midwifery education should be designed in such a way that it could ensure the spiritual development of students and improve their ability to meet the spiritual needs of patients.
The present study provides preliminary information on the spirituality, and spiritual care perspectives of midwifery students. Further studies should be performed to determine the best way to teach midwifery students spiritual care both in the classroom and during clinical practices, and to identify barriers to the improvement of students’ spiritual care skills. Clinical settings provide students with numerous experiences to explore dimensions of spirituality, and midwives working in clinical areas should be role models for students. Thus, students who will become midwives in the future will be able to increase their awareness, knowledge and skills about the concepts related to spirituality and spiritual care, and they will be able to provide spiritual care to their patients after being entitled to become a midwife.
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.
Funding: None
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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9. Ross L, McSherry W, Giske T, van Leeuwen R, Schep-Akkerman A, Koslander T, et al. Nursing and midwifery students’ perceptions of spirituality, spiritual care, and spiritual care competency: A prospective, longitudinal, correlational European study. Nurse Educ Today. 2018; 67:64–71. DOI:10.1016/j.nedt.2018.05.002
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Evrim Çelebi, Hafize Öztürk Can. Factors affecting midwifery students’ perceptions of spiritual care: A cross-sectional study of the Eastern Region of Turkey. Ann Clin Anal Med 2021;12(Suppl 4): S404-409
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Retrospective evaluation of hematological parameters for the differentiation between non-st elevation myocardial infarction and unstable angina
Gökhan Yılmaz 1, Özkan Erarslan 2, Şeref Emre Atiş 3, Bahadır Çağlar 4, Ufuk Öner 1, Süha Serin 4, Oğuzhan Bol 1, Ziya Şimşek 5, Mustafa Erkan 1, Umut Şaşmaz 1, Murat Çelik 1
1 Department of Emergency Medicine, Kayseri City Hospital, Kayseri, 2 Department of Emergency Medicine, Cizre State Hospital, Şırnak, 3 Department of Emergency Medicine, Mersin City Hospital, Mersin, 4 Department of Emergency Medicine, Balıkesir University, Balıkesir, 5 Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
DOI: 10.4328/ACAM.20617 Received: 2021-04-01 Accepted: 2021-07-14 Published Online: 2021-08-01 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S410-413
Corresponding Author: Özkan Erarslan, Cizre State Hospital, Department of Emergency Medicine, Şırnak, Turkey. E-mail: dr.ozkanerarslan@gmail.com P: +90 555 397 49 64 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4606-3467
Aim: In this study, we aimed to investigate the utility of hematological parameters associated with acute coronary syndrome (ACS) in the differentiation of non-ST elevation myocardial infarction (NSTEMI) from unstable angina (UA).
Material and Methods: The retrospective study included patients aged over 18 years who presented to the emergency department with a prediagnosis of ACS and were diagnosed with NSTEMI and UA between January 1, 2014 and February 28, 2018. Sociodemographic and clinical characteristics, including age, gender, and white blood cell count (WBC), platelet count (PLT), mean platelet volume (MPV), red cell distribution width (RDW), and neutrophil-to-lymphocyte ratio (NLR) were recorded for each patient.
Results: The study included a total of 1005 patients (749 NSTEMI and 256 UA). In multivariate logistic regression analysis, the mean WBC level was 1.375(1.258- 1.503) times and the mean NLR was 3.631(range, 2.864-4.602) times higher in the NSTEMI group compared to the UA group(p<0.001). In the ROC analysis, the cutoff value of NLR for the differentiationof NSTEMI from UA was 2.237, with a sensitivity of 84.1% and a specificity of 81.6%.
Discussion: WBC and NLR values can be used as inflammatory markers in the differentiation of NSTEMI from UA.
Keywords: Hematological parameters; Unstable angina; NSTEMI; Neutrophil-to-lymphocyte ratio
Introduction
The clinical spectrum ofacute coronary syndrome (ACS) is classified into ST-elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS) based on electrocardiography (ECG) findings. The NSTE-ACS group is further divided into non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA)[1]. A pathological correlate for ACS at the myocardial level is cardiomyocyte necrosis in patients with NSTEMI and myocardial ischemia without cell damage in patients with UA [2]. Due to the differences in their pathophysiological processes and treatment strategies, the differentiationof these two clinical conditions in the early period in the emergency department is of paramount importance. Diagnosis, treatment, and risk management ofpatients with suspected NSTE-ACS often includes clinical evaluation, 12- lead ECG, and biomarkers. Moreover, measurement of cardiac troponin, the most important biomarker of cardiomyocyte damage, is mandatory, sincetroponin levels are often positive in NSTEMI and are often negative in UA [3-5]. Additionally, troponin is the most sensitive and tissue-specific cardiac markerand is also considered the golden-standard biochemical tool for ACS risk stratification. Nonetheless, troponin positivitymay not be detected in approximately 40-60% of patients with ACS [6]. There have been recent studies investigating the inflammatory mechanism in the ACS processand these studies have shown the efficacy of numerous hematological parameters in the diagnosis of ACS, including white blood cell count (WBC), platelet count (PLT), mean platelet volume (MPV), red cell distribution width (RDW), and neutrophil-to-lymphocyte ratio (NLR) [7-9]. However, to our knowledge, there have been no large-scale studies investigating the utility of hematological parameters in the differential diagnosis of NSTEMI and UA. The aimedthis studywas to investigate the utility of hematological parameters, along with cardiac troponin measured at the time of admission to the emergency department in the differential diagnosis of NSTEMI and UA.
Material and Methods
Study design and setting
Ethics committee approval was obtained before starting the study (Erciyes University Ethics Committee approval date: 20.06.2018 and the Decision Number: 2018/325). The study was conducted in an emergency department, which is visited by approximately 300.000 patients a year. The retrospective study included patients aged over 18 years who presented to the emergency departmentwith a prediagnosis of ACS and were diagnosed with NSTEMI and UA between January 1, 2014, and February 28, 2018.The patients included in the study were selected from the hospital data registry system, taking into account the relevant ICD codes (chest pain R07.4, unstable angina pectoris I20.1, acute subendocardial myocardial infarction I21.4).The NSTEMI group was determined as the patients with non-ST elevation, with troponin positivity and having lesion, detected in coronary angiography. The unstable angina group, on the other hand, was composed of patients with clinical symptoms of unstable angina, with the negativity of troponin, and lesions detected in coronary angiography. Sociodemographic and clinical characteristics including age, gender, and WBC, NLR, RDW, MPV, and PLT levels were recorded for each patient.
Inclusion and exclusion criteria
All male and female patients over the age of 18 who met the diagnostic criteria for UA and NSTEMI were included in the study. Patients agedunder the age of 18 and those with a diagnosis of STEMI, patients with missing data, patients with a normal coronary artery in coronary angiography, patients with a history of hematological disease (anemia, thrombocytopenia, bicytopenia, pancytopenia, immune thrombocytopenic purpura, thrombotic thrombocytopenic purpura, leukemia, lymphoma etc.),and patients with evidence of infection (those who were started antibiotic treatment during hospitalization due to infection, such as pneumonia, urinary tract, etc., or who were asked for an infectious diseases consultation during hospitalization)were excluded from the study (Figure 1). Statistical analysis
Data were analyzed using SPSS for Windows version 25.0 (Armonk, NY: IBM Corp.). Normal distribution of continuous variables was assessed using the Lilliefors-corrected Kolmogorov-Smirnov test. Continuous variables (age, WBC, NLR, RDW, MPV,and PLT) were compared between the two groups (NSTEMI and UA) using the Mann-Whitney U Test with Monte Carlo Simulation. Categorical variables (treatment method and gender) were compared between the two groups usingPearson’s Chi-Squared test, followed byFisher’s exact test for gender and Monte Carlosimulation for treatment method.Subsequently,column proportions were compared and expressed according to the Benjamini-Hochberg adjustedp- value.Multivariate Logistic Regression (method=enter)was used to determine the cause-effect relationship between the diagnosis (NSTEMI and UA) and continuousvariables (age, WBC, NLR, RDW, MPV,and PLT)and categorical variables (treatment method). Continuous variables were expressed as medians (minimum/maximum), and categorical variables were expressed as frequencies (n). A p-value <0.05 was considered significant.
Results
The study included 1005 patients (749 NSTEMI and 256 UA). Table 1 presents the demographic data of the patients. The mean WBC level in all patients was 9.5 (range, 4.0-27.6) x103/ uL, mean NLR was 2.9 (range, 0.5-42.4), mean RDW was 42.1 (range, 31.8-69.2) fL, mean MPV was 10.2 (range, 7.7-14.0) fL, and mean PLT was 240 (range, 54-736) x 103/uL.
A significant difference was found between the two groups with regard to WBC, PLT, RDW, and NLR values (p<0.05), whereas no significant difference was found with regard to MPV values (p= 0.123) (Table 1).
The mean WBC level was 1.375(1.258-1.503) times and the mean NLR was 3.631(range, 2.864-4.602) times higher in the NSTEMI group compared to the UA group (Figure 2).
The multivariate logistic regression model indicated that both NLR and WBC predicted NSTEMI and UA with a sensitivity of 92.8% and 66.8%, respectively, and also had an overall sensitivity of 86.2% (model, p=0.001), which suggests that both NLR and WBC were significant independent predictors of NSTEMI (Table 2).
Discussion
Troponin is the most important biomarker in patients admitted tothe emergency department with a prediagnosis of ACS[10]. Our findings indicated that hematological parameters could be beneficial when used togetherwith the troponin value in the differential diagnosis of NSTE-ACS in the emergency department. To our knowledge, there have been no studies evaluating the utility of hematological parameters in the differential diagnosis of NSTE-ACS.
Studies have shown that inflammation plays akey role in the pathogenesis and progression of atherosclerosis by participating in many processes such as endothelial damage and plaque formation[11,12]. In the literature, proinflammatory functional responses of neutrophils have been shown to be associated with cardiovascular risk factors in atherosclerosis, andthe role of neutrophils has been shown in both acute and chronic vascular damage [13,14]. Lymphocytes constitutea heterogeneous subgroup of WBC, along with pro-atherogenic and pro-inflammatory cells, and also may influence immune regulatory pathways [15]. NLR has recently emerged as a novel potential biomarker in the detection of individuals at risk for new cardiovascular events. Aprevious reviewindicated that NLR is the best predictor of death and major adverse cardiovascular events in patients with ACS[16].Another studyreported that the NLR value, assessed on admission, is a strong and independent predictor of cardiovascular mortality in NSTEMI and UA patients [17]. Tahto et al. evaluated the inflammatory parameters of 50 acute myocardial infarction (AMI) and 50 UA patients and reportedthat the mean NLR value was significantlyhigher in the AMI group compared to the UA group (7.22 vs.4.62) [18]. In our study, the mean NLR was 3.6 in the NSTEMI group as opposed to 1.7 in the UA group. Moreover, the mean WBC level was 1.375(1.258-1.503) times and the mean NLR was 3.631(range, 2.864-4.602) times higher in the NSTEMI group compared to the UA group. Accordingly, the higher levels of WBC and NLR in our NSTEMI group compared to the UA group support the literature findings.In addition to these findings, multivariate logistic regression analysisrevealed that WBC and NLR were strong predictors in the differentiation between NSTEMI and UA.
Limitations
The fact that our study was retrospective and conducted as a review of the data recording system caused difficulties in the classification of patients and in determining the missing parts in the history. Again, it is possible that we have no idea about the way and duration of taking the hemogram panel, determining other factors that will cause variations in the parameters. Another problem is that the approach of the cardiologist in determining the treatment method is uncertain. Another limitation is that we cannot include patients with unstable angina who were discharged despite admitting to the emergency department and could not be detected.
Conclusion
Our study is the first step towards using hematological parameters in the differential diagnosis of NSTE-ACS. WBC and NLR can be safely used as independent markers in the differential diagnosis of NSTEMI and UA. Further multi-center and comprehensive studies are needed to substantiate our findings.
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.
Funding: None
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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Gökhan Yılmaz, Özkan Erarslan, Şeref Emre Atiş, Bahadır Çağlar, Ufuk Öner, Süha Serin, Oğuzhan Bol, Ziya Şimşek, Mustafa Erkan, Umut Şaşmaz, Murat Çelik. Retrospective evaluation of hematological parameters for the differentiation between non-st elevation myocardial infarction and unstable angina. Ann Clin Anal Med 2021;12(Suppl 4): S410-413
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Investigation of the frequency and relationship of fragmented QRS in patients with ischemic stroke
Mustafa Cam 1, Ümit Ali Malçok 2, Ercan Akşit 3, Özgül Ocak 1
1 Department of Neurology, 2 Department of Neurosurgery, 3 Department of Cardiology, Canakkale Onsekiz Mart University, Canakkale, Turkey
DOI: 10.4328/ACAM.20618 Received: 2021-03-29 Accepted: 2021-06-11 Published Online: 2021-07-13 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S414-418
Corresponding Author: Mustafa Cam, Canakkale Onsekiz Mart University Department of Neurology, Barbaros Street, Terzioglu Campus, Canakkale, Turkey. E-mail: mustafacam20@hotmail.com P: +90 5066493267 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3116-203X
Aim: Acute ischemic stroke is an important cause of morbidity and mortality. Fragmented QRS (fQRS) is a depolarization disorder, which may be easily detected in 12-lead superficial electrocardiography (ECG), which displays a conduction delay caused by myocardial fibrotic tissue. Although the association of fQRS with ischemic heart disease is well known, there is no clear information about its relationship with ischemic stroke. In the present study, we aimed to investigate the relationship between fQRS and ischemic stroke.
Material and Methods: Seventy consecutive patients with a diagnosis of ischemic stroke and 48 healthy individuals were included in this cross-sectional study. Baseline demographic and echocardiographic characteristics were recorded, and surface 12-lead standard ECGs were used.
Results: The mean age of the patients was 65.19±13.91 years, and 46.6% were male. The number of patients with fQRS in the ischemic stroke group was greater than in the control group (p = 0.009). In multiple logistic regression analysis, left ventricular end-systolic diameter (LVESD) (p = 0.013, Odds ratio (OR) = 4.284, 95% Confidence interval (C.I.) = 1.366–13.432), and left atrium diameter (p = 0.020, OR = 3.985, 95% C.I. = 1.240–12.803) were found to be independent predictors of ischemic stroke.
Discussion: The current study was the first to focus on evaluating the relationship between fQRS and ischemic stroke. In light of these results, we can say that patients with fQRS, who had lower LVEF, greater LVESD, and larger left atrium represent a high-risk group for ischemic stroke. fQRS may be utilized in a follow-up of these patients and in any consideration of early anticoagulation treatment
Keywords: Ischemic Stroke; Fragmented QRS; Echocardiography
Introduction
Acute ischemic stroke is an important cause of morbidity and mortality, and cardiovascular complications are common after an acute stroke [1,2]. Ischemic stroke accounts for approximately 85% of all stroke cases and can be classified into five main subtypes based on their etiopathogeneses: 1) small vessel occlusion (lacunar infarction), 2) large artery atherosclerosis (atherothrombotic), 3) cardio-embolism, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology [3]. In particular, patients with cardio-embolic stroke tend to have higher mortality, disability, and poor neurological outcomes compared to the other types of ischemic stroke. Previous studies have demonstrated that atrial fibrillation (AF) is the most common source of cardio-embolism due to the formation of left atrial thrombus [4]. However, there is no clear information about left ventricle-associated ischemic stroke except for left ventricular apical thrombus after myocardial infarction. Several electrocardiographic (ECG) abnormalities have been reported in patients following acute cerebrovascular events including QT interval prolongation, ST-segment deviation, and T-wave changes [5]. Dysregulation of autonomic nervous system after acute cerebrovascular events can causes sympathetic activation leading to cardiac arrhythmia. Besides the effect of acute cerebrovascular events on ECG, some abnormal findings detectedinECGarealsoassociatedwithacutecerebrovascular events. Fragmented QRS (fQRS) is a depolarization disorder that can be easily detected in 12-lead superficial ECG, which displays conduction delay caused by myocardial fibrotic tissue. Fibrotic tissue slows down the electrical conduction and causes notching in the QRS complex [6,7].
Although the association of fQRS with ischemic heart disease is well known, there is insufficient information about its relationship with ischemic stroke. In the present study, we aimed to investigate the relationship between fQRS and ischemic stroke.
Material and Methods
Study population
Seventy consecutive patients aged 18-80 years, who were hospitalized in Neurology and Neurosurgery clinics with a diagnosis of ischemic stroke between February 2018 and August 2019, and 48 healthy individuals were included in this cross-sectional study. Patients with a history of cranial surgery and/or cerebral endovascular intervention, hemorrhagic stroke, coronary endovascular intervention and/or open cardiac surgery in the previous 3 months, prior atrial arrhythmias (atrial fibrillation, atrial flutter, atrial tachycardia etc.), heart failure, cardiac pacemaker, bundle branch block, severe valvular disease, cardiomyopathy, pericardial disease, patients under 18 and over 80 years of age, and with poor ECG quality were excluded from the study. The study was approved by the local ethics committee. All patients signed an informed consent form. Demographic and echocardiographic evaluation of patients Baseline demographic characteristics of the study population were recorded. Hypertension (HT) was defined by a previous diagnosis of HT or the presence of systolic blood pressure (SBP) ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg. Diabetes mellitus (DM) was defined as fasting plasma glucose level ≥126 mg/dl or plasma glucose level ≥200 mg/dl 2 hours after the 75 mg oral glucose tolerance test or glycated hemoglobin ≥6.5% or patients using antidiabetic medications. Cigarette smoking was defined as smoking ≥1 packet of cigarettes per day.
All patients underwent 2-dimensional transthoracic echocardiography (HD11 XE Ultrasound system, Philips, Canada) equipped with a 1.5- 4.0 MHz transducer. Left ventricular ejection fraction (LVEF) was obtained using a modified Simpson’s method as specified in the current American Society of Echocardiography guidelines for chamber quantification [8]. ECG analysis
Surface 12-lead standard ECGs were recorded in each patient with a 25 mm/s paper speed at 10 mm/mV amplitude (Nihon Kohden Cardiofax M ECG-1350). fQRS was defined as the presence of an additional R wave (R’), a notch of a R or S wave, or the presence of fragmentation (more than one R’) in two contiguous leads on ECGs [6, 9]. All ECG measurements were analyzed by two cardiologists who were blinded to all other data. The intraobserver and interobserver variations for all measurements were less than 5% and therefore nonsignificant.
Statistical analysis
SPSS 26.0 (IBM Corp., Armonk, NY, USA) was used in the analysis of variables. Correspondence of univariate data to normal distribution was assessed using the Shapiro-Wilk Francia test, while the homogeneity of variance was evaluated by the Levene test. Independent Samples t- test was used in conjunction with Bootstrap results, while the Mann-Whitney U test was used with the Monte Carlo simulation technique in comparing two independent groups with each other according to the quantitative data. In the comparison of categorical variables with each other, the Pearson Chi-Square test was tested using Exact results, and the column proportions were compared with each other and expressed according to the Benjamini-Hochberg corrected p- value results. The Odds ratio was used with a 95% confidence interval to show how many times those with a risk factor were higher than those without. The sensitivity and specificity coefficients for the relationship between the classification separated by the cut- off value calculated according to the variables of the groups and the actual classification were investigated and expressed using the ROC (Receiver Operating Curve) curve analysis. In order to reveal the causality between the dependent variable and the independent variables in the form of a mathematical model, binary logistic regression analysis was tested with the backward method. Normally distributed continuous data were expressed as mean ± standard deviation. Continuous variables that were not normally distributed were expressed as median (percentile 25/percentile 75), and categorical variables were shown as n (%) in tables. The variables were examined with a 95% confidence level. A p-value < 0.05 was considered statistically significant.
Results
Demographic and echocardiographic characteristics of the study population are presented in Table 1. The current study consisted of 70 patients with ischemic stroke and 48 patients without ischemic stroke (control group). The mean age of the patients was 65.19±13.91 years, and 46.6% were male. Among all patients, 66.9% had HT, 33.9% had DM, and 37.3% were current smokers (Table 1). The patients with ischemic stroke had more comorbidities, including HT and DM than those without ischemic stroke (p = 0.048, and p = 0.048, respectively). The number of patients with fQRS in the ischemic stroke group was greater than in the control group (p = 0.009) (Table 1). There were not any significant differences between groups in respect of age, heart rate, and smoking (Table 1).
In the echocardiographic assessment; left atrium diameter and left ventricular end-systolic diameter (LVESD) were significantly higher in the ischemic stroke group than in the control group (p = 0.002, and p = 0.001, respectively). LVEF was also significantly lower in the ischemic stroke group than in the control group (p = 0.002) (Table 1).
After performing multiple logistic regression analysis, LVESD (p = 0.013, Odds ratio (OR) = 4.284, 95% Confidence interval (C.I.) = 1.366–13.432), tricuspid annular plane systolic excursion (TAPSE) (p = 0.016, OR = 1.362, 95% C.I. = 1.059–1.752), male gender (p = 0.017, OR = 3.292, 95% C.I. = 1.234–8.786), and left atrium diameter (p = 0.020, OR = 3.985, 95% C.I. = 1.240– 12.803) were found to be independent predictors of ischemic stroke (Table 2).
In order to determine the ideal cut-off values to predict the presence of ischemic stroke, ROC analyses were performed. An LVESD value of > 31 had a 70% sensitivity and 64.6% specificity; an LVEF value of ≤ 60 had an 88.6% sensitivity and 37.5% specificity; and a left atrium diameter value of > 41 had a 41.4% sensitivity and 83.3% specificity in detecting the presence of ischemic stroke [AUC 0.687, (p < 0.001); AUC 0.667, (p = 0.001); and AUC 0.660, (p = 0.001), respectively] (Figures 1a, 1b, and 1c).
Discussion
In the present study, we found that patients with ischemic stroke had greater LVESD and lower LVEF compared to those in the control group. In addition, the left atrium diameter was greater in patients with ischemic stroke. Although the frequency of fQRS was significantly higher in the ischemic stroke group compared to that in the control group (p = 0.009), it did not reach statistical significance in predicting ischemic stroke as an independent predictor (p = 0.115). To the best of our knowledge, the present study was the first to focus on evaluating the relationship between fQRS, reflecting abnormal ventricular depolarization and ischemic stroke.
Recent studies have demonstrated that the LVEF is strongly correlated with the formation of left atrial thrombus in patients with atrial fibrillation (AF) undergoing transesophageal echocardiography (TEE) examination. Rader et al. found that an LVEF <40% was an independent predictor of left atrial thrombus in 524 patients with AF, who underwent TEE [10]. Ayirala et al. performed a study in patients with AF, who had undergone TEE examination for the presence of left atrial thrombus, and they showed that LVEF was an independent predictor of left atrial thrombus [11]. Cinar et al. aimed to determine independent predictors of left atrial thrombus in acute ischemic stroke patients without AF using TEE. They demonstrated that a low LVEF was an independent predictor of left atrial thrombus [12]. Consistent with these studies, it was shown in our study that without AF, lower LVEF is associated with ischemic stroke. An LVEF <60% and an LVESD> 31 mm were found to be independent predictors of ischemic stroke. A left atrium diameter (>41 mm) was also found to be an independent predictor in our study in terms of its leading to left atrial thrombus and causing ischemic stroke.
Although the presence of fQRS on ECG seems to also be associated with non-cardiac conditions and cardiac diseases other than coronary artery disease (CAD) [13,14]; its importance and prognostic value have been well demonstrated in patients with CAD and acute myocardial infarction (AMI) [15,16]. The importance of fQRS was first described in patients with CAD, and as a sign of inhomogeneous ventricular conduction, the presence of fQRS on ECG indicates myocardial fibrosis and scar tissue in these patients [17,18]. fQRS also seems to be associated with impaired cardiac structure, unfavorable left ventricular remodeling, increased risk of adverse events and more severe CAD in patients with AMI [19, 20]. Although the association of fQRS with cardiovascular disease is well known, fQRS has not been adequately investigated in patients with ischemic stroke. In the current study, we aimed to assess the relationship between fQRS and ischemic stroke. We found that the frequency of fQRS was significantly higher in the ischemic stroke group compared to that in the control group. More frequent detection of fQRS, which is an indicator of impaired cardiac structure in the ischemic stroke group, can be associated with an increased LVESD and a decreased LVEF. Impaired cardiac structure may have paved the way for the cardio-embolic source even in the absence of overt thrombus. Given its association with left ventricular impairment and electromechanical dysfunction, fQRS may facilitate the anatomical-electrical substrate for thrombus formation and embolism. According to these inferences, fQRS, a simple ECG finding, may be utilized to identify high-risk ischemic stroke patients, in a follow-up of these patients and in any consideration of early anticoagulation treatment
Limitations
The present study had several limitations. This study had a limited number of patients (118). Due to the cross-sectional design of our study, we were unable to distinguish causality between fQRS and ischemic stroke clearly. More large-scale, multicenter studies with follow-up are needed to validate our findings.
Conclusion
In conclusion, the current study was the first to focus on evaluating the relationship between fQRS and ischemic stroke. We consider that our findings may be useful in terms of clinical applicability. We can say that patients with fQRS, who had a lower LVEF, a greater LVESD, and a larger left atrium represent a high-risk group for ischemic stroke. fQRS may be utilized in a follow-up of these patients and in any consideration of early anticoagulation treatment.
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.
Funding: None
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.
References
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2. Malik AN, Gross BA, Rosalind Lai PM, Moses ZB, Du R. Neurogenic Stress Cardiomyopathy After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg. 2015; 83(6):880‐5.
3. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993; 24(1):35‐41.
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5. Ramani A, Shetty U, Kundaje GN. Electrocardiographic abnormalities in cerebrovascular accidents. Angiology. 1990; 41:681‐6.
6. Das MK, Zipes DP. Fragmented QRS: a predictor of mortality and sudden cardiac death. Heart Rhythm. 2009; 6(Suppl. 3):8‐14.
7. Eyuboglu M, Yilmaz A, Dalgic O, Topaloglu C, Karabag Y, Akdeniz B. Body mass index is a predictor of presence of fragmented QRS complexes on electrocardiography independent of underlying cardiovascular status. J Electrocardiol. 2018; 51(5):833‐6.
8. Lang RM, Badano LP, Mor‐Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28(1):1‐39.
9. Bekar L, Katar M, Yetim M, Celik O, Kilci H, Onalan O. Fragmented QRS complexes are a marker of myocardial fibrosis in hypertensive heart disease. Turk Kardiyol Dern Ars. 2016; 44:554‐60.
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11. Ayirala S, Kumar S, O’Sullivan DM, Silverman DI. Echocardiographic predictors of left atrial appendage thrombus formation. J Am Soc Echocardiogr. 2011; 24(5):499‐505.
12. Cinar T, Hayiroglu MI, Cicek V, Asal S, Atmaca MM, Keser N, et al. Predictors of left atrial thrombus in acute ischemic stroke patients without atrial fibrillation: A single‐center cross‐sectional study. Rev Assoc Med Bras. 2020; 66(10):1437‐43.
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Mustafa Cam, Ümit Ali Malçok, Ercan Akşit, Özgül Ocak. Investigation of the frequency and relationship of fragmented QRS in patients with ischemic stroke. Ann Clin Anal Med 2021;12(Suppl 4): S414‐418
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Obstetric outcomes of ureteral catheterization during pregnancy, our clinical experience
Alev Esercan 1, Emre Ekmekci 1, Tuncer Bahceci 2
1 Department of Obstetrics and Gynaecology, 2 Department of Urology, Sanliurfa Education and Training Hospital, Sanliurfa, Turkey
DOI: 10.4328/ACAM.20621 Received: 2021-04-03 Accepted: 2021-07-10 Published Online: 2021-07-29 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S419-422
Corresponding Author: Alev Esercan, Sanliurfa Education and Training Hospital, Obstetrics and Gynecology Department, Sanliurfa, Turkey. E-mail: alevesercan@gmail.com P: +90 5052634609 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6215-6532
Aim: Hydronephrosis is a common condition in pregnancy, especially on the right side. Probable causes are ureteral stones and the physiological state of pregnancy. Conservative treatments are preferred unless the flank pain persists and becomes intractable, or if additional complications, including recurrent resistant urinary tract infections, persist or deterioration of the renal function occurs. In this study, we aimed to determine obstetric outcomes of ureteral catheterization during pregnancy.
Material and Methods: The data of patients who had ureteral catheterization during pregnancy due to intractable flank pain and hydronephrosis between June 2018-July 2020, were collected from the hospital data system. Pregnant women with singleton pregnancies with intractable flank pain and hydronephrosis who were treated with double J stent (DJS) were included in this study. Mean or median values were used for descriptive analysis of the characteristics of data for the normal distribution. Categorical data were given as percentages. Chi-square and Fisher Exact tests were used for categorical data.
Results: Thirty-six pregnant women had ureteral catheterization (DJS) during pregnancy at various gestational ages. The mean age of women was 24.82± 3.78 (20-34) years. Eight out of 36 pregnant women were primigravid. The mean gestational age at DJS insertion time was 23.14 ± 5.68 (12-36) gestational weeks. In our study, among hydronephrosis patients, the normal rate of vaginal birth was significantly higher than the cesarean rate (p:0.03). There was no significant difference between the side of hydronephrosis according to the type of birth (p>0.05) There was no significant difference between the sides of hydronephrosis according to urinary tract infections (p>0.05).
Discussion: DJS treatment can be chosen without anxiety of premature birth.
Keywords: Hydronephrosis; Double Stent Insertion; Ureteral Stone; Urinary Tract Infection
Introduction
Several changes occur in the urinary system during pregnancy. There are also significant changes in the urinary system anatomy, as well as functional changes. The renal calyces and ureters dilate in more than 80% of pregnancies by mid- gestation and increase in size as the pregnancy progresses. Dilatation is more common on the right side than on the left [1]. The predisposition of physiologic dilatation on the right side is caused by compression on the right ureter from the dextrorotated uterus. Also, the left ureter is protected from compression by a gas-filled sigmoid colon [1]. Clinically, these changes result in an increased risk of ascending urinary tract infections and urinary system calculi due to urinary stasis. Also, sonographic difficulties occur when differentiating real pathological conditions from physiologic changes like hydronephrosis [2].
Although hydronephrosis is a common condition and may be severe with advancing gestation, it has a poor correlation with maternal symptoms. Flank pain is not associated with the degree of hydronephrosis during pregnancy. Furthermore, physiological changes in the urinary tract during pregnancy may not only predispose the patient to urolithiasis formation, but may also pose a diagnostic challenge. Although physiologic hydronephrosis of pregnancy is usually asymptomatic, it may cause flank pain lateralizing to the affected kidney. Conservative treatments are preferred unless the flank pain persists and becomes intractable, or additional complications, including recurrent resistant urinary tract infections, persist, or deterioration of the renal function occurs [2, 3].
Urolithiasis is the other frequent cause of flank pain in pregnancy. The incidence of symptomatic urinary calculi does not change in pregnancy, and the incidence has been reported as 1/244 to 1/3300 and is similar to that in non-pregnant women of the same age [4]. Urolithiasis symptoms frequently occur in the second and third trimesters. The association of symptomatic urolithiasis with preterm labor and spontaneous rupture of membranes has been reported in several studies. This association seems to be significant [5]; 70-80% of symptomatic calculi passage spontaneously and do not necessitate any surgical intervention [6].
Ureteral catheterization and percutaneous nephrostomy are preferred management methods for symptomatic urolithiasis and intractable flank pain in pregnancy. However, it is a controversial issue whether to treat or not, due to the risk of adverse effects of surgery and stent on pregnancy. In this study, we aimed to determine obstetric outcomes of ureteral catheterization during pregnancy.
Material and Methods
This is a retrospective study. The data of patients who underwent ureteral catheterization during pregnancy due to intractable flank pain and hydronephrosis between June 2018-July 2020 were collected from the hospital data system. Gestational ages of pregnancies were described according to the last menstrual period date and were verified by first trimester ultrasonographic fetal biometric measurements.
Before the surgical procedure, urinary ultrasonography (USG) was performed for the diagnosis and grading of hydronephrosis. The hydronephrosis grading was made according to the grading system of the Society of Fetal Ultrasound (SFU) [7]. According to this grading system, there is no hydronephrosis (HN) at grade 0. At grade 1, only the renal pelvis is visualized, HN grade 2 is present when a few but not all calices are identified in addition to the renal pelvis. HN grade 3 requires that virtually all calices are seen. HN grade 4 may have a similar appearance of the calices as grade 3, but the involved kidney has parenchymal thinning compared to the normal side.
Pregnant women with singleton pregnancies with intractable flank pain and hydronephrosis who were treated with double J stent (DJS) were included in this study. Pregnant women whohadrecurrentDJSinsertioninthesamepregnancy,twin pregnancies, patients with a history of recurrent preterm birth, patients who had DJS, but gave birth due to other indications were excluded. Preterm birth was defined as birth of a baby before 37 weeks of gestation
Pregnant women who had hydronephrosis with intractable flank pain underwent double J stent (DJS) ureteral catheterization treatment. Intractable pain was evaluated using the Visual Analog Scale (VAS) (no pain: 0–4 mm, mild pain: 5–44 mm, moderate pain: 45–74 mm, and severe pain: 75– 100 mm) [8]. Surgical procedure: Informed, written consent was obtained before the procedure. Sterile urine was provided by all patients before the surgery. DJS implementation was performed in lithotomy position under spinal anesthesia. An 8.5/10.5 Fr ureteroscope was introduced into the ureteral orifice. A sensor PTFE-Nitinol Guidewire was passed through the ureteroscope into the renal collecting system and a 6 Fr DJS was placed by sliding over the sensor. After making sure that the DJS was in the renal collecting system with USG peroperatively, surgical procedure was completed.
All pregnant women were followed up until birth after the surgical procedure. Ages of patients, gravidity, parity, gestational age at DJS insertion, symptoms before DJS, gestational age at birth, indication of birth, side of hydronephrosis, presence of urinary stone, presence of urinary infection, laboratory findings at DJS insertion, presence of pregnancy complications, neonatal outcome were evaluated.
Written informed consent for participation in the study was obtained from all the patients, and the study was conducted in accordance with the Declaration of Helsinki.
Ethical approval was taken from Harran University Faculty of Medicine Medical Research Studies Ethics Committee (HRU/20.18.01).
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS.22, IBM SPSS Statistics for Windows, Version 22.0, IBM Corp., Armonk, NY, USA). The Kolmogorov–Smirnov test were used to verify the normality of distribution. Mean or median values were used for descriptive analysis of the characteristics of the data for normal distribution. Categorical data were given as percentages. Chi- square and Fisher Exact tests were used for categorical data. T-test was used for calculating 2 independent means, for all tests, significance level was defined as p <0.05.
Results
Thirty-six pregnant women underwent ureteral catheterization (DJS) during pregnancy at various gestational ages between June 2018 and July 2020. The ,ean age of women was 24.82± 3.78 (20-34) years. Eight out of 36 pregnant women were primigravid.
Indications for surgical intervention were ureteral stones in 5 patients, symptomatic hydronephrosis in 31 patients due to the physiological state of pregnancy. A total of 34 patients had grade 3 hydronephrosis, only 2 patients had grade 4 hydronephrosis. The hydronephrosis side among pregnant women who had surgical intervention was predominantly right- sided (p<0.05). Four patients (11%) had hydronephrosis on the left side, 32 patients (89%) had onthe right side, but the side of hydronephrosis according to gravidity was not significant. The mean gestational age at DJS insertion time was 23.14 ± 5.68 (12-36) gestational weeks. DJS of all patients were withdrawn postpartum. Eleven patients (30.6 %) had a cesarean section, 25 patients had vaginal delivery (69.4%). Thirteen (36.1%) patients, had urinary system infection during pregnancy. The mean gestational age at birth was 36.5±2.65 (29-40) gestational weeks. None of the patients had a history of DJS insertion at previous pregnancy. The mean interval time between DJS and birth was 13.23±5.95 (1-24) gestational weeks.
Discussion
Hydronephrosis is a common condition during pregnancy due to mechanical factors and hormonal changes with the increased circulating estrogen, progestational hormones and prostaglandin-like agents [9]. Hydronephrosis is common, especially in the second and third trimesters. The fact that ureteral dilatation is more frequent starting from the 2nd trimester and progresses faster supports the theory that the ureters are put under pressure by the pregnant uterus.
In our study, the mean gestational age of DJS inserting time was 23.14 ± 5.68 (12-36) gestational weeks. There was no statistically significant difference between gravidity and side of hydronephrosis according to DJS inserting time (p>0.05). Hydronephrosis of only 2 patients out of 36 was determined in the first trimester (12th week). One of these was primigravid, and one was multigravid patients.
Dilatations up to Grade II in the right kidney are considered normal and usually do not require any intervention [10]. In our study, 34 patients had grade 3 hydronephrosis, only 2 patients had grade 4 hydronephrosis. There was no statistically significant difference between the side of hydronephrosis according to the grade of hydronephrosis(p>0.05).
In our study, we included DJS inserted patients due to intractable flank pain. The mean VAS score in our patients was 9.2±0.62. This score was at the level, describing severe pain (75– 100 mm). There was no statistically significant difference between the groups according to the side of hydronephrosis(p>0.05). Dilatation is seen 3 times more in the right kidney than in the left. One of the reasons why dilatation is seen more on the right side is that the sigmoid colon on the left side relatively protects the left ureter from compression. Since the right ureter crosses the iliac vessels more proximally, pressure and tension are higher in the right ureter. In addition, the dextrorotation of the growing uterus in the midtrimester is also an important factor [11, 12]. In our study, 4 patients (11%) had hydronephrosis on the left side, 32 patients (89%) had on the right side. There was no significant difference between the number of patients according to the side of hydronephrosis.
In the literature, in cases of left ureteral dilatation, ureteral stones are more common [13]. In our study, only one of the total 4 left-sided ureteral dilatations was associated with ureteral stone (p>0.05). Although Stothers et al reported that urinary stones are more common in multipar women [14], there was no statistically significant difference between primi/multigravid patients according to the presence of the ureteral stone (p>0.05) in our study. There was also no significant relationship between the ureteral stone and side of hydronephrosis (p>0.05). Eleven patients (30.6 %) had a cesarean section, 25 patients had vaginal delivery (69.4%). In our study, among hydronephrosis patients, normal vaginal birth rate was significantly more than the cesarean rate (p:0.03). There was no cesarean section in primigravid group. In our hospital, we encourage vaginal delivery, unless emerging situations and the necessity for cesarean occur during labor but there was no significant difference according to the side of hydronephrosis (p>0.05).
The mean gestational age at birth was 36.5±2.65 (29-40) gestational weeks. We categorized patients as preterm birth (<37 weeks), no preterm birth (≥37 weeks); 12 (33%) patients had preterm birth; there was no significant difference between the side of hydronephrosis (p>0.05). There was no significant difference between the sides of hydronephrosis according to urinary tract infections (p>0.05). The mean interval time between DJS inserting time and birth was 13.23±5.95 gestational weeks. There was no significant difference between the sides of hydronephrosis according to the interval time between DJS inserting time and birth (p>0.05).
Although a study by Faundes et al found that hydronephrosis was seen in primigravid [9], in our study, the number of multigravid patients was more than primigravid (p>0.05). The mean gravidity was 3.4±1.80 pregnancies.
Our study has some limitations. We included only patients who underwent DJS insertion due to hydronephrosis with intractable flank pain, a limited number of 36 patients. Our indication was restricted to only this indication. The strength of our study was that our hospital is a single-center for the diagnosis and treatment of pregnant patients with hydronephrosis. Thus, we can easily follow up our patients. Although hydronephrosis patients had intractable flank pain, preterm birth and cesarean rates did not increase.
Conclusion:
Although hydronephrosis is a common condition in pregnancy, only a small part of patients need invasive treatment, and invasive treatment can be chosen without anxiety of premature birth.
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.
Funding: None
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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Alev Esercan, Emre Ekmekci, Tuncer Bahceci. Obstetric outcomes of ureteral catheterization during pregnancy, our clinical experience. Ann Clin Anal Med 2021;12(Suppl 4): S419-422
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The experience of an emergency intensive care unit during the COVID-19 pandemic: A retrospective cohort study
Guven Ramazan 1, Cander Basar 1, Genc Yavuz Burcu 2, Unal Ramazan 1, Ak Ertugrul 1, Fettahoglu Salih 1
1 Department of Emergency Medicine, University of Health Sciences, Kanuni Training and Research Hospital, 2 Department of Emergency Medicine, University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20622 Received: 2021-03-29 Accepted: 2021-05-28 Published Online: 2021-06-12 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S423-427
Corresponding Author: Ramazan Guven, University of Health Sciences, Kanuni Training and Research Hospital, Department of Emergency Medicine, Atakent Mh, Turgut Özal Bulvari No:46/1, 34303, Küçükçekmece, Istanbul, Turkey. E-mail: drramazanguven@gmail.com P: +90 5324935995 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4129-8985
Aim: The availability of an intensive care unit in the emergency departments (EDICU) is one of the most important issues discussed recently in terms of in- creasing the quality of emergency patient care. In this study, we aimed to investigate the clinical characteristics and factors affecting the mortality in patients with COVID-19.
Material and Methods: This is a retrospective study of patients with COVID-19 hospitalized in EDICU. Patients were divided into mortality and survival groups, and the clinical characteristics of these groups were compared.
Results: A total of 38 patients were included; 47.4% (n = 18) were in the survival group. Oxygen saturation level was significantly different between the mortal- ity and survival groups [78.0% (63.7-83.0) vs 88.5% (81.5-93.2), p = 0.001]. Patients in the mortality group had higher plasma levels of lactate dehydrogenase (LDH), procalcitonin, C-reactive protein (CRP), lactate, ferritin and D-dimer. Univariate regression analysis showed that oxygen saturation, LDH, CRP and endotracheal intubation (ETI) were significant markers in predicting mortality (p = 0.011, p = 0.035, p <0.001, respectively). A CRP level ≥ 91.9 mg/L predicts mortality with a sensitivity of 66.6% and a specificity of 80.0% (AUC: 0.781, 95% CI: 0.617- 0,898).
Discussion: This study showed that oxygen saturation, ETI, LDH and CRP levels were significantly successful in predicting mortality. Therefore, early administra- tion of antibiotherapy and timely use of ETI may increase the quality of patient care.
Keywords: COVID-19; Emergency Medicine; Intensive Care Unit; Mortality Rate
Introduction
The COVID-19 virus, which caused the greatest pandemic of the last century, rapidly causes pneumonia and acute respiratory distress syndrome (ARDS), as well as high contagiousness [1]. In the first wave of the pandemic, there were patients with ARDS table waiting for intensive care beds for days in the emergency services of many European countries, especially Italy, Spain and England [2]. In order to avoid a similar picture in our country, the intensive care capacities of hospitals, especially those in Istanbul, have been increased across the country or the opening of new intensive care hospitals has been accelerated [3]. Critical care patients who are diagnosed as an emergency, might be cared for within 6 hours, sometimes more than twenty-four hours at ER, in case of intensive care units are totally in service for others [4]. In this case, emergency physicians also undertake the long-term critical care of these patients [5]. However, it is known that as the length of stay in emergency services increases, the general condition of the patients worsens [6]. Therefore, the EDICU model has been adopted in some emergency services to increase the quality of care of critical patients in emergency services and to reduce the length of stay [7]. Models, such as resource intensivist, hybrid and stand-alone, are used for EDICU [8]. EDICU has many benefits in the management of critical emergency patients, such as ensuring airway management using more advanced techniques such as bronchoscopy and more effective intervention of septic shock patients [9]. In addition, EDICU has also intensivists or emergency specialists who work for critical patients, communicate with other established ICUs, and reduce the length of stay of critical patients [10].
This study aimed to share the experiences regarding the follow- up and treatment of critical COVID-19 patients who were taken to EDICU with severe respiratory distress in the first wave of the pandemic.
Material and Methods
Study Population
This study was conducted among the patients hospitalized with the diagnosis of COVID-19 in the EDICU between March 10, 2020 and June 30, 2020, when the first case was seen in our country. EDICU serves as the first and unique intensive care unit in the emergency room in Istanbul, managed by emergency doctors. EDICU was established in order to manage the follow- up and treatment with intensive care discipline by admitting patients who who have been indicated for hospitalization in the intensive care unit after the emergency examinations and treatments were performed.
EDICU is managed by emergency specialists and is mostly a stand-alone model. EDICU is an isolated separate unit with ICU beds near the emergency service main area. During the first wave of the COVID-19 pandemic, patients with ARDS who admitted to the emergency room were first managed in EDICU as long as there was available beds. Emergency physicians working in EDICU have attended critical care courses and have critical care certificates. Doctors, working in EDICU, are only responsible for this area in EDICU shifts. Emergency specialists working in EDICU work in other areas of the emergency service in the remaining shifts.
For the diagnosis of COVID-19, either positive RT-PCR test ty or Chest CT scan in favor of COVID-19 was accepted. The Chest CT report is an official document of the hospital and is made by radiologists. The definition of suspicious COVID-19 by the Ministry of Health of the Republic of Turkey was determined according to current guidelines [11].
Study Design and Data collection
For the data of this retrospective study, U06.0 and U07.3 International Classification of Disease (ICD) diagnosis codes from the hospital automation system and EDICU’s archive were used. The patients included in the study were examined in two groups according to the mortality. The first group was the patients who were discharged directly from the intensive care unit as a result of the improvement of the medical condition (survival group), and the second group was the mortality group in the intensive care unit. This study was approved by the local ethics committees and the Ministry of Health with a clinicaltrial. gov ID of NCT04480060.
This retrospective, multi-center, observational study was approved by the Institutional Review Board of Kanuni Sultan Suleyman Research and Training Hospital in Istanbul, Turkey (no. 2020-KSSH-1331). The Advisory Board on Coronavirus Research of the Turkish Ministry of Health approved the study with a clinicaltrial.gov ID of NCT04479137.
Statistical analysis
All statistical analyses (sensitivity, specificity, negative predictive value, positive predictive value) were performed on MedCalc Statistical Software version v19.4.1 (MedCalc Software, Ostend, Belgium). The data of the patients are expressed as median (quartiles) for distributed data and percentage for categorical variables. The normality of the distribution of continuous variables was examined by the Shapiro-Wilk test. Between-group comparisons of normally distributed parameters were conducted by Student’s t-test; the Mann–Whitney U-test was applied for non-normally distributed parameters.
Results
Eighty-one patients were admitted to EDICU between the study dates; of them, 38 patients were included in the study because 43 patients were hospitalized for reasons other than COVID-19. Among those included in the study, 65.8% (n = 25) were male, with the median (quartiles) age of 70.0 (55.0-83.5) years, 34.2% (n = 13) were female, with the median (quartiles) age of 64.0 (42.5-85.5) years. While 47.4% (n = 18) of these 38 patients were discharged from EDICU and/or transferred to the service (survival group), 52.6% (n = 20) resulted in death (mortality group). When the RT-PCR results of the patients included in the study were examined, it was seen that 43.8% of the mortality group (n = 7) were positive, 18.8% of the survival group (n = 3) were positive, and 6 patients were inadequate or inappropriate specimen collection. Among the application complaints of the patients included in the study, 68.4% (n = 26) had shortness of breath, 36.8% (n = 14) had cough, 31.6% (n = 12) had unconsciousness, 18.4% (n = 7) malaise and malaise, 10.5% (n = 4) had fever (> 38 ° C). When the vital signs of the patients included in the study were examined, the systolic blood pressure median (quartiles) value was 120.5 (102.0-135.7) mmHg, diastolic blood pressure median (quartiles) value 76.0 (64.7-82.2) mmHg, the median (quartiles) value of the pulse measured per minute was 92.0 (76.7- 115.5), oxygen saturation median (quartiles) value was 82.5% (74.5- 91.2), body temperature median (quartiles) 37.1°C (36.1-37.6). Hypertension in 47.4% (n = 18) of patients, diabetes mellitus in 31.6% (n = 12), congestive heart failure in 21.1% (n = 8), coronary artery disease in 15.8% (n = 6), 15.8% (n = 6) had chronic obstructive pulmonary disease, 13.2% (n = 5) had renal failure, and 13.2% (n = 5) had previous cerebrovascular disease. The rates and significance levels of the characteristics of the study population according to the study groups (mortality group vs survival group) were examined. There was no significant difference in age (median, quartiles; 72.0 (56.2-85.7) vs 61.5 (44.0-78.5, p = 0.128) and sex (male; 70.0% (n = 14) vs 61.1% (n = 11), p = 0.564) between the mortality group and the survival group. Considering the significance level of the difference between mortality group and survival group according to the presence of comorbidity, those in the mortality group had a significantly higher rate of renal failure than the survival group (25.0% (n = 5) vs 0.0% (n = 0), p = 0.048). Only the baseline oxygen saturation level was significantly different between the groups (mortality vs survival) (78.0% (63.7-83.0) vs 88.5% (81.5-93.2), p = 0.001) among vital signs. While there was no significant difference in the application APACHE II score (20.0 (11.5-30.0) vs 15.5 (10.7-18.2), p = 0.203) in the mortality group compared to the survival group, the admission SOFA score (3.0 (3.0-6.0) vs 2.0 (2.0-3.0), p = 0.034) was higher in the mortality group.
The levels and intergroup significance levels of the first laboratory parameters taken during admission to intensive care according to the study groups are shown in Table 1.
The distribution and significance levels of the interventions and treatment by groups are shown in Table 2. Accordingly, it was observed that patients who required endotracheal intubation (ETI) resulted in mortality at a high significance level (16 (80.0) vs 1 (5.6), p <0.001). In the mortality group, 95% of the patients had secondary bacterial infection (p <0.001).
The results of univariate and multivariate logistic regression analysis applied to determine the independent risk factors (age, sex, vital signs, comorbidities, laboratory parameters, interventions) affecting mortality of patients hospitalized in EDICU with the diagnosis of COVID-19 are shown in Table 3. Univariate regression analysis demonstrated that admission oxygen saturation, LDH, CRP and ETI were significant markers in predicting mortality (p = 0.011, p = 0.035, p <0.001, respectively). In order to distinguish the mortality group from the survival group, when the cut-off value of the CRP level was taken as 91.9 mg / L in the ROC curve, the sensitivity was 66.6%, specificity 80.0%, positive likelihood ratio 3.3, negative likelihood ratio 0.4 (AUC: 0.781, 95% CI: 0.617- 0,898) (Figure 1).
Discussion
In this study, the experiences of managing critical COVID-19 patients admitted to the emergency department in EDICU and the factors affecting mortality were evaluated. In this study, which was examined in two groups as mortality and survival, it was observed that only the oxygen saturation level of the vital signs showed a significant difference between the groups (78.0 (63.7-83.0) vs 88.5 (81.5-93.2), p = 0.001), and low oxygen saturation level increased the risk of mortality (OR 0.864; 95% CI 0.772-0.967; p = 0.011). Among laboratory parameters, CRP was found to differ significantly between the groups (157.1 (76.3-289.6) vs 52.8 (19.6-134.1), p = 0.003) and high CRP was the best laboratory marker for predicting mortality (OR: 1.010; 95% CI 1.002-1.018; p = 0.011). A higher rate of secondary bacterial infections was found in the mortality group (p <0.001). All interventions that had a role in the literature in the pandemic period, such as ECMO, high flow oxygen and plasma, were used for the patients hospitalized in EDICU. It was observed that ETI was the best marker for predicting mortality, and 95% (19/20) of patients who received ETI died. A study conducted on patients hospitalized with COVID-19 defined 5 predictors of intensive care admission included LDH, procalcitonin, pulse oxygen saturation, smoking, and lymphopenia, and concluded that there are 7 predictors of mortality: heart failure, chronic obstructive pulmonary disease (COPD), heart rate, and age [12]. In a meta-analysis investigating the relationship between laboratory parameters and the severity of COVID-19 and mortality, the increase in D-dimer and procalcitonin levels was reported to be associated with poor prognosis and was one of the important markers of mortality [13]. In this meta- analysis, ferritin and CRP were parameters that are indicators of mortality and poor prognosis. In our study, the elevation of procalcitonin, ferritin, D-Dimer and CRP was significantly higher in the mortality group. However, among the laboratory parameters only CRP was significant in predicting mortality in regression analysis. Although a sensitivity rate of 66.6% was obtained for the CRP level of 91.9 mg/L in predicting mortality in EDICU, it had a better specificity rate of 80.0%. In a study investigating laboratory parameters of mild-to-moderate COVID-19 patients, progressing from non-severe to severe condition, it was concluded that procalcitonin and lymphocyte did not have a significant effect in distinguishing non-severe and severe groups, and CRP had high level of discrimination [14]. We suggest that the reason why CRP predicted the mortality best, might be associated with the higher rate of secondary bacterial infection in the mortality group compared to the survival group.
One of the controversial issues in critical COVID-19 patients is the timing of the application of ETI. In this regard, there are different opinions about whether early ETI gives better results or ETI should be reserved for patients who had no improvement after having high flow nasal cannula (HFNC) and/or continue noninvasive mechanic ventilation [15]. In patients followed up in EDICU, the ETI decision was made according to the clinical status and blood gas results.
A total of 80% (n = 16) of the patients in the mortality group and 5.6% (n = 1) of the survival group were required ETI during follow-up. Prospective multi-center studies are needed to define when and what criteria ETI should be applied in critical COVID-19 patients. In a case series of 24 patients referred to ICU from 9 hospitals in Seattle-area hospitals, 50% of the patients followed in ICU died in the first 18 days [16]. In a retrospective observational study conducted in China in the first months of the pandemic, the mortality rate of COVID-19 patients followed in ICU was 61.5% [17]. In our study, the mortality rate was 52.6%. The COVID-19 pandemic, which started in China in December 2019, was seen for the first time in our country in March 2020. Despite the possibility of increasing the need for intensive care in the emergency, the number of EDICU beds doubled, as well as the number of nurses and mechanical ventilation.
Limitations
The limitations of this study can be defined as it was a single- center study, and the other limitation was that the statistical method used to calculate the differences between groups of treatments was the Fisher Exact test instead of the Pearson Chi-Squared test, due to the small sample size. It is thought that this was the reason,even if there was a difference between the groups, it could not be shown by statistical analysis. Conclusion
In conclusion, EDICU had similar mortality rates and similar results with ICUs of other hospitals. Secondary infection risk should be taken into consideration for patients followed up in ICU and it should be considered that this may be related with mortality. Therefore, early antibiotics may be recommended. CRP can be used to predict mortality in patients with ICU. A standard protocol is needed to be developed regarding when ETI should be applied. In the COVID-19 pandemic, EDICU is shown to be effective in improving the quality of care by reducing the length of stay of critical patients in the emergency room.
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.
Funding: None
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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Healthcare personnels’ technostress and individual innovativeness levels: Digital hospital example
Zülfünaz Özer 1, Semanur Kumral Özçelik 2, Ayşe Nefise Bahçecik 1, Suna Ekmekçioğlu Uçar 3
1 Department of Nursing, Faculty of Health Sciences, Istanbul Sabahattin Zaim University, Istanbul, 2 Department of Nursing, Faculty of Health Sciences, Marmara University, Istanbul, 3 Institute of Science Internal Diseases Nursing, Istanbul Sabahattin Zaim University, Istanbul, Turkey
DOI: 10.4328/ACAM.20623 Received: 2021-03-29 Accepted: 2021-06-07 Published Online: 2021-06-18 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S428-432
Corresponding Author: Zülfünaz Özer, Department of Nursing, Faculty of Health Sciences, Istanbul Sabahattin Zaim University, Istanbul, Turkey. E-mail: zulfinazozer@gmail.com P: +90 2126928978 F: +90 212 6938229 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2431-2346
Aim: In this study, we aimed to investigate the relationship between healthcare personnels’ technostress and individual innovativeness levels.
Material and Methods: The descriptive, correlative, and cross-sectional study was conducted with 156 healthcare personnel working at a hospital with a digi- tal hospital certificate. The data were collected using an Information Form, Technostress Scale (TS) and Individual Innovativeness Scale (IIS). The data were analyzed using descriptive statistics, Pearson correlation analysis and multiple linear regression analysis.
Results: The total mean score of the healthcare personnel from TS was 2.57±0.43, with the highest score being from the techno-uncertainty (3.07±0.75), and the lowest from the techno-insecurity (2.06±0.64) sub-dimensions. The total mean score from IIS was 69.07±8.88. A statistically significant negative correlation was found between the individual innovativeness levels of the healthcare workers and their levels of technostress scale in total and from the techno-complexity, and techno-insecurity and techno-overload sub-dimensions. A statistically significant positive correlation was found between the individual innovativeness levels of the healthcare workers and their levels of techno-uncertainty. Techno-insecurity negatively affected individual innovativeness, and techno-uncertainty had a positive impact.
Discussion: The technostress level of the healthcare personnel was at a moderate level, the individual innovativeness category was in the interrogator category, and techno-insecurity and techno-uncertainty were significant predictors that predicted the individual innovativeness of the healthcare personnel. As individu- als’ technostress levels increased, their perception of innovations decreased.
Keywords: Digital Hospital; Healthcare Personnel; Innovativeness; Technostress
Introduction
Today, the complexity and rapidly changing nature of information and communication and the difficulty of learning new technologies require more intense work [1]. Some individuals may experience negative emotions of concern, stress, anxiety and even fear due to the use of technology [2]. This stress is called technostress as it is caused by changes in technologies [3].
The concept of technostress is defined with terms like cyberphobia, computer phobia, computer stress and negative computer behaviors [2]; however, considering the use of information and communication technologies, it is also defined as the problems like stress, inability to cope with continuously developing technology and inadequacy in adaptation to these technologies by users in workplaces, arising from multitasking duties, permanent connection, knowledge overload, frequent system updates, continuous re-learning and corporate use of information and communication technologies [4,5]. As technostress develops, individuals become alienated from existing or changing technologies in their institutions and become afraid of making mistakes. Emotions such as worry, anxiety, and concern experienced by the staff cause them to develop a prejudice against technological tools, to have doubts and to have a limited sense of self-efficacy [6].
Tarafdar et al. (2010) explain technostress in the following five different dimensions: Techno-overload occurs when people using information and communication technologies work harder and faster. Techno-invasion requires employees to be constantly connected and available everywhere. Techno-complexity stems from the fact that rapidly and continuously developing technologies require the use of new applications, hardware and software whereby users need to spend more time and effort to understand new applications. Techno-insecurity arises when users fear losing their jobs because of those who are better at using new applications and technologies. Techno-uncertainty occurs when constant changes and advancing technologies do not give employees the opportunity to experience and specialize in certain applications, where employees feel “unsettled” because their knowledge has become “obsolete” in the face of rapidly changing information [4]. Although they may be enthusiastic early on, their constant need for renewal results in frustration and anxiety. Anxiety, technophobia, fear and worries against computer technologies caused by technostress can change the perception and behavior of individuals towards innovations and make them resist innovation [1].
Individual innovativeness is defined as the attitudes of people towards innovations, acceptance of technological developments, willingness to change and going beyond the known by taking risks [7]. Within the scope of its goals in the new era, Turkey focuses on digitization of hospitals to improve health services and increase efficiency [8], and during this process individuals have to meet different information and communication technologies [1].
Digital hospitals are hospitals where all operations are run, monitored and managed through a full automation system and advanced technology is utilized. In these hospitals, all information systems within the health institution are fully integrated with all kinds of medical and non-medical technologies. Reliable data flow standards are determined, healthcare personnel are provided with mobile access to the necessary information from anywhere with less time and energy, with paperless work and no manual operations [9]. On the other hand, healthcare services in digital hospitals are becoming more complex day by day, and employees are becoming computer-dependent [10]. Although technology has been introduced and recognized as timesaving, it has increased the expectations that should be met in institutions [2]. It has been stated that individuals feel psychological and physical fatigue due to their involvement with information and communication technologies [6]. Technostress is widely recognized as a phenomenon associated with the “dark side” of technology [4].
The ongoing technological innovations in healthcare institutions and corresponding modifications in the job descriptions of healthcare personnel lead to changes in expectations and differentiation in the attitude and perception towards innovations [11]. In this context, considering the growing complexity of technological innovations and developments [1], it is of great importance that healthcare personnels’ attitudes and perceptions towards technology or innovation are not adversely affected and that the technostress they may experience do not prevent innovation. Therefore, studies analyzing technostress in healthcare personnel are needed. The purpose of the study, therefore, was to investigate the relationship between healthcare personnels’ technostress and level of individual innovativeness.
Material and Methods
The design of the study
This descriptive, correlative, and cross-sectional study was conducted in November 2019. The questionnaires were distributed to the healthcare personnel and the completed questionnaires were collected back from them.
Population and sample
This study was conducted at a digital hospital in Turkey. The population of the study was the healthcare personnel working (300 healthcare workers) in the hospital, and the sample (156 healthcare workers) consisted of those who accepted to participate in the study.
Data collection tools
The data were collected using the Information Form, the Technostress Scale and an Individual Innovativeness Scale. The Information Form consists of 13 questions, including the demographic and professional characteristics of healthcare personnel, and their views on technology use.
The Technostress Scale (TS) was developed by Tarafdar et al. (2007), and its reliability and validity were established by Ilgaz et al. (2016). The scale consists of 23 items and 5 sub- dimensions (techno-overload-6 items, techno-invasion-3 items, techno-complexity-5 items, techno-insecurity-5 items and techno-uncertainty-4 items). Items are measured on a 5-point Likert- type (1 strongly disagree, 5 strongly agree) scale. The technostress level increases with an increase in the individual score (Ilgaz G, Özgür H, Çuhadar C. The Adaptation of Technostress Scale into Turkish. Abstracts of the 11th International Balkan Education and Science Congress. 2016; Poreč, Croatia) [12]. In this study, the total and sub-dimension values of the Cronbach Alpha scale varied between 0.69 and 0.81.
The Individual Innovativeness Scale (IIS) was developed by Hurt et al. (1977), and its reliability and validity were established by Sarıoğlu Kemer and Altuntaş (2017). The scale consists of 18 items and 3 sub-dimensions (opinion leadership, resistance to change, risk- taking). Items are measured on a 5-point Likert- type (1 strongly disagree, 5 strongly agree) scale.
The scale is evaluated according to the total score. When calculating the total score, items in the resistance to change dimension are reverse coded. Individuals who score 57 and less on the scale are classified as traditionalists, those who score between 58-65 as skeptical, those who score between 66-74 as interrogators, those who score between 75-82 as pioneers, and those who score 82 and above as innovative [14]. In this study, the Cronbach Alpha Value of the scale was found to be 0.89. Evaluation of data
The demographic and occupational characteristics of healthcare workers and their views on the use of technology were expressed by number, percentage, mean and standard deviation, technostress and individual innovation levels with the minimum, maximum, average and standard deviation, and the relationship between individual innovativeness levels and technostress levels using Pearson’s correlation analysis. Multiple regression analysis was performed to determine the predictive power of the sub-dimensions of the technostress scale for innovativeness. Fom the technostress dimensions, technostress-complexity, technostress-insecurity and technostress-uncertainty were accepted as independent variables, and individual innovativeness as dependent variables in the analysis.
Ethical considerations
Approval was obtained from Istanbul Sabahattin Zaim University Ethics Committee (31 October 2019, number 2019/09). This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Volunteering participants were included in the study and their personal identity information was kept confidential. In addition, consent was obtained from individuals participating in the study after the purpose of the study had been explained to them. Participation relied on the provision of verbal consent.
Results
The mean age of the participants was 35.58 ± 7.67 years, 59.6% of them were women, 79.5% were married, 42.3% were dentists, 20.5% were nurses, 20.0% were health technicians, 14.7% were clinical support workers and 2.5% others (Physician, Sociologist). The average time of working in the profession was 12.28 ± 8.12 years, and the average working time in the institution was 6.88 ± 4.77 years; 95.5% of the participants had a computer and 97.4% could use a computer; 51.3% stated that the hospital information system was easy, 82.1% received training on the hospital information system, 58.1% thought that the training they received was adequate and 64.1% found themselves competent in using technology.
The total mean score of the healthcare personnel from TS was 2.57±0.43, with the highest score being from the techno- uncertainty (3.07±0.75), and the lowest from the techno-insecurity (2.06±0.64) sub-dimensions. The total mean score of healthcare personnels from IIS was 69.07±8.88 (Table 1).
A statistically significant negative correlation was found between the healthcare personnels’ individual innovativeness levels and their levels of technostress total (r=-0.337; p<0.001) and techno-complexity (r=-0.405; p<0.001) and techno- insecurity (r=-0.579; p<0.001) and techno-overload (r =-0.197; p<0.05) subdimensions. A statistically significant positive correlation was found between the healthcare personnels’ individual innovativeness levels and their levels of techno- uncertainty (r=0.348; p<0.001). No significant relationship was found between healthcare personnels’ individual innovativeness level and techno-invasion levels (p=0.05) (Table 2).
The model created in the multiple regression analysis to determine the predictive power of the technostress scale sub- dimensions for individual innovativeness was found to be highly significant (F = 40.495; p <0.001). The independent variables included in the model (techno-complexity, techno-insecurity, techno-uncertainty) explained 44% of the total variance in individual innovativeness (R2=0.444). In addition, techno- insecurity and techno-uncertainty were significant predictors of individual innovativeness level. Techno-insecurity negatively affected individual innovativeness, and techno-uncertainty had a positive impact (p<0.001) According to the regression coefficient, individual innovativeness was influenced by techno- uncertainty, and to the highest extend, by techno-insecurity (= -0.517) (Table 3).
Discussion
In this study, conducted in a digital hospital, the individual innovativeness levels of the healthcare professionals, who were mostly women, married and had been working in their institutions for an average of 7 years, were found to be in the Interrogator category, consistent with some study results [15,16]. In other words, healthcare professionals rarely lead in implementing new ideas, behave cautiously against innovations, and spend a great deal of time thinking about it before adopting innovations.
Healthcare personnel working in the digital hospital were observed to experience moderate technostress. While Mahdian et al.’s (2017) study with nurses and Çoban’s (2019) study with medical staff reported that nurses and healthcare personnel experienced moderate technostress (Çoban İ. Teknolojik Değişimin Hastane Çalışanları Üzerine Etkileri: Bir Devlet Hastanesi Örneği (Master’s thesis) 2019; Kırklareli Üniversitesi) [17], Khuntia et al. (2015) reported in their study with nurses using smart care systems that these systems caused stimuli fatigue and technostress. As can be seen, new applications brought about by constantly developing technologies can cause technostress in healthcare personnel [18].
When the sub-dimensions of the technostress scale were examined in the study, it was seen that the healthcare personnel received the highest score from the technostress uncertainty dimension and the lowest score from the technostress insecurity dimension. This shows that healthcare personnel have a low fear of losing their job, and that new technological applications have motivated them at first. However, innovations and changes brought about by technology invalidate hard-gained knowledge and experience and create continuous learning and development pressure [4]. For this reason, it is seen that employees experience concern, disappointment and anxiety. In other words, it can be said that employees are enthusiastic about innovations, but they experience stress due to innovations in the process.
In the study, techno-uncertainty, followed by techno-insecurity, respectively, affected the individual innovation level of healthcare personnel the most. In other words, a decrease in the techno- insecurity levels of the health personnel and an increase in their techno-uncertainty levels positively affected the individual innovation levels. Similar to the research findings, Çetin and Bülbül (2017) found a negative relationship between individual innovativeness and techno-confusion and techno-insecurity and a positive and significant relationship with techno-uncertainty, and explained that this may be due to the fact that developing technologies and new applications could be attractive at first to users [1]. The study reported that nurses stated that learning new technologies was challenging and they only used the parts they knew about in the system and could not explore the system much due to its complexity . In addition, it was stated that nurses increase the level of technostress [19]. Employees will be more open to innovations when they do not fear losing their jobs. This was the expected result. Technostress is defined as a disease that occurs in adapting to modern technology. The reasons that significantly increase technostress among healthcare personnel are new and growing fears or difficulties associated with computers or other modern equipment [4]. When individuals start working with new technologies, they experience stress, make more mistakes, try to stay away from work, lack confidence, and experience disappointment and lack of concentration [20]. It is thought that the stress caused by all these experiences may lead to confusion, uncertainty, insecurity, and negative attitudes such as resisting innovations. In order to adapt to increasingly important technological changes and reduce the associated stress, institutions should be able to successfully manage technostress and innovativeness [21]. Leadership and support of management are considered a prerequisite for innovativeness. It is of great importance that managers support and believe in innovation, in other words, leadership of the top management is critical [22]. In addition, it has been stated that innovations made by giving voice to the demands of the employees reduce the resistance to innovation as they meet expectations of the employees and increase their satisfaction [23].
Conclusion
Research questions were answered by the findings that the health personnel had a moderate level of technostress, that the individual innovativeness category was the Interrogator category, that there was a significant relationship between technostress level of healthcare personnel and that individual innovativeness and techno-insecurity and techno-uncertainty subdimensions of technostress were significant predictors that predicted individual innovativeness of healthcare personnel. This finding is important as it shows that technostress is an effective factor on innovation culture in health institutions. As the technostress levels of individuals increase, their perspective towards innovations decreases. Technostress changes individuals’ perceptions and behaviors towards innovations and may cause them to resist innovation.
Providing an innovative organizational culture in institutions and determining policies in this direction will significantly reduce the techno-stress level of health personnel. The fact that innovation in currently heavily emphasized in hospitals increases the need for individuals who are open to innovation. In order to develop innovative behaviors, it is recommended that healthcare professionals see themselves as innovative leaders, and to encourage them to be open to innovation, and provide sufficient time and resources.
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.
Funding: None
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.20623
Zülfünaz Özer, Semanur Kumral Özçelik, Ayşe Nefise Bahçecik, Suna Ekmekçioğlu Uçar. Healthcare personnels’ technostress and individual innovativeness levels: Digital hospital example. Ann Clin Anal Med 2021;12(Suppl 4): S428-432
Citations in Google Scholar: Google Scholar
Impact of the Covid-19 pandemic on endoscopic activity, gastric and colorectal cancer detection rate
Mecdi Gurhan Balci, Gizem Issin, Mahir Tayfur, Diren Vuslat Cagatay
Department of Pathology, Erzincan Binali Yıldırım University, Faculty of Medicine, Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
DOI: 10.4328/ACAM.20624 Received: 2021-03-29 Accepted: 2021-07-06 Published Online: 2021-07-20 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S433-436
Corresponding Author: Mecdi Gurhan Balci, Erzincan Binali Yıldırım University, Faculty of Medicine, Mengücek Gazi Training and Research Hospital, Department of Pathology. Erzincan, Turkey. E-mail: gurhanbalci@hotmail.com P: +90 5428022498 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3713-3344
Aim: The COVID-19 pandemic has adversely affected health systems all over the world and has caused more than 3 million deaths to date. This has caused delays in the diagnosis and treatment of cancer and many diseases due to disruptions in health services and the hesitation of patients to apply to health institutions during the pandemic period.
Material and Methods: In the current study, the electronic records of health centers in Erzincan were retrospectively examined and the cases that underwent gastric and colonic endoscopic biopsy between January 2019 and January 2021 were identified. The cases were divided into two groups as the pre-pandemic group that underwent endoscopic biopsy between January 2019 and 2020, and the pandemic group, where the endoscopic biopsy was performed between 2020 and 2021.
Results: There was a significant decrease in the number of gastric and colon endoscopic biopsies and gastric cancer, although there was no abnormal popula- tion movement and no new healthcare institution in the province the pre-pandemic period and during the pandemic period.
Discussion: The findings of the current study showed that there was a significant decrease in the number of gastric and colon endoscopic biopsies and gastric cancer cases during the pandemic period. In addition to the primary health problems associated with severe acute respiratory syndrome – coronavirus 2 (SARS- CoV-2) infections during the pandemic period, delays in the detection of cancer and precancerous lesions due to the decrease in the number of endoscopic biopsies may cause significant problems in the future.
Keywords: COVID-19; Pandemic; Gastric Cancer; Endoscopic Biopsy; Colorectal Cancer
Introduction
The severe acute respiratory syndrome – coronavirus 2 (SARS- CoV-2) infection, which was first identified in Wuhan, China in late 2019, was declared a pandemic in March 2020 (available at: https://www.bbc.com/news/world-51839944).The pandemic has put enormous pressure on healthcare systems around the world [1]. It has caused the death of more than 3 million people so far (available at: https://ourworldindata.org/coronavirus). The fear of getting sick caused hesitation in applying to the hospital, especially in those with chronic diseases and elderly patients [2]. This problem can cause diagnostic delays in many diseases.
Cancer is one of the leading causes of death, and the average life expectancy of the disease is closely related to the disease stage at the time of diagnosis [3]. Early diagnosis and treatment are vital in cancer patients [4].
Gastric cancer is the fifth most common malignancy and is the third most common cause of cancer-related death [5]. It is most common in the 50-70 age groups and more often in men [6]. Symptoms such as dyspepsia, vomiting, and dysphasia can be seen in gastric cancer. Since these findings can be observed in many different diseases, gastrointestinal endoscopy plays an important role in the differential diagnosis [7]. In addition, endoscopic biopsy in gastric cancer will provide early diagnosis of gastric cancer; it will reduce the risk of cancer development because it will provide the diagnosis and early treatment of helicobacter pylori, which is effective in the development of gastric cancer [8].
Colorectal cancer is the third most common malignancy and the second most common cause of cancer-related death [9]. Colon cancers occur equally in men and women, with the average age of 62 years [10]. Colonoscopic screening is recommended to begin at the age of 50 to diagnose early-stage colorectal cancers [11]. Colonoscopic biopsy in colorectal cancers is very important for diagnosis, removal of a polyp that may be a tumor precursor, and determination of the appropriate treatment as a result of pathological examination [12].
The aim of this study is to emphasize that delay in the number of endoscopic and colonoscopic biopsies and cancer diagnoses during the COVID-19 pandemic may cause significant problems in the morbidity and mortality rates of patients in the future.
Material and Methods
Ethical approval was received from Erzincan Binali Yıldırım University clinical research ethics committee, dated May 24, 2021 and numbered 07/08. In the current study, the pathology archives of all health centers (Erzincan Binali Yıldırım University Mengücekgazi Training and Research Hospital, Private Neon Hospital) in Erzincan were retrospectively examined, and cases that underwent gastric and colonic endoscopic biopsy between January 2019-January 2021 were identified. The cases were divided into two groups as a pre-pandemic group that underwent endoscopic biopsy between January 2019 and January 2020, and a pandemic group, who underwent endoscopic biopsy between 2020 and 2021. Pathology reports of the cases were examined and cases cancer were identified. The age range and mean age for both gastric and colorectal cancer types were determined and compared to non-cancerous cases. The cases were divided into groups according to their gender, and it was evaluated whether there was a difference in cancer incidence according to gender. The number of patients who underwent gastric and colon endoscopic biopsy and the number of patients diagnosed with cancer were compared in the pre-pandemic period and during the pandemic period. The data were evaluated by a simple statistical method. The results were expressed as percentages.
Results
The number of gastric endoscopic biopsies in the pre-pandemic period was 2711 and during the pandemic period, it was 1297. The number of cases detected with gastric cancer was 49 in the pre-pandemic period and 35 during the pandemic period. The age range of gastric cancer cases was 40-93, the average age was 69. The average age in non-cancer cases was 53. In the distribution of gastric cancer cases by gender, the incidence rate in men was higher than in women, 61% of cases were men. According to the number of endoscopic biopsies, the rate of gastric cancer was 1.8% in the pre-pandemic period and 2.7% during the pandemic period. Detailed gastric endoscopic biopsy and gastric cancer cases rates for the pre-pandemic and during the pandemic period are given in Table 1.
The number of colonoscopic biopsies in the pre-pandemic period was 419, and it was 333 during the pandemic period. The number of detected cases of colorectal cancer was 39 in the pre-pandemic period and 38 during the pandemic period. The age range of colorectal cancer cases was 35-87, the average age was 64. The average age in non-cancer cases was 55. In the distribution of colorectal cancer cases by gender, the incidence rate in men was higher than in women, 58% of cases were men. According to the number of colonoscopic biopsies, the rate of colorectal cancer was 9.3% in the pre-pandemic period and 11.4% during the pandemic period. The detailed colonoscopic biopsy and colorectal cancer cases rates for the pre-pandemic and during the pandemic period are given in Table 2.
During the pandemic period, there was a significant decrease in the number of gastric endoscopic biopsies and colonoscopic biopsies, especially in gastric endoscopic biopsies. The decrease in the number of gastric endoscopic biopsies during the pandemic period compared to the pre-pandemic period was 52%, and the decrease in the number of colonoscopic biopsies was 21% (Figure 1).
While there was a significant decrease in the number of gastric cancer cases detected during the pandemic period, the decrease in the number of colorectal cancers was minimal. There was a 29% decrease in cases with gastric cancer in the pandemic period compared to the pre-pandemic period, and a 3% decrease in cases with colorectal cancer (Figure 2).
Discussion
COVID-19 pandemic caused more than 150 million sicknesses and over 3 million deaths so far (available at: https:// ourworldindata.org/coronavirus). The fear of getting SARS- CoV-2 infection caused hesitation in patients when applying to the hospital [2].
Early diagnosis is important in cancer treatment, and fear of going to the health institutions, especially in chronic and elderly patients, due to the pandemic, and malfunctions in the health system may cause delays in cancer diagnosis [13]. Diagnoses and treatments delayed due to the pandemic will affect the progression of cancers and long-term survival of patients [14]. As pointed out by Helsper CW et al, cancer has not disappeared during the pandemic, so it is important to make arrangements for early detection of cancer and care of cancer patients [15]. Maringe C et al. evaluated the impact of the COVID-19 pandemic on cancer deaths due to the delay in diagnosis in a study involving lung, breast, colorectal and esophageal cancers. In their study, they assessed that diagnostic delay due to the COVID-19 pandemic in the United Kingdom would lead to significant increases in the number of preventable cancer deaths [16]. In the study conducted by Rutter et al., they detected that there was a significant decrease in cancer detection rates as a result of the decrease in the number of endoscopic biopsies during the COVID-19 period. In their study, they reported a 52% decrease in the number of gastric cancer cases and a 72% decrease in the incidence of colorectal cancer during the pandemic period compared to the pre-pandemic period [17]. Similarly, Kaufman HW et al. detected that there was a decrease in the number of endoscopies during the pandemic period, and a 50% reduction in colorectal cancer diagnoses as a result [18].
In the current study, it was found that there was a significant decrease by 52%, 21% and 29% in the number of gastric endoscopic biopsy, colonoscopic biopsy, gastric cancer cases in the pandemic period compared to the pre-pandemic period, respectively. Considering that there was no abnormal population movement in the province or there was no new health institution service, we think that the reason for the decrease in the number of endoscopic biopsies and gastric cancer diagnoses during the pandemic period may be the hesitation of people to go to the hospital during this period. Arrangement of appropriate physical environments for endoscopic biopsy units can reduce these hesitations of the patients.
The decrease in the number of colon cancer cases was only 3%. Another remarkable finding was that the number of colon biopsies was very low compared to the number of gastric biopsies in both pandemic and pre-pandemic periods, and the rate of cancer according to the number of biopsies was higher in colorectal cancers compared to gastric cancer. In our opinion, the reason for the low rate of decrease in colorectal cancers during the pandemic and the low number of colon biopsies compared to the number of gastric biopsies may be that patients do not go to the hospital for colonoscopy because they are embarrassed and afraid unless they have very serious symptoms in both periods. In our opinion, this problem may be a geographical and cultural that must be overcome through education and providing people with more information.
The limitations of this study were retrospective design and small sample size. Further multi-centric studies to be carried out in the post-pandemic period will reveal more clearly the effect of the pandemic on the decrease in endoscopic biopsy and cancer detection rates and in the general health area.
In conclusion, it should be noted that during the pandemic period, there was a significant decrease in the number of gastric and colon endoscopic biopsies and gastric cancer cases. In addition to the primary health problems associated with severe acute respiratory syndrome – coronavirus 2 (SARS-CoV-2) infections during the pandemic period, delays in the detection of cancer and precancerous lesions due to the decrease in the number of endoscopic biopsies may cause significant problems in the future.
Acknowledgment
We would like to thank the general surgeon Mehmet Zeki Baltacı for his help in collecting endoscopic biopsy results at Erzincan Private Neon Hospital.
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.
Funding: None
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.20624
Mecdi Gurhan Balci, Gizem Issin, Mahir Tayfur, Diren Vuslat Cagatay. Impact of the Covid-19 pandemic on endoscopic activity, gastric and colorectal cancer detection rate. Ann Clin Anal Med 2021;12(Suppl 4): S433-436
Citations in Google Scholar: Google Scholar
Diagnostic value of imaging methods in diagnosing acute appendicitis in comparison with leukocyte counts
Esra Dişçi 1, Rıfat Peksöz 2, Kamber Kaşali 3, Bahattin Bayar 2
1 Department of General surgery, Atatürk University Faculty of Medicine, Erzurum, 2 Department of General Surgery, Muş State Hospital, Muş, 3 Department of Biostatistics, Ataturk University Faculty of Medicine, Erzurum, Turkey
DOI: 10.4328/ACAM.20626 Received: 2021-03-31 Accepted: 2021-06-02 Published Online: 2021-06-16 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S437-441
Corresponding Author: Rıfat Peksöz, Department of General Surgery, Muş State Hospital, 49400, Muş, Turkey. E-mail: rifat-peksoz@hotmail.com P: +90 5349214382 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4658-5254
Aim: Acute appendicitis (AA) is the most common cause of acute abdomen. Early diagnosis and treatment are life-saving, as delay leads to high mortality and morbidity. In this study, we aimed to investigate the diagnostic values of leukocyte count and imaging methods such as CT (Computed tomography) and USG (Ultrasonography) for patients pre-diagnosed with AA.
Material and Methods: A retrospective study included 425 patients who admitted to the emergency room with abdominal pain and operated for pre-diagnosis of AA.
Results: The patients were divided into groups by appendix histopathology: Group I included 53 patients (12.5%) with a normal appendix, Group II included 289 patients (68%) with noncomplicated appendicitis, and Group III included 83 patients (19.5%) with complicated appendicitis. Two hundred sixty-three patients were male (61.8%), 162 (32.8%) were female, and their mean age was 34.7 (18-82) years. In AA diagnosis, the sensitivity and specificity of leukocyte count were 81.45% and 45.2%, respectively, while USG had a sensitivity of 95% and specificity of 84%, and CT had a sensitivity of 86% and specificity of 59%. There was a significant difference between groups I-II and II-III in terms of leukocyte count (p<0.001) in determining the severity of AA.
Discussion: When diagnosing AA, radiological methods such as USG and CT are also used along with physical and laboratory examinations. Since CT is an expensive and difficult-to-access method using contrast materials, USG should be the first radiological method as it has acceptable sensitivity and specificity. To render USG accessible, emergency medical or general surgical specialization training should incorporate emergency USG training.
Keywords: Acute Appendicitis; Leukocyte; Ultrasonography; Computed Tomography
Introduction
Acute appendicitis (AA) is an acute inflammatory condition that develops in the appendix tissue as a result of obstruction of the appendix lumen for various reasons [1]. It is the most common cause of acute abdomen in surgery clinics, and its lifelong prevalence is 7% [2]. Appendectomy, applied in the treatment of acute appendicitis, is the most common emergency abdominal surgery operation performed in all surgical clinics worldwide [3]. The timing of the surgery is very important. Early surgical decisions result in 15-30% negative laparotomy; however, when the surgical decision is delayed, the appendix becomes perforated, and the delay period increases mortality and morbidity [2].
In addition to physical examination and scoring systems, radiological methods such as ultrasonography (USG), computed tomography (CT), magnetic resonance (MR) and diagnostic laparoscopy can be used in the diagnosis of acute appendicitis [4,5]. Despite the use of methods such as CT, USG, laparoscopy, and scoring systems, the rate of missing acute appendicitis and/or appendix perforation has not changed (15%), and there is still no single and reliable laboratory test or clinical test to be used for these diagnoses [6].
In this study, it was aimed to compare the leukocyte count, which can be easily studied in serum in the diagnosis of AA, with imaging methods such as CT and USG, and to discuss the value of these methods in the diagnosis of acute appendicitis in the light of literature.
Material and Methods
After obtaining approval from the Ethics Committee of Erzurum Atatürk University Faculty of Medicine, patients who were admitted to the Muş State Hospital Emergency Department with a pre-diagnosis of AA between January 2018 and April 2019 were analyzed retrospectively. In addition to taking blood samples from patients in the emergency department, imaging methods such as standing direct abdominal radiography (SDAR), USG, CT, and MRI were used. The gender, age, leukocyte value at the time of application, the surgery performed with the radiological examinations performed, the type of anesthesia applied, and the postoperative pathology information of the patients were recorded. All patients were adults over the age of 18, and patients who were found to have other pathological findings in addition to acute appendicitis during surgery were excluded from the study.
Serum leukocyte levels, the values such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Likelihood Ratio positive (LR +), and Likelihood Ratio negative (LR) values of patients applying with the diagnosis of acute appendicitis used for the USG and CT among imaging methods were analyzed statistically.
Appendectomy materials of the patients were classified into 3 groups by the histopathological results as follows: Group I: Patients with normal appendix, lymphoid hyperplasia, obliterative appendix were evaluated as normal (Negative appendectomy); Group II: Patients with phlegmonous appendicitis, catarrhal appendicitis, suppurative appendicitis were evaluated as non-complicated appendicitis; Group III: Patients with gangrenous appendicitis, perforated appendicitis were evaluated as complicated appendicitis. Patients with appendix diameter greater than 6 mm on USG and CT were evaluated as acute appendicitis.
Statistical Analysis
Results were presented as numbers for categorical variables, and as mean ± standard deviation for continuous percentage variables. The normality of continuous variables was evaluated using the Shapiro-Wilk-W and Kolmogorov- Smirnov test. Chi-square and Fisher-Freeman-Halton tests were used for comparing categorical variables. ROC analysis was used to determine whether the continuous variable can be used in diagnosis. In addition, the Youden-Index was used to determine the cut-off value. All analyzes were performed at a 95% confidence interval. The p-value <0.05 was considered significant, while p<0.001 was considered extremely significant. IBM SPSS 20 package software was used for statistical analyses.
Results
We examined 463 patients who were operated consecutively with a pre-diagnosis of acute appendicitis in a 1-year period between 2018-2019 were examined. Thirty-eight patients were excluded from the study (13 patients had other diseases in addition to acute appendicitis during surgery, and blood results or imaging methods were not available in 9 patients, 6 patients were reported as malignancy and 10 patients were pregnant). Among the patients, 263 were males (61.8%), 162 were females (38.1%), and the mean age of the patients was 34.65 (18-82) years.
The patients were classified into 3 groups by their pathology results as follows: Group I: those with pathology result as normal appendectomy material 53 (12.47%), Group II: noncomplicated 289 (68%), Group III: complicated 83 (19.52%) (Table 1).
Routine hemogram test, especially leukocyte count, is studied in patients with suspected acute appendicitis disease. When we took the upper reference range (11×103) of the device in our hospital as the cut-off value for leukocyte count, the sensitivity for leukocyte values of our patients was found to be 81.45%, specificity 45.2%, PPD 0.91, NPD 0.26, PLR 1.49, NLR 0.41. Leukocyte count was the highest in Group III, a statistically significant difference was found between Group I-II and GroupII-III (p <0.001) (Tables 2, 3).
SDAR (356 patients) and chest radiography (327 patients) are the first imaging methods requested from patients who applied to the emergency department with complaints of abdominal pain. As an advanced imaging method, USG was performed in 153 (36%) patients, CT in 342 (80.5%) patients and MRI in 1 pregnant patient.
The diagnostic values of USG for acute appendicitis were found as sensitivity 95%, specificity 84%, PPD 0.98, NPD 0.7, PLR 6, NLR 0.06. The diagnostic values of CT for acute appendicitis were found as sensitivity 86%, specificity 59%, PPD 0.93, NPD 0.38, PLR 2.1, NLR 0.24. (Table 3).
Discussion
Acute appendicitis is one of the most common causes of acute abdomen. Its diagnosis can be successfully made by using radiological methods together with physical examination and history [7]. Acute appendicitis can be seen at any age; however, it is most common between the ages of 20-40. The most common age that it is seen is 22 years, and the mean age of being seen is 31.3 years [8]. AA is 1.4 times more common in males than in females [9]. Although different percentages of gender ratio are reported for acute appendicitis patients in the literature, 61.8% of our patients were male, 38.1% were female, and the mean age of the patients was 34.65 (16-82) years, the findings are consistent with the literature. Considering the high incidence rate of acute appendicitis, its diagnosis is of great importance. Many markers have been investigated to prevent morbidity and mortality caused by delays in diagnosis. The complete blood count is one of the leading markers that are easily accessible and rapidly evaluated. WBC (Leukocyte), neutrophil, lymphocyte, and subparameters of complete blood count such as neutrophil- lymphocyte ratio, inflammatory markers, and especially leukocyte counts have been investigated in many studies. Leukocytes have been used to define the severity of infectious and inflammatory diseases such as acute appendicitis [10,11]. The higher the leukocyte value, the more likely the cases to be appendicitis. Perforation is more likely to occur in patients with high leukocyte count. Complicated appendicitis (perforation, gangrenous appendicitis, intraabdominal abscess, plastron formation, generalized peritonitis) constitutes 20-30% of all appendicitis cases. The leukocyte value is not found useful in distinguishing complicated and uncomplicated cases at the cut-off value calculated. In the literature, there are a few studies that have found a difference between complicated and uncomplicated groups [12,13].
In a meta-analysis study, the sensitivity of leukocytosis (> 10000/ mm3) in the diagnosis of acute appendicitis has been reported as 83% and specificity as 67% [14]. In studies conducted with AA patients, leukocyte levels in the uncomplicated group have been found to be higher than the normal appendix, and the leukocyte levels in the complicated group have been found to be higher than the noncomplicated appendicitis group [12,15]. In a large study group conducted by Sevinç et al. in a group of 3392 patients, when the cut-off value of leukocyte was taken as 11900/mm3, the sensitivity for acute appendicitis has been found to be 71.2%, specificity to be 67.2%, PPD: 0.92, NPD: 0.30, PLR: 2.15, NLR: 0.43 [10].
When we take the upper reference range (11×103) of the device in our hospital as the cut-off value for leukocyte count, the sensitivity for leukocyte values of our patients was found to be 81.45%, specificity 45.2%, PPD 0.91, NPD 0.26, PLR 1.49, NLR 0.41. These values are compatible with the values measured in a wide range in the literature. The low number of patients in the negative appendectomy group contributes to the low specificity value. In determining the severity of acute appendicitis, a statistically significant difference was found between groups I-II and II-III in terms of leukocyte count (p <0.001) (Table 2). Although high sensitivity rates have been stated for the diagnosis of acute appendicitis, it is seen that additional imaging methods are needed in the diagnosis of AA to prevent negative appendectomies due to low specificity values. It has been reported that negative appendectomy rates of 15-20% can be reduced by using imaging methods, and unnecessary surgeries, perforation rates and hospital stay can be reduced in patients without acute appendicitis [16].
Among the radiological imaging methods, especially USG and CT are the most used methods in the diagnosis of acute appendicitis and its complications [7]. USG is the first preferred imaging method in patients whose clinical findings suggest AA. However, which imaging method to use may vary depending on the physical conditions of that center, the experience of the radiologist and surgeon, and the characteristics of the patient [17]. We can count the advantages of USG as low cost, not giving ionized radiation to the patient, and the possibility of using it in pregnant women because of not using contrast material. However, the disadvantages are that it depends on the person performing it, it cannot be retrospectively examined, it cannot be optimally performed, or the appendix cannot be visualized due to patient-related problems (intestines full of gas, abdominal fat mass, etc.) [18]. In the studies performed, the sensitivity for diagnosing acute appendicitis for USG has been found to be 66-87%, specificity 46-84%, PPD 0.85-0. 90, NPD 0.23-0.47, and accuracy ranged from 73 to 80% [4,25,26]. In our study, the diagnostic values of USG for acute appendicitis were found as sensitivity 95%, specificity 84%, PPD 0.98, NPD 0.7, PLR 6, NLR 0.06, and the results are better to a certain extent than the literature. In suspicious cases, where USG is insufficient, CT should be preferred because its sensitivity, positive predictive value, and accuracy rates are higher [3]. Although contrast- enhanced CT is recommended, appropriately performed non- contrasted CT examinations are also sufficient [21]. In a review evaluating 23 prospective studies, the sensitivity rate for CT has been reported to be 77-100% and the diagnostic accuracy rate was 83-100% [22]. In another study, sensitivity for CT has been reported to be 94.12%, PPD 88.89%, and accuracy rate was 87.32% [3]. In our study, the diagnostic values of CT for acute appendicitis were found as sensitivity 86%, specificity 59%, PPD 0.93, NPD 0.38, PLR 2.1, NLR 0.24. According to USG and CT report results, there was no statistically significant difference between the results obtained when the patients whose appendix could not be visualized were accepted as acute appendicitis, and the results obtained when these patients were excluded from the study (p> 0.05). We could not find any study with this patient group in the literature, we think more research should be conducted with this patient group. Although CT is superior to USG in the diagnosis of AA, its disadvantages are that it cannot be found everywhere, its cost is high, it contains ionizing radiation, contrast medium reactions, and increases the time until surgery [23]. CT was used significantly more than USG in patients who applied to the emergency department with abdominal pain due to the absence of a radiologist outside of working hours in our hospital (p <0.001). In the literature, the superiority of CT in recognizing acute appendicitis compared to USG has been demonstrated, however, in our study, USG has superiority in contrast to the literature, because in many health centers in our country, CT reports are carried out through the service procurement system. Therefore, communication difficulties are experienced between the physician who carries out the patient’s treatment and the physician who reports the CT result, and the radiologist cannot obtain enough information about the patient. We think that that it is necessary to change the working hours of radiology specialists and provide them with sufficient equipment. For such a common disease, USG training programs should be conducted for general surgery or emergency specialists or emergency USG training should be provided within the specialty training program.
Despite physical examination, laboratory findings, and auxiliary radiological methods, negative appendectomies in a ratio of 15-30% are still performed [2,10]. Negative appendectomy is more common in females due to the confusion of gynecological pathologies with acute appendicitis [24]. In our study, the number of patients with negative appendectomy was higher among male patients, contrary to the literature; however, there is no statistically significant difference (p> 0.05). This may be due to the low number of patients. The negative appendectomy rate was 12.5%, with slightly better results compared to the literature.
Conclusion
Leukocyte value, which is a subparameter of complete blood count, is an easily accessible and rapidly evaluated marker in diagnosing acute appendicitis and determining the severity of appendicitis; although its high sensitivity, the specificity is low. Therefore, we use radiological methods such as USG and CT in addition to physical examination and blood parameters when determining the diagnosis of acute appendicitis. Although the sensitivity and specificity values of CT are higher in the literature, the first radiological method to be applied should be USG with acceptable sensitivity and specificity, as it includes a contrast medium and is expensive. In order for USG to be easily accessible, emergency USG training should also be included within the emergency medicine specialty or general surgery specialty education.
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.
Funding: None
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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Esra Dişçi, Rıfat Peksöz, Kamber Kaşali, Bahattin Bayar. Diagnostic value of imaging methods in diagnosing acute appendicitis in comparison with leukocyte counts. Ann Clin Anal Med 2021;12(Suppl 4): S437-441
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The level of knowledge about menopause and attitudes towards menopause in women in the climacteric period
Jule Eric Horasanlı 1, Nur Demirbas 2
1 Department of Gynecology and Obstetrics, 2 Department of Family Medicine, Necmettin Erbakan Üniversity, Meram Faculty of Medicine, Konya, Turkey
DOI: 10.4328/ACAM.20632 Received: 2021-04-01 Accepted: 2021-06-02 Published Online: 2021-07-29 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S442-446
Corresponding Author: Nur Demirbas, Necmettin Erbakan University, Meram Faculty of Medicine, Department of Family Medicine , Konya, Turkey. E-mail: ndemirbas76@hotmail.com P: +90 5053476672 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4038-9386
Aim: This study aimed to determine the level of awareness and knowledge about menopause in women aged 40–65 in the climacteric period, and examine the symptoms of menopause and the relationship with their attitudes towards menopause.
Material and Methods: The study included 224 women who applied to Obstetrics and Family Medicine outpatient clinics. The Sociodemographic Information Form, Menopause Information and Awareness Form, Menopause Attitude Assessment Scale (ATMS), and the Menopause Rating Scale (MRS) were applied to the participants.
Results: Among the participants, 71.0% had gone through menopause, whereas 21.0% had not, and 8.0% did not know whether they had gone through meno- pause or not. The mean age of the women who had gone through menopause was 47.79±4.5 years. While the mean ATMS score was 43.97±10.93, 37.9% of the women had a negative attitude (40 points and below). The mean MRS somatic complaint score was 6.43±3.74, the mean psychological complaint score was 6.21±4.09, and the mean urogenital complaint score was 3.88±2.65. There was a moderately significant negative correlation between their ATMS scores and their menopause-related psychological complaints (r=–0.317, p<0.001). As their positive attitude towards menopause increased, their psychological com- plaints decreased. As their awareness of menopause increased, their psychological complaints decreased.
Discussion: Increased awareness of menopause provided a decrease in the psychological complaints of menopause. In the study, it was seen that the attitudes of women toward menopause were an effective variable in the emergence of menopause complaints. Improving the attitudes of the women towards meno- pause is important for reducing menopausal symptoms.
Keywords: Menopause; Climacteric Period; Knowledge; Attitude
Introduction
The life of a female consists of five periods, comprising childhood, adolescence, sexual maturity, menopause, and old age. Each of these periods has its own physical, psychological, and hormonal differences [1]. The climacteric period covers the perimenopausal, menopausal, and postmenopausal periods, and is a period of life in which the woman transitions from reproductive age to the age in which the reproductive cycle ends. After the final menstrual cycle, menopause is characterized as 12 months of amenorrhea, representing an almost complete but normal decrease in ovarian hormone secretion [2]. The average age for natural menopause is about 51 and varies in different populations [3]. On average, one-third of a women’s life passes in menopause. The menopausal period is an important period that brings many physical and psychological changes and significantly affects the family and society [4]. In order to have a healthy and happy period that cannot be underestimated for human life, women need to know how to deal with the problems of the menopausal period. Night sweats, hot flashes, and sleep problems, psychological problems (anxiety, depression, discomfort, sexual abstinence, etc.) and atrophic changes (vaginal atrophy, stress incontinence, and dyspareunia, etc.) are the most common problems during this period. Osteoporosis and cardiovascular diseases occur, as well. Although the exact causes of the complaints observed during menopause are not known, they are generally thought to be caused by the lack of estrogen [5]. The most common symptoms reported by women in the menopausal period are hot flashes and night sweats, which occur during the transition to menopause. Although it affects about 70% of women in Northern Europe and America, the prevalence of vasomotor symptoms and the experience of menopause vary significantly between cultures [6]. Moreover, eating habits, and cultural and ethnic differences are among the factors considered to be effective in the emergence of menopausal complaints [7]. Symptoms that occur in menopause cover as a whole the physical changes, cultural influences, and individual perceptions. To understand menopause well, it is necessary to take into account biological factors as well as psychological, social, and cultural ones.
Women’s perceptions of menopause as a natural process of life or disease, and the developments in their lives that occur with middle age, affect their attitudes about menopause. In the studies on menopausal complaints, it was reported that the attitudes of women toward menopause were an effective variable in the occurrence and severity of menopause complaints. It is possible to reduce the frequency and severity of menopausal symptoms through studies aimed at improving menopause knowledge level and menopause attitude [7]. Sexual problems have an important place during menopause. Studies have reported a decrease in the sexual interest and frequency of sexual intercourse, a loss of sexual desire by 47%–85%, a decrease in the frequency of orgasms by 20%, a decrease in the frequency of sexual intercourse by 20%–70%, and an increase in dyspareunia in the first couple of years of menopause by 40%. These results are thought to be the result of estrogen deficiency, as well as androgen deficiency [8]. Maintaining the quality of life in menopause is an important goal, and it is one of the responsibilities of health professionals to eliminate the complaints of women in this period, and to determine the quality of life and the situations associated with it. Patient education during menopause and knowing the symptoms experienced or likely to be experienced during menopause will make it easier for the woman to deal with these problems. In this context, this study aimed to determine the levels of knowledge and awareness of women about menopause in the climacteric period, to determine the symptoms of menopause and women’s attitudes towards menopause, and compare them with their level of knowledge.
Material and Methods
Type, place, and population of the research Women between the ages of 40 and 65, who consulted the Obstetrics and Family Medicine outpatient clinics, between October and November 2020, were included in this study, which was planned as descriptive and cross-sectional research.
Ethical permission for the study
Ethical permission for the study was granted prior to the start of the study by the Ethics Committee (Number:2020/2941). Participants were informed about the study, and their written and verbal consent was obtained according to the ethical principles of the Helsinki Declaration.
Data collection tools
A four-section questionnaire was filled out using a face-to-face interview method, which was applied to volunteer participants who agreed to participate in the study. Patients receiving hormone replacement therapy, Spironolactone, selective serotonin reuptake inhibitor, or antidepressant therapy were excluded from the study.
Sociodemographic Information Form: The questionnaire, which contains introductory information about a person, consists of 8 questions about their age, marital status, income level, level of education, and menopausal status.
Menopause Knowledge and Awareness Form: The literature on the subject was scanned and prepared by the researchers. In this form, which consists of 10 questions about knowledge and awareness concerning menopause, the total menopause knowledge and awareness score was calculated by giving 1 point for correct answers, and 0 points for false answers as well as “I don’t know” answers. The first 5 questions in the form measure general information about menopause and the last 5 questions measure the awareness that the woman has of her own menopause period.
Menopause Attitude Assessment Scale: The Menopause Attitude Assessment Scale (ATMS) was developed by Uçanok (1994) to measure the attitudes of women of different age groups towards menopausal life and its aftermath [9]. A high score obtained from the scale shows a positive attitude towards menopause, while a low score shows a negative attitude. It is accepted that the attitude is more positive as the scores increase above the average score 40. The Cronbach Alpha coefficient of the scale is 0.86.
Menopause Rating Scale: The Menopause Rating Scale (MRS) was developed by Schneider et al. to measure the severity of menopausal symptoms and was adapted to Turkish by Gürkan (2005) in Turkey. The total score of the scale is calculated based on the scores given for each item. The lowest score that can be obtained is 0 and the highest score is 44. The increase in the total score on the scale shows an increase in the severity of the complaints experienced.
Statistical analysis
In the study, when evaluating all the data obtained through surveys that were filled out using the face-to-face interview method, the mean and standard deviation values of the numerical data were calculated. Normal distribution conformity was evaluated using the Kolmogorov-Smirnov test; categorical and numeric data were compared using statistical analyses, such as chi-square test, student t-test, and one-way ANOVA. P<0.05 was considered statistically significant. The reliability scores of each scale were calculated via the Cronbach alpha; correlation analysis was used to determine the relationship between the level of knowledge, and attitudes and symptoms.
Results
The study included 224 women with a mean age of 53.0±6.1 (42–65) years. Among the participants, 75.9% (n=170) were married, whereas 7.6% (n=17) were single, and 16.5% (n=37) were divorced. (n=74); 33.0% were primary school graduates, 63.8% (n=143) had a balance of income and expenses, and 58.0% had no chronic diseases. Moreover, 71.0% of the respondents had gone through menopause, whereas 21.0% had not; and 8.0% did not know if they were menopause or not. The mean age of the first menstrual period of the women was 13.02±1.31 (10–16) years, the median number of births was 2 (0–9), the mean menopausal age of women who had gone through menopause was 47.79 ± 4.5 (38–58) years (Table 1). Nearly half (56.7%) of the respondents said that they had previously received information about menopause. Among these women, 59.4% had received information from doctors, whereas 18.8% from midwives, 12.1% from social media, 18.3% from acquaintances, and 8% received it from radio- TV. Among the participants, 82.6% thought that women who had gone through menopause or doubted so should consult a doctor. The mean menopause knowledge score of the women was 4.90±2.63 (1–10), and the average awareness score was 4.08±1.40 (1–6). Those with higher levels of education had higher awareness scores, and those with lower income levels had lower awareness.
While the mean ATMS score of the women was 43.97±10.93 (11–70), 37.9% had a negative attitude (40 points and below) and 62.1% had a positive attitude (above 40 points). A statistically significant relationship was found between the marital and educational status of the participants and the ATM score (p=0.008). The ATMS score of those who were married (44.95±11.35) was higher than that of the single women (40.89 ± 8.91).
On the MRS scale, the mean somatic complaint score was found to be 6.43±3.74, whereas the psychological complaint score was 6.21±4.09, urogenital complaint score was 3.88±2.65, and the total mean MRS score was 16.53 ± 8.92. A statistically significant relationship was found between the marital status, educational status, presence of chronic disease, and menopause status of the participants, and the MRS score (p<0.001). Psychological complaints (7.46±4.68), urogenital complaints (4.31±2.98), and MRS total scores (18.02±10.14) of the women with negative attitudes about menopause were found to be statistically significantly higher than those of the women with positive attitudes (p=0.001, p=0.038, and p=0.049, respectively) (Table 2). Somatic (7.64±3.71), psychological (8.21±4.28), and urogenital (5.90±2.78) complaints of the women who indicated that they performed no physical activity in daily life and lived a sedentary life were found to be higher than those who performed mild to moderate physical activity (p=0.045, p=0.002, p=0.002, and p<0.001).
Among the women, 31.7% (n=71) were in the perimenopausal period, 28.1% (n=63) were in the menopausal period, and 40.2% (n=90) were in the postmenopausal period. Somatic (8.05±3.34), psychological (7.43±3.89), and urogenital (3.79±2.94) complaints of the women in the menopausal period were higher than those of the women in the perimenopausal and postmenopausal periods (p<0.001). While the attitudes of the women about menopause did not change in any of the 3 stages of the climacteric period, the level of knowledge about menopause was higher in menopausal women than in women in the perimenopausal and postmenopausal periods (p<0.001) (Table 3).
There was a moderately significant negative relationship between the ATMS scores of the women participating in the study and their psychological complaints due to menopause (r=0.317, p=0.001). As their positive attitude towards menopause increased, their psychological complaints decreased. However, there was a moderately significant negative relationship between the menopause awareness status and psychological complaints of the women (r=–0.288, p=0.001). As their menopause awareness increased, their psychological complaints decreased.
Discussion
Menopause and its complications can impair the feeling of well- being and health, and affect the quality of life. The intensity and effect of menopausal symptoms differ among people and societies. Some women may experience more severe symptoms that can have a profound impact on their personal and social performance, and quality of life, and cause them to encounter numerous serious problems in their lives. Therefore, the severity of menopause symptoms can affect their quality of life, both physiologically and psychologically [10].
The age of menopause differs from society to society. The menopausal age in Turkey varies between 48–51 years [11]. In the present study, the average age at onset of natural menopause in the women was calculated as 47.79±4.5 (38–58) years. In the current study, 37.9% of the participants were found to have a negative attitude towards menopause, whereas 62.1% had a positive attitude. When evaluating studies in the literature on women’s attitudes towards menopause, reports of both positive and negative attitudes were found. An Iranian study found that 6.3% of women had a negative attitude towards menopause, whereas 71% had a neutral attitude, and 22.8% had a positive attitude [12]. One study found that women with negative attitudes towards menopause reported more frequent complaints when compared to women with positive attitudes [13]. In the present study, the psychological and genitourinary complaint scores of the women who had negative attitudes about menopause were found to be higher than those of women who had positive attitudes. Women with a positive attitude reported significantly fewer symptoms of menopause. The reason why women during menopause with high levels of education had higher physical quality of life scores may have been due to the fact that they were more advantageous in regular access to health care, they were informed, and they consulted physicians. According to the research, a negative relationship was found between the level of knowledge and the severity of menopause symptoms [14]. That is to say, less educated women experience more severe symptoms, and highly-educated women are more aware of the menopause symptoms, strategies to deal with them, and are more likely to look for treatment for their symptoms. In the present study, the results showed that women with a higher level of education women had a positive attitude about menopause and a healthy living. This study has found a relationship between the marital status, educational status, presence of chronic diseases and menopausal status of the women, and the severity of their menopause symptoms. Symptom severity was found to be lower in the married women. With a clear statement, menopausal symptoms were less felt in the participants who were married or had a high level of education. The menopausal period is also a process in which a large number of chronic diseases appear. Sometimes it can be quite difficult to distinguish between symptoms caused by chronic diseases and those caused by estrogen deficiency. Numerous studies have reported that more symptoms of menopause were observed among women with chronic diseases [15].
To reduce psychological and vasomotor symptoms, it is recommended to exercise during menopausal and perimenopausal periods. Doing exercise generally has positive effects on mood and sleep disorders in women. Vasomotor symptoms such as hot flashes and night sweats improve with weight loss involving physical activity in obese women who have a higher body mass index [16]. It also has a positive relationship with lowering cholesterol, triglycerides, apolipoprotein, and glucose levels [17], and accordingly, is associated with reducing the symptoms of hot flashes [18]. On the contrary, Poppel et al. showed that physical activity did not reduce vasomotor and mental symptoms during menopause [19]. A study involving middle-aged Australian women stated that exercise was beneficial for somatic and psychological symptoms, such as depression and anxiety, but not for vasomotor symptoms or sexual function [20]. As a result of estrogen deprivation during the menopause transition, the sex drive of women decreases, and vaginal dryness, signs of thinning of the wall of the womb and sexual dysfunction commonly occur. A study of 42 women in the postmenopausal periods, did not report any effects on genitourinary complaints or sexual symptoms [18]. However, in a cross-sectional study of 151 women who practiced physical activity, improvement in sexual symptoms was reported [21]. In the study presented herein, the somatic, psychological, and genitourinary complaints of the women who stated that they pursued a sedentary life were found to be higher than those whose physical activity was at mild to moderate levels.
It is known that the level of estrogen in the blood is lower in women who smoke when compared to non-smokers. It can be thought that lower estrogen levels may cause more severe menopausal symptoms [22]. The presented study also found a significant relationship between smoking and menopausal symptoms. In several studies, the Internet and friends have been the source of information about menopause [23,24]. Asian women did not report a need for information because they perceived menopause as a natural transition period [25]. In the presented study, approximately half of the participants stated that they had knowledge of menopause symptoms in advance, whereas 59.4% stated that they had discussed menopause symptoms with other individuals.
Conclusion
It is possible to reduce the frequency and severity of menopause symptoms through research aimed at improving the menopause attitude of women. An increase in awareness concerning menopause leads to a decrease in menopausal psychological complaints. As in studies on menopausal complaints, it was seen in this study that women’s attitudes toward menopause were an effective variable in the emergence of menopausal complaints. The positive development of women’s attitudes towards menopause was important in reducing their menopausal symptoms. It was concluded that the health and lifestyle behaviors of women, as well as an evaluation of potential tools or programs to combat menopausal symptoms and improvement in overall quality of life during the menopause transition, are important, especially in groups of patients with low levels of education and income. In this study, it was found that there was a significant relationship between the menopausal complaints of the women and their attitude towards menopause, and that having a positive attitude towards menopause caused fewer menopausal complaints. According to this result, it can be said that the symptoms of menopause decrease as the positive attitude towards menopause increases. Lifestyle changes and training to be applied for menopause should be evaluated according to the realities of the country.
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.
Funding: None
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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Jule Eric Horasanlı, Nur Demirbas. The level of knowledge about menopause and attitudes towards menopause in women in the climacteric period. Ann Clin Anal Med 2021;12(Suppl 4): S442-446
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Correlation between Vitamin D deficiency and Pre-diabetes in Arar, Saudi Arabia
Jamal Alruwaili
Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Northern Border University, Arar, Saudi Arabia
DOI: 10.4328/ACAM.20633 Received: 2021-04-03 Accepted: 2021-06-24 Published Online: 2021-07-25 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S447-450
Corresponding Author: Jamal Alruwaili, Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Northern Border University, Arar, 91431, Saudi Arabia. E-mail: jamalalruwaili786@gmail.com P: +966 55 136 5859 F: +966146620771 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3189-3107
Aim: Prediabetes is implicated in obesity, fatty liver disease and metabolic syndrome and an increased risk of type 2 diabetes (T2DM). This case-control study aimed at finding a correlation between vitamin D (VitD) deficiency and prediabetes.
Material and Methods: Sixty participants (age >30 years) were selected. Thirty of them comprised of prediabetic subjects and thirty were normoglycemic healthy controls. The subjects suffering of kidney, heart, liver and autoimmune diseases, diabetes, and pregnancy were not included. Plasma VitD (measured as 25-hydroxycholecalciferol; 25-OH-VitD) and fasting plasma glucose (FPG) levels were assessed immunometrically and colorimetrically, respectively.
Results: The results showed that prediabetic subjects had significantly lower plasma levels of 25-OH-VitD (P = 0.000) compared to normoglycemic controls; where their median levels were 17.68 and 31.72 mmol/L, respectively with a strong negative correlation against FPG (r = -0.649, P = 0.000) and a high odds ratio (OR) of 4.078.
Discussion: The study found a significant inverse correlation between plasma VitD and FPG levels in prediabetic subjects. The high OR for VitD deficiency in the normoglycemic and prediabetic participants suggests a strong possibility of a causal link between low plasma VitD levels and prediabetes, as major risk factor for T2DM.
Keywords: Vitamin D; Pre-Diabetes; HbA1C; Fasting Plasma Glucose
Introduction
The relationship between vitamin D (VitD) deficiency and the development of type 2 diabetes mellitus (T2DM) has been established by previously published research. Several studies have found a correlation between low VitD level and diabetes mellitus [1-4]. However, the evidence for direct causal link between VitD deficiency and diabetes mellitus is contradictory, and further studies are still necessary since only a limited number of studies using the human model have been conducted so far [5,6].
Prediabetes is a transition stage between normoglycemia and T2DM. A person is considered prediabetic when his/her blood glucose level is increased above normal but is still not high enough to be classified as diabetes. Based on WHO criterion, prediabetes is diagnosed as having a fasting blood glucose level of 110 – 125 mg/dL, and, based on American Diabetes Association criterion, fasting blood glucose level of 100 – 125 mg/dL/5.6 – 6.9 mmol/L is diagnostic [7]. The onset of prediabetes occurs when the body manifests insulin resistance or becomes unable to utilize insulin. Risk factors for prediabetes include family history of full diabetes, obesity, cardiovascular disease, increased serum triglycerides, lowered serum HDL- cholesterol, raised blood pressure, and elevated plasma glucose fasting level. Factors in females also include those having polycystic ovarian syndrome or gestational diabetes.
Pittas et al. [1] have reported a correlation between fasting plasma glucose (FPG) level and VitD deficiency. Insulin resistance was documented using the Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) for subjects exhibiting prediabetes [8]. A separate study had correlated VitD deficiency and prediabetes. Subsequently, they intervened utilizing VitD supplements. However, no significant change in either insulin sensitivity or progression into diabetes, although glycated hemoglobin (HbA1C) was found to be significantly decreased [9]. Another Indian study reported a decrease in both FPG and insulin resistance along with inflammatory markers among those taking VitD supplements [10]. The current study investigated a possible correlation between low VitD levels and the high prevalence of prediabetes among population in Arar, Saudi Arabia.
Material and Methods
Setting and Participants:
The protocols used in this study were in line with the ethical standards laid down by the Arar Central Hospital, Arar, Saudi Arabia, and in accordance with the Helsinki Declaration of 1975 that was revised in 2013. The study was conducted from January to March 2017. It recruited 60 participants of both genders aging ≥30 years. They were selected by sequential enrollment from those visiting/working in Arar Central Hospital, Arar, Saudi Arabia.
Inclusion criteria were the classic symptoms of prediabetes such as increased thirst, polyuria, fatigue and blurred vision on top of the diagnostic FPG levels. The research participants were categorized into two groups: 30 prediabetic subjects and 30 healthy normoglycemic controls after careful clinical assessment to meet all the inclusion criteria shown in Table 1. The gender distribution of the subjects was 76.7% females and 23.3% males. There was no difference in age between prediabetic subjects and controls. The median age of the research subjects was 45 and 43.8 years for males and females, respectively.
Based on the measured FPG level, the patients were divided into two groups. Patients exhibiting diabetes mellitus, immobilized, or autoimmune, renal, liver and heart diseases were excluded from the study. In addition, pregnant female subjects and those using VitD supplements were excluded. All subjects exhibiting VitD levels <20 ng/mL (<50 nmol/L) were considered VitD deficient, while subjects with FPG of 100 – 126 mg/dL (5.6 – 6.9 mmol/L) were considered prediabetic. After a 12-hour overnight fast, 3 mL of venous blood samples were collected to recover plasma. The samples were then analyzed for FPG and VitD levels.
Measurement of FPG Level:
FPG measurements are the basis for the diagnosis of T2DM, idiopathic hypoglycemia, neonatal hypoglycemia and pancreatic islet cell carcinoma. In this study, FPG was measured by the enzymatic colorimetric test using the BS-400® Chemistry Analyzer (Mindray Medical Int. Ltd, Shenzhen, China). Measurement of Vitamin D Level:
Both VitD2 and D3 are carried in the blood plasma as complex with the VitD-binding protein. VitD is carried to the liver to be hydroxylated into calcifediol (25-hydroxycholecalciferol; 25-OH- VitD). 25-OH-VitD represents the main storage form of VitD in the body. Its concentration in the blood is used for assessing the overall VitD status. For the purpose of this study, 25-OH- VitD levels were determined using the Elecsys Vitamin D Total Assay that demonstrated a high degree of comparability to the LC-MS-MS with a minimum detection limit of <5 ng/mL (Roche Diagnostics International AG, Rotkreuz, Switzerland). Statistical Analysis:
Statistical Analysis was performed with SPSS v.23 (Chicago, USA). Mean VitD levels were compared in prediabetic and normoglycemic subjects. The frequency for different age groups was expressed as a percentage. Pearson correlation analysis was done to check the relationship with FPG and odds ratio (OR) was used to quantify the possible causal association between VitD deficiency and prediabetes.
Results
Prediabetic subjects were found to have significantly lower levels of VitD (median plasma level of 17.68) compared to normoglycemic healthy participants (median plasma level of 31.72 nmol/L; P = 0.000), respectively (Table 1). Pearson correlation analysis showed a significant inverse correlation between plasma VitD and FPG levels (r = -0.649, P = 0.000) in the prediabetic groups, as shown in Table 2. The odds ratio (OR) for VitD deficiency in normoglycemic and prediabetic groups was found to be 4.078 (P <0.0001), which suggests a strong possibility of a plausibly causal link between low VitD levels and prediabetes (Table 2).
Discussion
It is already known that polymorphisms in the VitD receptor gene and the resulting inefficiency of VitD and/or VitD deficiency can lead to the development of diabetes mellitus [11-20]. The activated VitD receptor controls gene expression and ensures that intracellular levels of Ca+2 and reactive oxygen species are maintained at normally low physiological levels. This harmonizes the homeostasis of several metabolic and immunological activities towards the prevention of diabetes mellitus [21]. Prediabetes is an early stage of diabetes and considered to be a significant risk factor for development of microvascular and cardiovascular disorders, along with complications arising from T2DM such as nephropathy, neuropathy and retinopathy [22]. In the current study, the samples were acquired from the population of the Northern Border Region of Arar, Saudi Arabia, and the VitD levels were measured to estimate the possible correlation with prediabetes. It was found that prediabetic subjects have significantly low levels of VitD in comparison with those of normoglycemic healthy controls. A significant inverse correlation was seen between plasma VitD and FPG levels, as shown in Table 2. The odds ratio of 4.078 for VitD deficiency in the normoglycemic and prediabetic groups suggests a strong possibility of a causal link between low VitD levels and prediabetes (Table 2).
The findings of this study correspond with those obtained by Qurrat-ul-Ain et al. [23] who reported that low VitD levels correlates with glucose intolerance in adults. Another study by Pinelli [24], comprising Arab Americans, reported that males with glucose intolerance tend to have reduced levels of VitD.
Other studies report varying modes of correlation between VitD level and prediabetes. According to the data reported by NHANES III, non-Hispanic blacks show no correlation between the two parameters. Furthermore, one study in Finland involving 7503 subjects has shown that high levels of VitD lowered the incidence of diabetes by 72% among males. However, it showed no significant change among females after adjustment for T2DM risk factors [25].
Discrepancy between the findings of this study and the previously published studies can be explained by taking into consideration the differences between the participants in terms of ethnicity, body mass index, and other environmental/life style factors that contribute to low VitD levels and high blood glucose levels [22]. The negative correlation of VitD deficiency with prediabetes with a high OR found here causally involve VitD level in blood glucose regulation, prediabetes and diabetes. However, the influence of VitD level on glucose metabolism may also depend on other factors such as ethnic and genetic background, gender, obesity and co-morbidities [1].
Conclusions
VitD deficiency causes an increase in the concentration of intracellular Ca+2 and Reactive Oxygen Species, which causes a decline in the Insulin signaling pathway, insulin resistance, prediabetes and the onset of diabetes. The results from this study prove that the mean plasma VitD level of prediabetic and normoglycemic subjects is significantly different and negatively correlated with FPG. A causal relationship for such deficiency was inferred from the high OR. This suggests that people with VitD deficiency carry a greater risk for developing T2DM, and indicates the need for VitD supplementation of the general population and prediabetic subjects in particular.
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.
Funding: None
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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Jamal Alruwaili. Correlation between Vitamin D deficiency and Pre-diabetes in Arar, Saudi Arabia. Ann Clin Anal Med 2021;12(Suppl 4): S447-450
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Comparing lateral or supine positions without using traction table in the treatment of per-trochanteric femur fractures
Esra Demirel 1, Kadri Yıldız 2
1 Orthopedia and Traumatology Clinic, Regional Research and Training Hospital, Erzurum, 2 Department of Orthopaedics and Traumatology, Kafkas University, School of Medicine, Kars, Turkey
DOI: 10.4328/ACAM.20636 Received: 2021-04-02 Accepted: 2021-07-27 Published Online: 2021-08-10 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S451-455
Corresponding Author: Kadri YILDIZ, Assoc. Prof., Kafkas University Medical School Orthopeadia and Traumatology Department, 36000, Kars, Turkey. E-mail: drkadri1980@hotmail.com P: +90 538 545 0559 / +90 474 225 2106-7625 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8164-7687
Aim: This study aims to compare the duration of operation, quality of reduction, and complications in cases of per-trochanteric femur fractures fixed by proxi- mal femoral anti-rotational nail at the lateral and supine positions without using a traction table.
Material and Methods: A total of 160 patients between January 2008 and December 2014 (61 females, 99 males; mean age: 75.9) were presented. The proximal femoral anti-rotational nail was performed at the lateral and supine positions in 89 and 71 patients, ordinarily. All patients have evaluated for Evans and AO (American Orthopedics Classification) fracture classifications, duration of operations, postoperative complications, tip-apex diameter, collodiaphyseal angles, axial reduction range, and position of the helical blade according to Herman’s criteria.
Results: The mean duration of operation in the lateral and supine position groups were 60.7±20.2 and 56.4±18.5 minutes, ordinarily. The mean tip-apex dis- tance was 25.91 mm in the lateral group and 26.11 mm in the supine group. The mean collodiaphyseal angle was 135.55° in the lateral group and 136.92° in the supine group. The mean axial reduction distance was 4.01 mm in the lateral group and 3.84 mm in the supine group. Helical blade placing was within the safe zone in 59.6% of the lateral group and 49.3% of the supine group according to Herman’s criteria.
Discussion: There was no statistically significant difference in the results and complications in comparing both positions. When the traction table is not avail- able, lateral and supine positions can be used to fix the per-trochanteric femur fractures.
Keywords: Per-trochanteric/Intertrochanteric; Femur fractures; Supine position; Lateral position; Traction table; Proximal; Femoral; Anti-rotational nail (PFN-A)
Introduction
In the literature, there are few studies about the Proximal Femoral Nail-A (PFN-A) in the supine position without using a traction table [1-4]. On the other hand, Ozturk et al compared results of both cephalomedullary nailing (CMN) and proximal femur locking plates (PFLP). They found satisfactory results in the surgery time, peroperative transfusion need, length of hospital stay in the postoperative period, mechanical failure and reoperation rates [5].
This study aims to compare the results of these two methods, while the traction table was not used in both techniques. For both methods, duration of operations, radiological measurements (preoperative and postoperative), and complications were evaluated. Also, we aim to find answers to the question of the superiority of these two techniques over each other according to clinical and radiological outcomes, secondary.
Material and Methods
Patients, screened for per-trochanteric femur fractures, who applied to our emergency service between January 2008 and December 2014 were included in a cross-sectional study. The inclusion criteria for study groups were the presence of unstable per-trochanteric femur fractures, PFN-A application in the lateral and supine position without using a traction table, availability of proper antero-posterior and lateral postoperative X-rays, availability of follow-up X-rays obtained at least in the first post-operative year. Patients with metastatic femur fractures, open fractures, additional fractures, patients with inadequate pre-operative and post-operative X-rays, and patients with insufficient archive records were excluded from the study. Operations were performed by 6 different surgeons on a radiolucent operation table. The classifications were made according to AO and Evans fracture classifications (available at:https://surgeryreference.aofoundation.org/orthopedic- trauma/adulttrauma/proximal-femur) [6]. In the radiological evaluation, the collo-diaphyseal angle, tip-apex diameters, reduction range, and localization of the helical blade placing according to Herman criteria were used [7,8].
The duration of operations and complications were assessed statistically. Patients were permitted to walk up to 4 to 8 weeks according to their radiological control X-ray and clinical pain scores. Control visits were made in the third and sixth months of a clinical trial. X-ray views were obtained for comparing preoperative radiological findings using the Picture Archiving and Communication System (PACS) of our hospital. Also, epicrises of the discharged patients and operation reports were obtained from archive files. The radiographic findings of all the subjects were evaluated by a senior orthopedist. Prophylactic parenteral cefazolin sodium (1000 mg) was given to all patients pre- and postoperatively. Lateral and Supine positions are shown in Figure 1.
Lateral position: Two methods were used to obtain lateral X-ray: firstly, the image was obtained by flexion, abduction, and external rotation positions of the hip with fluoroscopy at U shape. Secondly, the hip was not positioned and the image was obtained by keeping the fluoroscopy at C shape with approximately 30°-40° toward cranial (to see the intertrochanteric region by preventing superposition of PFN guide at following stages) and approximately 20° toward dorsal (to take the proper lateral image by considering femoral anteversion). In the proper position, the nail was extended from the guide and sent to a helical blade, and then the distal locking screw was applied.
Supine position: After anesthetic induction, the patient was positioned in the supine position. After sterilization, an elevation material for the hip of about 10 cm (pillow or roll wrap) was placed under the fractured hip without causing excess from the table laterally. Before the sterilization procedure, lateral and antero-posterior X-ray imaging by C-armed fluoroscopy was controlled. Antero-posterior and lateral images were obtained when the fluoroscopy was in C and U positions, ordinally. STATA® 12 Statistical Software (Texas, USA) program was used for statistical analysis. A Chi-square test was used for binary comparison analysis of categorical databases. The T-test (two groups mean-comparison test) was used in comparison with normally distributed parameters to measure significance. The independent samples t-test was employed, which compares the difference in the means from the two groups with a specific value of zero in the study. The significance was assessed at the level of p<0.05. Corresponding two-tailed p-values were calculated to be greater than 0.05 or less. Thus, it can be investigated whether the mean difference in lateral and supine positions is different from 0. Parameters normally distributing as well as descriptive statistical methods (mean values, standard deviation, median, frequency, rate, 95% confidence interval) were calculated for the assessment of databases in the study.
Results
Considering the inclusion and exclusion criteria, 160 patients eligible for the study were identified. A total of 160 patients [61 (38.1%) females and 99 (61.9%) males] were evaluated for this study. This study included 160 patients with per-trochanteric femur fractures, of whom 89 (56%) were operated in the lateral position and 71 patients (44%) were operated in the supine position. The mean age of the study group was 75.9±12.3 years. Twenty-six patients (78.8%) were operated under spinal anesthesia and 34 (21.2%) were operated under general anesthesia. When comparing supine (n=71) and lateral (n==89) group databases, the F/M ratio in the gender distribution was 25/46 and 36/53, respectively, 0.498 (p≥0.05).
As for the etiology, it was a fall in 144 patients (90%), falling down from a height in 9 patients (5.6%), and a traffic accident in 7 patients (4.4%). The types of Evans fractures were evaluated as follows: 14 patients (8.8%) were Type 1, 23 patients (14.4%) were Type 2, 31 patients (19.4%) were Type 3, 34 patients (21.3%) were Type 4, 40 patients (25.0%) were Type 5 and a reverse oblique fracture was present in 18 patients (11.3%). The mean operation day after admission to the hospital was 2.25±1.72 days. The mean duration of operation was 60.90±23.03 minutes. Although the duration of operation was longer in the lateral position group, no statistically significant difference was presented between the two (p≥0.05). The mean hospital stay was 6.5±3.49 days.
The mean PFNA sizes were 232.4±7.3 mm in the lateral position group, and 231.7±6.4 mm; the mean sizes of lag screw were 99.8±2.3 mm in the lateral position group, and 98.9±3.7 mm (p=0.467). There was no statistically significant difference in mean tip-apex distance (TAD) and collo-diaphyseal angle (CDA) (p≥0.05). The reduction range measured on lateral X-rays of the patients informed us about the quality of the reduction. There was no statistically significant difference in the mean reduction range between the two groups (p≥0.05). In our patients operated with PFN-A, stability was assessed as a criterion for whether helical blade placing was in the safe zone or not. Helical blade placing was in the safe zone in 59 of 89 (66.3%) patients in the lateral group and in 35 of 71 (49.3%) patients in the supine group. Although helical blade placing appeared in a stable position in most cases in the lateral group, no statistically significant difference was attained between the two groups (p≥0.05).
On the fracture side, the right/left ratio was 40/31 in the supine group and 48/41 in the lateral group, 0.761 (p≥0.05). The ratio of stable/unstable fractures was 28/43 in the supine group and 39/50 in the lateral, 0.577 (p≥0.05). The mean duration of operation was 56.4 min in the supine group and 60.7 min in the lateral group, (p=0.271; p≥0.05). The mean in TAD was 26.1(±13.8) mm in the supine group and 25.9 (±11.6) in the lateral group, (0.263; p≥0.05). The mean reduction was 3.84 mm in the supine group and 4.01 in the lateral group, (0.375; p≥0.05). The mean CDA was 136.9° (±6.4) in the supine group and 135.6° in the lateral group (±7.6), (0.301; p≥0.05). The mean value of the helical blade in the safe zone was 35 (49.3%) in the supine group and 59 (66.3%) in the lateral group, (0.030; p≥0.05). The number of general complications was 19 (26.7%) in the supine group and 17 (19.1%) in the lateral group, (0.498; p≥0.05). The number of cut-out was 3 (4.2%) in the supine group and 4 (%4.5) in the lateral group, 0.293 (p≥0.05). The number of migrations was 2 (2.9%) in the supine group and 1 (%1.1) in the lateral group, 0.305 (p≥0.05). The number of varus was 4 (5.6%) in the supine group and 6 (6.7%) in the lateral group, 0.479 (p≥0.05). The distribution of complications according to operation position was 10 of the general complications (avascular necrosis, heterotopic ossification, wound infection) in the supine group, 6 of the general complications in the lateral group. The number of biomechanical complications (migration, cut-out, varus) was 9 in the supine group and 11 in the lateral group. The number of complications were 36, 19 of 36 in the supine group and 17 of 36 in the lateral group (p=0.296). X-rays of patients with removal and migration are shown in Figure 2. The mean TAD was 34.9 mm in patients with removal complications. The mean TAD was 10.3 mm in three patients with medial migration. Helical blade placing was in the safe zone in 3 patients and outside the safe zone in 7 patients. Varus deformity was assigned in 5 of 7 patients with removal. All complications were treated in the revision process according to etiological factors. One patient underwent surgical procedure as arthroplasty after a failed revision surgery.
Tip-apex distance, collo-diaphyseal angle, and reduction range were individually compared for stable and unstable fractures. A statistically significant difference was observed only for the reduction range values (p<0.05). The mean of the reduction range was significantly higher in the unstable group (5.7 mm) than in the stable group (1.9 mm) (p<0.01). Both groups were treated equally post-operatively as to rehabilitation/physical therapy protocols, aside from ambulation.
Discussion
This study showed that one of both positions did not predominate over the other to reduce rates and surgical complications. The advantages of the supine position can be listed as reduced operation duration, easy application in patients with contra-lateral extremity fracture, technical ease in patients with planned surgery during the same session for contra-lateral extremity, and easy interpretation of the fluoroscopy image due to its compliance with the patient’s position. The advantages of the lateral position include a more comfortable incision and exposure, applicability in obese patients, and a contribution to the reduction due to adduction posture. Therefore, its advantages are its applicability in obese patients and contribution to the reduction due to adduction posture.
Herman and colleagues established the localization of lag screws in the safe region in addition to the tip-apex distance, and this was measured on the antero-posterior X-ray, which was among the most important criteria to evaluate the stability in cases of intertrochanteric fractures fixed by the proximal femoral nail [8]. A line is drawn from the midpoint of the neck to the center of the femur head, then a line is drawn to join the femoral head and neck, and the safe zone is accepted as two-third from the inferior part of this line (Figure 3). Herman established that the lag screw was not in a safe zone in the majority of patients developing post-operative mechanical complications [7]. In this study, the term Herman’s safe zone, calculated by linear lines, was used. In this study, the helical blade was placed out of the safe zone in 5 of 7 patients with removal complications. The localization of the helical blade placing was not affected by the supine or the lateral operation position. Herman also determined that the lag screw was out of the safe zone in 11 of 15 patients with cut-out [7].
Several studies indicated that the need for a TAD less than 25 mm is the rule only for Dynamic Hip Screw (DHS) and that TAD should be between 20 and 30 mm in PFN-A cases to prevent medial migration and cut-out [9]. However, TAD not exceeding the range of 15 to 45 mm, did not primarily affect the cut-out [10]. According to the common point of view in the literature, TAD affects stability. In this study, TAD was observed more than 30 mm in patients with removal and less than 15 mm in patients with immigration. Wrong position of the hip screw or its improper extension may result in the removal of the screw from the femur head (cut-out) [11,12]. The reported rate was up to 10% for screw removal [13,14]. The removal rate of 3.6% and 2% were in the supine position on a traction table. In another study, in which the operation position was not reported, the removal rate was 4.7% [11, 15, 16]. In this study, removal was observed in 7 patients (4.4%). Among them, 4 cases were in the lateral group and 3 were in the supine group. The tip-apex distance was over 25 mm in all of these patients, and varus was presented in 5 patients.
Varus deformity is the most important complication increasing the removal. In a study, the mean collodiaphyseal angle was 125.6 ̊ in patients with removal development [17]. In our study, the mean collodiaphyseal angle was 126.3 ̊ in 7 with removal development. In all patients, varus deformity was detected using X-rays obtained in the second and third months.
Xue et al established the mean operation time using a traction table for the lateral position group as 50.6 minutes, and the supine position group as 65.67 minutes. Turgut et al determined the mean operation duration as 57.2 minutes and 76.50 minutes in the lateral position groups. Pahlanvanhosseini et al demonstrated the mean operation duration as 79.50 minutes and 35 minutes in the supine position group using the traction table. In studies comparing PFN-A patients in the supine and lateral position on a traction table, no difference was found in complications and all studies were consistent with the literature [16, 18, 19-22]. In this study, we detected the mean operation time as 60.73±24.20 minutes (55.63-65.83) in the lateral position group with 89 patients and 61.12±21.63 minutes (56.00-66.24) in the supine position group with 71 patients. There was no statistical difference in the mean operation duration of both groups (p>0.914).
Handicaps for both positions are the need for technical experience to interpret the image due to contralateral leg superposition on the fluoroscopy image, as well as the need for continuous manual traction during the whole operation. The advantages of both positions are the unnecessity of the traction table, elimination of complications due to the traction table, and even reduced operation duration.
This research, however, has several limitations: 1) the number of cases was relatively small compared to other similar studies, 2) more emphasis could be placed on a question-based framework, 3) a prospective study could have been chosen, rather than a retrospective study, 4) more emphasis needed, based on complications and outcomes of the study groups, 5) another limitation point was the number of surgeons as six senior orthopedists.
Conclusion
We conclude that a full lateral image can be obtained, appropriate reduction can be achieved and successful PFN-A fixation can be performed by continuous manual traction in the lateral and supine positions without using a traction table. There is no difference between the two positions in terms of results and complications. If the traction table was not accessible, this surgery can be performed in the lateral and supine positions with a radio-lucent table.
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.
Funding: None
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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Esra Demirel, Kadri Yıldız. Comparing lateral or supine positions without using traction table in the treatment of per-trochanteric femur fractures. Ann Clin Anal Med 2021;12(Suppl 4): S451-455
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Applicability of the modified Demirjian’s method for age estimation in a sample of Egyptian children using dental radiography
Abeer Abd Elmoneim Sheta 1, Nagwa Mostafa Enany 2, Naglaa Hassan Salama 1, Rania Abd Elmaguid Ahmed 1, Marwa Ismail Mohamed Haiba 1
1 Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Alexandria University, 2 Orthodontics Faculty of Dentistry, University of Alexandria, Egypt
DOI: 10.4328/ACAM.20637 Received: 2021-04-05 Accepted: 2021-05-12 Published Online: 2021-06-27 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S456-460
Corresponding Author: Marwa Ismail Mohamed Haiba, Assistant lecturer in Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Alexandria University, Egypt. E-mail: marwaismailhaiba@gmail.com P: 01007507669 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4829-1305
Aim: Age estimation is a challenging task in forensic practice. Teeth are employed primarily in the age estimation of children as a result of their low variability and less exposure to environmental, endocrine and nutritional factors. Thus, the current study aimed to test the applicability of the modified Demirjian method on a sample of Egyptian children.
Material and Methods: Panoramic radiographs of 140 randomly selected individuals (70 males and 70 females) aged from 8 to 18 years were evaluated based on the modified Demirjian’s method.
Results: In males, there was a statistically significant correlation between chronological age (CA) and dental age (DA) using the modified Demirjian method; this method underestimated the age in all age groups by 0.45 to 1.77 years, with the exception of age group 10, where overestimation by 0.05±0.07 years was found, dental age (DA) was underestimated in males with an overall mean difference of 1.30 years. In females, there was a statistically significant correlation between chronological age (CA) and dental age (DA). DA was underestimated by 0.20 to 2.38 years in all groups, except for group 13, where overestimation was noticed by 1.20±0.94 years, DA was underestimated with an overall mean difference of 1.27 years.
Discussion: Age estimation using the modified Demirjian’s method narrows down the mean difference of age to less than one year in some age groups, espe- cially in early adolescence in both sexes; however, the applicability of the current method in the identification of certain age groups among Egyptian children should be taken with caution because of significant results variations. Thus, in these age groups, it is advisable to confirm the estimated age using adjuvant methods.
Keywords: Age Estimation; Dental Age; Forensic Odontology; Challiet–Demirjian; Modified Demirjian’s Method
Introduction
Age estimation is an integral part of forensic investigations with an alarming increase in crimes involving juveniles worldwide. Marriage validation and child work are amongst other related issues that require accurate age estimation [1].
Identification of age among children can be done using skeletal, dental, anthropological and physiological methods. Dental development is a useful indicator of maturation because it is highly reliable with a low coefficient of variation, and resistance to environmental factors [1, 2].
Dental age estimation methods have become popular in recent years due to simplicity and less time requirement. Several age estimation methods were created depending on dental development pattern using panoramic radiographs and hence different standards had been established [1].
Currently, Demirjian’s method is the most commonly used method for children; it is based on French-Canadians. According to this method, orthopantomograms (OPGs) are utilized to assess the extent of mineralization (calcification) of dental tissues and the stage of maturation of the seven left permanent mandibular teeth from the central incisor to the second molar [2].
It was reported that Demirjian’s method was less accurate when conducted on populations other than the original population (French-Canadians). These results revealed the necessity to establish standards representative of each population; therefore, some researchers modified Demirjian’s method using standards based on their population data [3].
The original Demirjian’s method excluded the third molar due to its variability. As a result of its exclusion, the original Demirjian’s method is not suitable for age estimation after about 16 years of age [4, 5].
The third molar offers the only reliable radiological parameter for age estimation in the age group of 16–23 years. Yet, it was concluded by Mincer et al. (1993) that a third molar may indicate with reasonable accuracy that a person is at least 18 years of age, rather than giving an exact chronological age, due to the absence of any other marker in the late adolescence [6]. In 2004, Chaillet and Demirjian conducted a research with 1031 dental panoramic radiographs of healthy southern French subjects aged between 2 and 18 years and implemented new dental developmental scores for children. A modification of the original Demirjian’s method was done to increase applicability to 18-year-old individuals by including a third molar [7].
Since few studies have evaluated dental maturation techniques in Egypt, the aim of the present study was to assess the applicability of modified Demirjian’s method for age estimation among a sample of Egyptian children.
Material and Methods
The study was conducted in the Department of Orthodontics, Faculty of Dentistry, Alexandria University, following the ethical approval from the Ethics Committee of the Faculty of Medicine, Alexandria University (FWA number: 00018699, IRB number: 00012098, approval serial number: 0201226). Parents/ guardian agreements were obtained in each case.
Sampling method: In this cross-sectional observational study, panoramic radiographs of 70 randomly selected males and 70 randomly selected females were collected.
Sample size: Based on previous studies, the Pearson correlation between chronological age and estimated age among males and females was 0.882 and 0.956 respectively. Using alpha error =5% and study power of 85%, the minimum sample size required is 140 children, with 70 children for each group. The sample size was calculated using G. Power software
Inclusion criteria: Panoramic radiography was done for each patient as part of the patient investigation protocol. Only patients with confirmed chronological ages were included.
The age of participants ranged from 8 and 18 years. Only healthy individuals with a complete set of eight mandibular permanent teeth from the central incisor to the third molar whether erupted or not were included.
Exclusion criteria: children with unconfirmed chronological age, individuals with congenital anomalies, local trauma affecting the primary teeth, gross pathological problems and systemic diseases or growth disorders were excluded. Also, distorted radiographs due to faulty position or movement during exposure, or unclear images were excluded.
Calculation of dental age (DA) by Chaillet-Demirjian (modified Demirjian) method: dental age estimation was done by evaluating the digital radiographs and determining the stage of maturation (calcification) of each tooth of the 8 left mandibular teeth. The maturity score of each tooth was assigned (Figure 1) [5]. The sum of maturity scores of all 8 teeth was obtained and designated as the ‘ maturity score = S ‘ for each subject (Tables 1 and 2). Dental age was measured using a special formula for each sex, involving this maturity score [7].
Age in males = (0.0000550 ×S3) – (0.0095 ×S2) + (0.6479×S) – 8.4583. Age in females = (0.0000615 ×S3) – (0.0106 ×S2) + (0.6997×S) – 9.3178. Examples of evaluation of dental maturity score and the calculated dental age of both sexes were demonstrated in Figure 2 in males and Figure 3 in females.
The difference between the calculated dental and chronological age was tabulated and compared statistically.
Reproducibility of measurements: Two trained forensic physicians analyzed all images separately. To assess intra- observer reliability, the first examiner reevaluated a randomly selected 30 radiographs after 2 weeks at least. To test inter- observer reliability, examination of randomly selected 30 radiographs (15 males and 15 females) by the first and the second examiner was conducted.
Statistical analysis:
The obtained data were tabulated and analyzed using SPSS version 20.0 (IBM, Armonk, New York, USA). The intra-class correlation coefficient (ICC) was used to evaluate intra-and inter-observer agreement and the repeatability between measurements. The Kolmogorov-Smirnov and Shapiro-Wilk tests were performed to test the normality of the data. A positive result indicated an overestimation, and a negative result indicated an underestimation of age. The correlation between dental and chronological age was analyzed using Spearman’s rank correlation coefficient.
Results
The intra-class correlation coefficient (ICC) value for the inter- observer reliability was as high as 0.93, indicating excellent reliability. The repeatability between the measurements for the same observer (intra-observer agreement) was also high (0.95). Comparisons between the mean ages calculated using the Chaillet-Demirjian (modified Demirjian) method and the mean chronological age showed the following results:
Table (1) shows that the mean chronological age for males was 12.07±2.89 years, while for females it was 12.42 ± 2.72 years. The mean age calculated by the Chaillet-Demirjian method was 11.04±3.05 years in males, with a mean difference of 1.30 ± 1.30 years compared to the chronological age. Regarding females, the mean dental age was 11.15±3.09 years with a mean difference of 1.27 ± 1.59 years compared to chronological age. This method showed an overall underestimation of the calculated dental age in both sexes. A statistically significant difference between the calculated dental age and chronological age in both sexes was noticed, where P < 0.001, as shown in Tables 2 and 3).
In males, the Chaillet-Demirjian’s method underestimated the age in all age groups by 0.45 to 1.77 years, except for age group 10, where an overestimation by 0.05±0.07 years was found. Regarding age groups, the mean difference was < ±1 year in the 9, 10, 12, 13 age groups, while it was > ±1 year in the 8, 11, 14, 15 and 17 age groups (Table 2).
Table 3 also shows that in females, an underestimation of the age by 0.20 to 2.38 years was observed in all groups, except for group 13, where an overestimation was noticed by 1.20±0.94 years. The mean difference was < ±1 year in the 11, 12 age groups, while it was > ±1 year in most age groups (8, 9, 10, 13-16).
The results of the Spearman correlation coefficient test, performed for males and females, showed a strong linear correlations between the chronological age and the Chaillet- Demirjian dental age, r value was 0.918 in males and 0.858 in females.
Discussion
There has been a terrifying increase in the number of unidentified corpses and human remains, as well as the rising number of cases requiring age estimation, especially among refugees and individuals with no valid proof of date of birth. This is a result of territorial mobility and migration accompanying political changes in the Middle East [8-11].
There are different patterns of dental development recognized among different populations; therefore, no universal method for age estimation can be applied to every population [12, 13]. The sample in the present study was divided into males and females because of the widely-reported prevalence of sexual dimorphism in dental development [3].
In the present study, only the mandibular teeth were evaluated, as radiographs of the developing maxillary permanent teeth are often obstructed by the bony structures of the maxilla, while teeth of the mandible, on the other hand, are quite clearly visible in an OPG [3].
Since the presence of a very high degree of symmetry between the teeth of the left and right sides has been well-established, only the mandibular teeth of the left quadrant were evaluated [3].
The original Demirjian method was tested in a sample of Egyptian children in two different governorates (Tanta and Minia) and showed an overestimation for both sexes. In Tanta in 2016, an examination of a sample of panoramic radiographs of Egyptian children showed an overestimation of age for almost all the studied subjects [14].
Three years later, in 2019 in Minia, the same results were reported as both boys and girls showed advanced dental age compared with their chronological age [15]. Both studies concluded that the Demirjian standards were not applicable to Egyptian children [14, 15].
To date, the modified Demirjian method (Challiet-Demirjian method) was not applied to Egyptian children yet. Thus, the present study evaluated its applicability among Egyptian children.
Results in the current research revealed that the Challiet- Demirjian method underestimated the age by a mean difference of more than 1 year for both sexes. In males, the mean age calculated by the Chaillet-Demirjian method was 11.04±3.05 years with a mean difference of 1.30 ± 1.30 years compared to chronological age. In females, the mean dental age was 11.15±3.09 years with a mean difference of 1.27 ± 1.59 years compared to chronological age.
There was a statistically significant difference between the calculated dental age and chronological age in both groups. In males, a mean difference of one year was recorded in the 9, 10, 12, 13 age groups, while it was > ±1 year in the 8, 11, 14, 15 and 17 groups. Whereas, in females, the mean difference was < ±1 year in the 11, 12 age groups, while it was > ±1 year in most age groups (8, 9, 10, 13, 14, 15, 16). It is important to consider the presence of clinically significant results in the absence of a statistically significant difference due to a small sample size in certain age groups.
In agreement with the results of the present study, underestimation of age was noted in Mohammed et al.’s study (2014). However, they found that the modified Demirjian’s method underestimated the mean age of males by 0.8 years and females by 0.5 years among southern Indian children, and also showed that females mature earlier than males in the selected population [16].
Likewise, the results of another study in India that included 250 individuals showed that the modified Demirjian’s method underestimated dental age by 0.84 years in males and 0.83 years in females [17].
The same findings were concluded in the study by Cruz-Landeira and Linares-Argote in 2010. In that study, the original method and the modified Demirjian method were tested on Spanish and Venezuelan children. In the Venezuelan Amerindian sample, the original Demirjian’s method underestimated the age, and the underestimation was even higher when the modified method was applied [18].
Dental maturity in Korean juveniles and adolescents was assessed using the modified Demirjian method as well; an underestimation of the dental age was observed with a mean difference of 0.38 and 0.31 years in males and females, respectively [19].
Another study, which was conducted upon Kosovar children showed that underestimation was noticed by 0.24 years and 0.35 years in males and females, respectively [20].
In contrast to the previous studies, the modified Demirjian’s method overestimated DA when compared to CA in some other studies.
Kumar and Gopal in 2014 used the modified Demirjian method among a sample of Indian children; the study included radiographs in the age range from 7 to 23 years for both boys and girls, and overestimation of DA for both males and females was reported, which might be due to the inclusion of third molars, as they explained [3].
Furthermore, Tandon et al. (2015) also observed an overestimation of DA in Indians. The mean estimated age was found to be significantly higher compared to CA for the overall sample as well as both sexes. The mean age difference was 0.85 years for males and 0.87 years for females [21]. Conclusion and Recommendations:
The results of this method could be reliable among some age groups (9, 10, 12, 13) in males and (11,12) in females, since the mean difference between the calculated dental age and chronological age in these groups was less than one year.
The underlying stages of tooth calcification proved to be sound as the observed levels of inter and intra-observer agreements were high. However, the applicability of the current method in the identification of age in certain age groups among Egyptian children should be taken with caution because of significant variations in results. Thus, in these age groups, it is advisable to confirm the estimated age using adjuvant methods.
Using a larger sample size should be employed to achieve the most accurate age assessment, also population-specific standards and specific regression formula for both sexes should be considered.
The introduction of adaptable conversion tables to transform the maturity score into a dental age for Egyptian children is advisable and may be a suitable alternative.
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.
Funding: None
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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Abeer Abd Elmoneim Sheta, Nagwa Mostafa Enany, Naglaa Hassan Salama, Rania Abd Elmaguid Ahmed, Marwa Ismail Mohamed Haiba. Applicability of the modified Demirjian’s method for age estimation in a sample of Egyptian children using dental radiography. Ann Clin Anal Med 2021;12(Suppl 4): S456-460
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Evaluation of the clinical and laboratory characteristics of children diagnosed with celiac disease
Uğur Deveci 1, Ufuk Acar 2
1 Department of Child Health and Diseases, Pediatric Gastroenterology, Fırat University Medical Faculty Hospital, Elazığ, 2 Department of Public Health, Noncommunicable Diseases Unit, Şanlıurfa Provincial Health Directorate, Şanlıurfa, Turkey
DOI: 10.4328/ACAM.20641 Received: 2021-04-06 Accepted: 2021-06-09 Published Online:2021-06-24 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S461-465
Corresponding Author: Ufuk Acar, Şanlıurfa Provincial Health Directorate, Non-Communicable Diseases Unit, Şanlıurfa, Turkey. E-mail: iksir1532@gmail.com P: +90 (506)5789879 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2663-8307
Aim: Celiac disease is an important autoimmune disease, which leads to malabsorption in childhood. Morbidity and mortality can be prevented with early diagnosis and treatment. The aim of this study was to evaluate the clinical and laboratory characteristics of children diagnosed with celiac disease.
Material and Method: A retrospective evaluation was made of the medical records of patients diagnosed with celiac disease in the Paediatric Gastroenterology Department of Şanlıurfa Training and Research Hospital between June 2016 and May 2018. The patients were evaluated in respect of age, gender, height, weight, complaints, age at diagnosis, and laboratory and histopathological findings.
Results: A total of 201 cases were included in the study, comprising 89 (44.3%) males and 112 (55.7%) females with a mean age of 8.22±4.11 years. At the time of presentation, the primary complaints were retarded development in 96.5%, chronic diarrhea in 17.4%, constipation in 15.9%, abdominal pain in 12.4%, vomiting in 5.5%, nausea in 3.5%, and bleeding in 0.5%. Six patients had a family history of celiac disease. Iron deficiency anemia was present in 58 cases. In the pathology examination of biopsies taken from the patients, Helicobacter pylori positivity was determined in 116 (57.7%).
Discussion: The clinical findings of celiac disease vary widely. In addition to gastrointestinal system findings, the most common complaint on presentation was retarded development. These patients should be evaluated in respect of comorbid diseases. Following diagnosis, the necessary medical and social support should be provided for both the patient and their family.
Keywords: Celiac Disease; Malabsorption; Child
Introduction
Celiac disease is an autoimmune enteropathy, which leads to malabsorption in childhood. In individuals with genetic susceptibility, damage develops in the mucosa of the small intestine with the intake of foodstuffs such as wheat, barley, and rye, which contain gluten [1]. Although the reason is not known, celiac disease is seen more in females than males. The disease frequency can show regional differences, but the frequency worldwide has been reported as 0.05%-0.1% [2]. In previous studies in Turkey, the disease frequency was reported as 0.9% per 1000 healthy children aged 2-18 years, and as 0.47% per 20,190 healthy children aged 7-18 years [3, 4]. The prevalence is rapidly increasing as a result of the use of screening tests and awareness worldwide [5]. Together with genetic susceptibility, environmental factors play a role in the emergence of the disease. It is often seen in the Middle East, Europe, and Australia, where there is greater wheat consumption [6]. There is also a high level of wheat consumption in Turkey, and celiac disease is often seen in the province of Sanliurfa and the surrounding areas.
Gliadin proteins such as glutamine and proline are found in high amounts in the structure of gluten. Gliadin proteins become complex through deamination with tissue transglutaminase enzyme in the lamina propria in the small intestine [5]. This complex is perceived as an antigen and proinflammatory cytokines form. As a result of inflammation created in the small intestine mucosa by cytokines, hyperplasia and villous atrophy develop in the intestinal crypts [7].
Celiac disease is seen more often in those with a family history, especially in a first-degree relative, and in those with diseases such as immunoglobulin A(IgA) deficiency, autoimmune thyroiditis, and type 1 diabetes mellitus [7]. The clinical findings of celiac disease are seen in a wide spectrum. Typical findings in children are abdominal pain, diarrhea, abdominal swelling, constipation, weight loss and retarded growth [8]. Atypical findings may include osteoporosis, dermatitis herpetiformis, listlessness, anemia, short stature, delayed puberty, and moderately elevated liver enzymes [7]. Tissue transglutaminase (TG) IgA antibody level has 99% sensitivity in the diagnosis of celiac disease [8], but small intestine biopsy is accepted as the gold standard in diagnosis [7].
Since the establishment of the Pediatric Gastroenterology Clinic and Pediatric Endoscopy Unit in Sanliurfa, this is the first study to have been conducted on children living in the Southeast Anatolia region of Turkey. The aim of this study was to examine the clinical and laboratory characteristics of children diagnosed with celiac disease in a tertiary level healthcare centre over a 2-year period. From a public health perspective towards celiac disease, it was also aimed to establish the appropriate sociological and cultural approaches required to be implemented for the families during the disease process.
Material and Methods
The study protocol was approved by the Non-Interventional Ethics Committee of Firat University (decision no: 13/3, dated: 19.07.2018). A retrospective examination was made of the medical records of patients diagnosed with celiac disease in the Pediatric Gastroenterology Department of Sanliurfa
Training and Research Hospital between June 2016 and May 2018. Patients who had been previously diagnosed with celiac disease at another healthcare centre and had started diet therapy were not included in the study. The tissue TG-IgA levels of the patients were examined using ELISA kits (Diesse Diagnostics, Siena, Italy). Tissue TG-IgA level <12 IU/mL was accepted as negative, 12-18 IU/mL as a borderline value, and >18 IU/mL as positive.
During an endoscopy, biopsy samples were taken from the upper gastrointestinal system (GIS), one from the duodenal bulbus and four from the second section of the duodenum. Samples evaluated as ≥ grade 2 according to the Marsh scoring system were accepted as significant for celiac disease.
Statistical Analysis:
Data obtained in the study were analyzed statistically using IBM-SPSS vn.22 software. Variables were stated as mean± standard deviation, number (n) and percentage (%) according to distribution. The Chi-square test was used in evaluations. A p- value <0.05 was accepted as statistically significant.
Results
A total of 201 cases were included in the study, comprising 89 (44.3%) males and 112 (55.7%) females with a mean age of 8.22±4.11 years (range, 1.0-18.0 years). The demographic data of all the cases, mean age, height, weight, height and weight Z scores according to age, and body mass index Z score according to age, are shown in Table 1.
At the time of presentation, the most common GIS complaint was chronic diarrhea (n: 35, 17.4%) and the most common non-GIS complaint was retarded development (n: 194, 96.5%). The complaints of the patients are shown in Table 2. The most common comorbidity in the study was Type 1 Diabetes with 4 cases (2%). Subsequently, 3 cases had IgA deficiency, 3 cases had PICA history, and 2 cases had epilepsy. There was one case each with Turner syndrome, Down syndrome, psoriasis, autoimmune thyroiditis and attention deficit and hyperactivity. Iron deficiency anemia was determined in 58 (28.9%) cases. The laboratory findings of the cases diagnosed with celiac disease are shown in Table 3.
The most common endoscopic examination findings in the study were duodenitis with 96.5% (n: 194), gastritis with 81.1% (n: 163) and duodenal irregularity with 67.1% (n: 135). Esophagitis in 9 cases, duodenal ulcer in 4 cases and gastric ulcer in 1 case were observed.
In the pathology examination of biopsies taken from the patients, Helicobacter pylori positivity was determined in 116 (57.7%). As a result of histopathological evaluation, the patients were classified according to the Marsh scores: 90 (44.7%) as 3a, 91 (45.3%) as 3b, 11 (5.5%) as 3c, and 9 (4.5%) as 2 (Figure 1).
Discussion
This study was conducted on children diagnosed with celiac disease in the province of Sanliurfa, where the prevalence of celiac disease is known to be above the average for Turkey. When the mean age of children diagnosed with celiac disease is examined in previous studies in Turkey, the mean age of cases was reported to be 7.2±4.3 years in a study conducted in Ankara in 2010 [9], 9.0±4.3 years a study in Izmir in 2013 [10], and 6.89 ± 2.41 years in a later study in Antalya [11]. Other studies have shown the mean age of children with celiac disease to be 7.4±4.3 years in Konya in 2017 [12], 8.6±4.7 years in Izmir in a study by Akay-Haci et al [13], 9.4±4.02 years in Kayseri [14], and 8.56±4.43 years in Erzurum [15]. The mean age of the cases in the current study can be seen to be in parallel with other similar studies in Turkey. This similarity can be attributed to increased awareness of celiac disease in Turkey in recent years and to the more widespread use of screening tests. It could also be due to the consideration of celiac disease in the differential diagnosis of children presenting with complaints other than in the gastrointestinal system.
In the current study, celiac disease was diagnosed more in females than males. In a study of 60 cases in Izmir followed up because of celiac disease, 38 (63.3%) females and 22 (36.7%) males were reported [13]. A study in Kayseri of 72 children with celiac disease comprised 44 (61.1%) females and 28 (39.9%) males [14]. In Antalya, 159 pediatric celiac cases comprised 94 (59.1%) females and 65 (40.9%) males [11]. Balamtekin et al reported that of 220 children followed up with celiac disease, 134 (60.9%) were female and 86 (39%) were male [9]. In a study conducted in Konya, out of 80 celiac cases, 49 (61.3%) were females and 31 (38.7%) were males [12], and in Izmir, out of 37 cases, 22 (59.5%) were females and 15 (40.5%) were males [10]. Celiac disease is reported to be seen more in female children in the literature [16]. The gender distribution data obtained in the current study were consistent with the literature and with some regional studies in Turkey.
Since celiac disease shows genetic transmission [2], family history is important in the diagnosis of patients. Different frequencies of celiac disease have been reported in the family history of children followed up for the diagnosis of celiac disease. Among 201 children with celiac disease in the current study, 6 (3%) had a positive family history. In a study conducted in Ankara, a history of celiac disease in the family was reported in 6.4% [9]. Emiroğlu et al reported a positive family history in 7.5% of the cases in a study in Konya [12].
The most common complaint on presentation in the present study of children diagnosed with celiac disease was retarded development (96.5%). In a study in Antalya of 159 cases of celiac disease, retarded development was reported in 62 (39%) [11]. In a study in Ankara, retarded development was determined in 53.1% of the cases aged >2 years [9]. Another study in Kayseri reported retarded development in 18 (25%) of 72 cases diagnosed with celiac disease [14]. Retarded development was also reported in 18 (48.6%) of 37 cases in Izmir [10], in 44 (55%) of 80 cases in Konya [12], and in 26 (50%) of 52 cases in Ankara [17].
Diarrhea is one of the most important complaints on presentation of celiac patients [2]. In the current study, 17.4% of the cases presented with diarrhea complaints. Since celiac disease causes damage to the most proximal section of the duodenum, this leads to chronic diarrhea. In a study in Konya, chronic diarrhea was reported in 21 (26.3%) of 80 cases with celiac disease [12]. Among 72 pediatric cases of celiac disease in Kayseri, diarrhea was reported in 38 (52%) [14]. Chronic diarrhea was reported in 22 (59.5%) of 37 cases in Izmir [10]. Diarrhea was also reported in 124 (78%) of 159 cases in Antalya [11], in 94 (42.7%) of 220 cases in Ankara [9], in 9 (15%) of 60 cases in Izmir [13], in 84 (60%) of 140 cases in Erzurum [15], in 36 (69.2%) of 52 cases in Ankara [17], and in 58 (53.2%) of 109 cases in a study by Kuloğlu et al [18].
Constipation may also be seen in celiac disease [2]. In the current study, constipation was determined in 15.9% of the cases. In studies conducted in Kayseri and Izmir, constipation was reported in 6.9% and 3.3%, respectively, of patients with celiac disease [14, 13]. Chronic constipation was determined in 17 (21.3%) of 80 cases with celiac disease in a study in Konya [12]. In a study in Ankara, Balamtekin et al reported constipation in 15 (6.8%) of 220 children followed up for a diagnosis of celiac disease [9], and in another study in Ankara, constipation was determined in 5 (9.6%) of 52 cases [17].
In the current study, abdominal pain was determined in 12.4% of the children with celiac disease. This rate was reported as 36% (57/159) in a study in Antalya [11], 62.2% (23/37) in Izmir [10], 15.5% (34/220) in Ankara [9], 43.8% (35/80) in Konya [12], 11.1% (8/72) in Kayseri [14], and 34.6% (18/52) in a study by Kondolat et al [17].
The complaint of vomiting was determined in the patients of the current study at the rate of 5.5%. Vomiting was reported in 12 (15%) of 80 celiac disease patients in a study in Konya [12], in 7 (18.9%) of 37 patients in Izmir [10], and in 17 (32.7%) of 52 patients in the study by Kondolat et al [17].
As can be seen from the above-mentioned studies conducted in different cities in Turkey, there are differences in the frequency of the symptoms of celiac disease at the time of presentation. As the sample size is larger, the overall strength of the current study in showing both classic and non-classic findings is higher. Autoimmune diseases may accompany celiac disease [2]. In the current study, type 1 diabetes was determined in 2% of the cases. Kondolat et al reported type 1 diabetes in 2 (3.8%) of 52 patients with celiac disease [17]. In other studies conducted in Turkey, type 1 diabetes was determined in 3 (5%) of 60 cases in Izmir [13], in 9 (4.1%) of 220 cases in Ankara [9], in 20 (13%) of 159 cases in Antalya [11], in 8 (10%) of 80 cases in Konya [12], in 9 (6.4%) of 140 cases in Erzurum [15], and in 2 (1.8%) of 109 cases reported by Kuloğlu et al [18].
The risk of celiac disease has been reported to be increased 10-fold in patients with selective IgA deficiency [19]. In the current study, selective IgA deficiency was determined in 1.5% of patients. In other studies conducted in Turkey, selective IgA deficiency was determined in 10 (9.1%) of 109 celiac disease cases in Ankara [18], in 9 (4.1%) of 220 cases in another study in Ankara [9], in 8 (6%) of 159 cases in Antalya [11], in 2 (2.5 %) of 80 cases in Konya [12], in 4 (5.5%) of 72 cases in Kayseri [14], and in 1 (1.9%) of 52 cases in another study in Ankara [17]. In the current study, pica was determined in 1.5% of the cases with celiac disease. It has been observed that children who are followed up because of pica eat substances rich in elements that they feel are lacking. Eating soil and ice has been reported in children associated with iron and zinc deficiency [20]. In the 3 current study patients determined with pica, there was seen to be iron deficiency anemia. Social support was provided for the families and following an improvement in the mother-child relationship and treatment for iron deficiency anemia, the pica was observed to decrease in all 3 cases. These findings were determined to be consistent with relevant studies in literature [21, 22].
Iron deficiency anemia may be seen in celiac disease [2]. In the current study, iron deficiency anemia was determined in 28.9% of the cases. In a study in conducted Erzurum involving 140 cases followed up with a diagnosis of celiac disease, iron deficiency anemia was reported in 64 (45.7%) [15]. Iron deficiency anemia is frequently seen because of impaired levels of iron absorption, especially in the duodenum, which has been associated with the pathogenesis of celiac disease.
In the current study, epilepsy was present in 1% of the celiac disease patients and attention deficit hyperactivity disorder in 0.5%. As in these cases, celiac disease can be seen together with neurological and psychiatric diseases [18]. The provision of the necessary medical and social support to families on the subject of the combination of celiac disease with comorbidities is an important intervention for treatment compliance. Autoimmune thyroiditis may accompany celiac disease [2]. In the current series, autoimmune thyroiditis was determined in 1 (0.5%) patient. In a study conducted in Antalya, hypothyroiditis was reported in 7% of cases followed up because of celiac disease [11]. In another study of 220 cases of celiac disease in Ankara, thyroiditis was reported in 7 (3.2%) [9].
Turner syndrome was determined in 1 (0.5%) of the current cases and Down’s syndrome in 1 (0.5%). Similarly, in a study in Ankara of 220 cases diagnosed with celiac disease, Down’s syndrome was reported in 2 (0.9%), and Turner syndrome in 2 (0.9%) [9].
In endoscopic examination of celiac disease patients, irregularity may be seen in the duodenum mucosa [2]. Accordingly, in the current study, irregularity was observed in the duodenum mucosa in 67.1% of the cases.
According to the histopathological scoring in the current study, 95.5% of the cases were determined with a Marsh score >2. Kondolat et al [17] reported that Marsh score 3 was determined most (82.7%) in the histopathological examination of 52 celiac patients. In a study conducted in Antalya, Marsh score 3 was determined histopathologically in 61.2% of celiac patients, Marsh score 2 in 26.7%, and Marsh score 1 in 12.1% [11].
In the pathology examination of the biopsies taken from the current study cases, Helicobacter pylori positivity was determined in 57.7%. In a study conducted in Adana, Helicobacter pylori positivity was reported in 63% of paediatric celiac disease patients who were followed up because of peptic ulcer [23]. In another study of 256 celiac patients in Adana, Helicobacter pylori positivity was determined in the pathology examination of 70 (27.4%) [24]. The high frequency of Helicobacter pylori in the current study may be associated with socioeconomic reasons and the nutritional habits of the children.
Celiac disease is one of the most common reasons of malabsorption in children. In parallel with an increase in the number of pediatric gastroenterology clinics in Turkey and the increasing awareness of the disease, celiac disease patients are now diagnosed at a younger age. As a result of early diagnosis and treatment, morbidity and mortality can be prevented. This study was the first of this kind to be conducted in the province of Sanliurfa, which has the highest birthrate and largest child population in Turkey. It can be considered that the data obtained in this study will be useful as a reference for further studies to be made in Turkey. In addition, the provision of sufficient and proper social support to families following diagnosis will make a positive contribution to the treatment and rehabilitation process. By establishing multidisciplinary study areas for this public health problem that can be diagnosed in childhood and has a lifelong effect, interventions can be made which will be of significant benefit in raising a healthy generation and improving the quality of life of these individuals.
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.
Funding: None
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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Uğur Deveci, Ufuk Acar. Evaluation of the clinical and laboratory characteristics of children diagnosed with celiac disease. Ann Clin Anal Med 2021;12(Suppl 4): S461-465
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Investigation of the spatio-temporal gait parameters in individuals with hemiparesis: The effect of lateralization
Gulsum Tıkac, Filiz Altug, Ayse Unal
Department of Neurological Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey
DOI: 10.4328/ACAM.20643 Received: 2021-04-06 Accepted: 2021-06-22 Published Online: 2021-07-15 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S466-471
Corresponding Author: Gulsum Tikac, Pamukkale University School of Physical Therapy and Rehabilitation, Department of Neurological Rehabilitation, Denizli, Turkey. E-mail: gtikac@pau.edu.tr P: +90 (258) 296 42 62 / (258) 296 44 94 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7375-6747
Aim: The aim of this study was to investigate the effect of lateralization on the spatio-temporal characteristics of gait in individuals with hemiparesis.
Material and Methods: A total of 108 individuals aged 20-65 years were included in the study. Thirty-six individuals were right hemiparetics (Group 1: 16F, 20M), 36 were left hemiparetics (Group 2: 16F, 20M) and 36 were healthy controls (Group 3: 19F, 17M). The Gait Analysis System was used to assess the spatio-temporal gait characteristics.
Results: The demographic and clinical characteristics of the groups were similar (p>0.05). When gait analysis, results were compared according to lateraliza- tion, the gait of the individuals in Group 1 was more symmetrical (p<0.05) and pelvis movements were more asymmetric than in Group 2 (p>0.05). When gait parameters of hemiparetic individuals were compared to healthy individuals, the cadence, gait speed, stride length and gait symmetry of the hemiparetic individuals were lower, but the gait period was longer than in Group 3 (p<0.05). Pelvic tilt, pelvic obliquity, and pelvic rotation symmetries of the hemiparetic individuals were lower than in Group 3 (p<0.05).
Discussion: Lateralization affects the spatio-temporal characteristics of gait in individuals with hemiparesis. Right hemiparetic individuals have a more sym- metrical gait and asymmetric pelvis movements when compared to the left hemiparetic individuals.
Keywords: Gait; Hemiparesis; Lateralization; Spatio-Temporal Analysis
Introduction
Hemiparesis is a clinical table in which one- half of the body performs its processes with mental, visual, intellectual and emotional disorders as well as motor and sensory loss [1]. These deficiencies, observed in hemiparetic patients, cause localization of the affected zone, and also the functional losses in different levels depending on the severity of affection. These functional losses are the disorder of balance and coordination, asymetric stance, increase in muscle tonus, postural control disorder, sensory and proprioceptive losses, cognitive problems and gait disorders [2].
Basic locomotor patterns that may distort the selective motor control occur in the period after stroke. This situation leads to changes in the intensity and severity of the normal timing in paretic extremity and muscle spasms [3]. This situation causes changes during gait in the parameters of speed, cadence, step length, stride length, length width, stance and swing phases and the time intervals of single support and double support periods [3,4].
Functional results of stroke change depending on the hemisphere involvement. The reason for this stems from the fact that right and left hemispheres control the tasks differently from each other [5]. For this reason, this study was conducted to investigate the spatio-temporal gait characteristics in right and left hemiparetic individuals and compare their differences with the gait of the healthy individuals.
Material and Methods
The present study was conducted at Pamukkale University, School of Physical Therapy and Rehabilitation, Department of Neurological Rehabilitation between June 2017-May 2018. This study was approved by Pamukkale University Medical Ethics Committee of Non-Interventional Clinical Researches (Approval date: 04.07.2017, no:09).
Participants:
As a result of the power analysis, it was calculated that when 108 people were taken into the study (36 for each group), 95% power with 80% confidence would be obtained. A total of 108 volunteer individuals aged between 20-65 years participated in the study. Thirty-three participants were right hemiparetic (Group1: 16 females, 20 males), 36 participants were left hemiparetic (Group2: 16 females, 20 males), and 36 participants were healthy controls (Group 3: 19 females, 17 males). Inclusion Criteria: Hemiparetic individuals aged 20-65 years, who had a stroke for the first time and one-sidedly, whose clinical state was stable, who had no cognitive disorder (Hodkinson Mental Test≥ 8), who received ≤ 3 points on the Modified Rankin Scale and those without vision and hearing problems were included in the study. Inclusion criteria for a healthy control group were to be between the ages of 20- 65 and have no neurological, musculoskeletal, cardiac and cognitive problems that they had previously experienced and that could affect walking.
Exclusion Criteria: Individuals who had any orthopedic, neurological or psychiatric problems that may affect walking and vision and hearing problems in both study and control groups were excluded.
All participants were informed about the study and their verbal and written consent was obtained before the study. After taking approvals, demographic and clinical data were recorded. Spatio-temporal characteristics and pelvis kinematics of gait were assessed with BTS G-Walk® Gait Analysis System. Assessment Methods:
1. Hodkinson Mental Test: It is used to assess cognitive functions. It consists of 10 questions in total. In the test whose minimum score is 0 and maximum score is 10, a score between 6-8 indicates slight cognitive disorder, a score between 4-6 indicates cognitive disorder in medium level and a score lower than this indicates heavy cognitive disorder [6].
2. Modified Rankin Scale: It is used to assess recovery after stroke. The scale, reliability and validity of which were conducted by Swieten et.al. in 1988 is graded between 0-6 points. On the scale whose score increases as the disability ratio increases; those with 1 and 2 points sustain their daily lives independently, and those with 3 and higher points sustain their daily lives dependently [7,8].
3. Assessment of the Gait Parameters: The BTS G-Walk Spatio- Temporal Gait Analysis System used for this test is the system in which the spatio-temporal characteristics, gait symmetry indexes of the individuals and the kinematic investigations in the pelvis and spine are provided with the help of a transport transmitted via Bluetooth. It is fastened to L5-S1 level with a pelvic belt and the activity of the individual convenient for the determined clinical test is demanded. The data of the patient is transmitted to a computer with the help of the connected transport and automatic reports are formed. It is used for soft tissue injuries, amputation and secondary walking problems associated with neurological illnesses [9] (available at: https:// www.imeko.org/publications/tc4-2014/IMEKO-TC4-2014-333. pdf). In this study, gait parameters have been recorded with the use of the BTS G-Walk Wireless Digital Gait Analysis System on a 10-meter smooth walking area.
Statistical Analysis: The analysis of the data attained from the study was conducted with SPSS for Windows 22.0 statistical package program. The significance level was obtained as p<0.05. Descriptive statistical data were given as mean ± standard deviation (X±SD) or percentage (%). All measurements were checked for normality with the Kolmogorov-Smirnov test. When parametric test assumptions were provided, Student’s t-test was used in the comparison of the independent group differences; when the parametric test assumptions were not met, the Mann-Whitney U test was used in the comparison of the independent group differences [10].
Results
The mean age of the participants was 51.25±12.81 years for Group 1, 50.42±11.28 years for Group 2, and 50.11±11.99 years for Group 3. The Mean period of hemiparesis was 19.74±28.08 months for Group 1 and 25.61±36.19 months for Group 2. The groups were similar in terms of age and hemiparesis periods (p>0.05). The demographic and clinical characteristics of the groups are given in Table 1.
When the spatio-temporal parameters were compared, both in Group 1 and in Group 2, swing phase were longer than stance phase of the hemiparetic side, and also single support period for the hemiparetic side was lower. When Group 1 and 2 were compared in terms of the gait symmetry percentage, it was found that the gait of Group 1 is more symmetrical (p=0.026) (Table 2).
When the gait parameters of Group 1 and 3 were compared, it was seen that the cadence, gait speed, stride length, ratio of the step length to the height, and gait symmetry of Group 1 were lower, time of gait period was longer for Group 1(p<0.05) (Table 2). were more assymetric, but there was no statistical significance between the groups in terms of pelvic movements (p>0.05). When comparing pelvic movements in Group 1 and 3, pelvic tilt symmetry, pelvic obliquity symmetry, pelvic rotation symmetry, right and left pelvic obliquity angle and pelvic rotation angle in Group 1 were lower (p<0.05). When the pelvic movements in Group 2 and 3 were investigated, it was seen that pelvic tilt, pelvic obliquity and pelvic rotation symmetry, right and left pelvic obliquity angle in Group 2 were lower than in Group 3 (p<0.05) (Table 3).
Discussion
In this study, which investigated the impact of lateralization on spatio-temporal gait characteristics in hemiparetic individuals, it was detected that the gait parameters are affected by lateralization in hemiparetic individuals. It was revealed that the gait periods of the left hemiparetic individuals are more asymetric than that of the right hemiparetic individuals. The cadence and gait speed of hemiparetic individuals decreased when compared to healthy individuals, and their walking period time increased. While the stance phase period of especially left hemiparetic individuals on the hemiparetic side decreased when compared to the healthy individuals, their swing phase period increased. Regarding the pelvis movements, pelvic tilt, pelvic obliquity, pelvic rotation symmetry, pelvic obliquity angle and pelvic rotation angles of the hemiparetic individuals decreased, and pelvic tilt angles increased when compared to the healthy individuals.
According to the World Health Organization, one-third of 15 million individuals with strokes every year have permanent walking problems causing functional dependence in daily life, and in-society ambulation restrictions create permanent impairment (available at: https://acikerisim.konya.edu.tr/ xmlui/handle/20.500.12452/5452). A study showed that the patients could not walk at the beginning, and only 15% of them could walk independently even after having rehabilitation. Although walking ability could be gained in 60% of hemiparetic individuals, the inability to form a functional walking period causes limitations in in-society ambulation [11].
The right and left hemispheres differ from each other in their specialized functions. For this reason, lateralization of the lesion causes different symptoms in patients [12]. In their study, Lopes et.al. expressed that motor activities, requiring planning and coordination, are controlled by the left hemisphere, and the sensorimotor data critical for sitting, standing and protecting the posture are integrated by the right hemisphere [13]. As a result of this study, it was found that the walking symmetries of right and left hemiparetic individuals distort when compared to the healthy individuals, and walking in left hemiparetic patients is more asymmetric.
In the study conducted by Adıgüzel et.al. in which the impact of lateralization on balance and walking has been assessed in hemiparetic individuals, it was detected that left hemiparetic individuals were better at balance scores and 50-step walking tests, but there was no significant difference between them when compared to right hemiparetic individuals (available at: https:// acikerisim.deu.edu.tr/xmlui/handle/20.500.12397/9887). In the study conducted by Polat in 2009, it was supported with the finding that there was no difference between gait parameters of right and left hemiparetic individuals (available at: https:// acikerisim.konya.edu.tr/xmlui/handle/20.500.12452/5452). In parallel with other studies, in this study, it was found that the gait speed, cadence, double support and single support period times of right and left hemiparetic individuals were similar.
Gama found that right hemiparetic individuals are more asymmetrical in swing phase compared to left hemiparetic individuals. However, he has found results similar to the literature that there was no difference in speed, stride length, stance in both extremities and swing phase, maximum hip flexion, knee flexion and extension and foot dorsiflexion [13, 14]. In this study, results similar to those of Gama were attained in speed, cadence, stride length, stance in both extremities and swing phase, as well as the fact that left hemiparetic individuals have more asymmetrical walking.
In the study conducted by Titianova et.al. comparing walking parameters in hemiparetic and healthy individuals, there was a decrease in speed, stride length and swing phase period, and an increase was observed in the stance phase and double support period time [15]. The study by Carmo et al. supports previous studies with similar results [16]. Results in parallel to the previous studies have been found in this study by finding a decrease in the cadence, speed and stride length in hemiparetic individuals. At the same time, an increase was detected in the hemiparetic side swing phase and double support phase periods, and a result different from the literature was found. The reason for this difference makes us think that it may stem from the decrease in sensory awareness on the hemiparetic side and the increase in the motor ignition period of the muscles forming the movement.
The fact that the body balance center oscillation is above normal in the hemiparetic individuals causes a compensatory overload in the pelvis during walking [17,18]. In the study conducted by Little et.al., it has been specified that the abnormalities in pelvis movements in individuals with stroke cause walking disorders [18]. In another conducted study, it has been determined that the pelvic tilt symmetries of hemiparetic and healthy individuals are similar, but the pelvic tilt amplitude of hemiparetic individuals has increased [19]. It has been determined in this study that the pelvic tilt angles of hemiparetic individuals have increased. Besides, in contrast to the conducted studies, the results of this study have revealed that the pelvic tilt symmetries decrease in hemiparetic individuals.
When the walking and pelvis movement in hemiparetic individuals are compared in respect to lateralization; while right hemiparetic individuals have a more symmetrical walking, they have more asymmetrical pelvis movement. It is considered that these results occur due to the impact of dominant hemisphere on walking.
The strong side of this study is that it has been conducted as based on objective data. Taking also lateralization into consideration in the comparison of the hemiparetic and healthy control groups is valuable in terms of attaining objective results depending on the direction of influence. Selection of the demographic data of the individuals in a homogenous way while determining the study and control groups and the inclusion of individuals below 65 terminates the impacts of personal data in this study. Consideration of the hemiparesis period decreases the impact of the individuals having rehabilitation on the results. Moreover, the examination of pelvis movements in this study is significant due to its impact on walking parameters.
The weak sides of this study are that etiology is not uniform and the inclusion of those that could walk with walking aids in the study. As well as objective assessment, conducting the evaluations with the fixation of walking speed, sequence and periods of muscle spasms and foot compression changes will provide opportunities for a better understanding of the differences in walking in future studies.
The results of the study show that lateralization has an impact on the difference in terms of walking symmetry in the right and left hemiparetic individuals during walking, but it does not have any impact on the other parameters of walking. Furthermore; right and left hemiparetic individuals have influences in terms of walking parameters when compared to healthy individuals. The reason for these results clearly indicates that hemiparesis affects walking and lateralization has an impact on walking.
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.
Funding: None
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.20643
Gulsum Tıkac, Filiz Altug, Ayse Unal. Investigation of the spatio-temporal gait parameters in individuals with hemiparesis: The effect of lateralization. Ann Clin Anal Med 2021;12(Suppl 4): S466-471
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Correlation of Copeptin with N-terminal pro-brain natriuretic peptide in predicting the severity and prognosis of acute pulmonary embolism
Özcan Yavaşi 1, Kamil Kayayurt 1, 2, Özlem Bilir 1, Gökhan Ersunan 1, Songül Özyurt 3, Aynur Kırbaş 4, Erhan Uğraş 1, 5
1 Department of Emergency Medicine, Recep Tayyip Erdoğan University, Rize, 2 Department of Emergency Medicine, Acıbadem University, School of Medicine, Istanbul, 3 Department of Chest Diaseases, Recep Tayyip Erdoğan University, Rize, 4 Private worker, Assoc. Prof. of Biochemistry, 5 Department of Emergency Medicine, Ordu University, Ordu, Turkey
DOI: 10.4328/ACAM.20645 Received: 2021-04-06 Accepted: 2021-06-02 Published Online: 2021-06-18 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S472-477
Corresponding Author: Özcan Yavaşi, Department of Emergency Medicine, Recep Tayyip Erdoğan University, 53020, Rize/Turkey. E-mail: ozcanyavasi@yahoo.com.tr P: +90 (464) 2130491 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8641-7031
Aim: In this study, we aimed to compare copeptin with N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin I for predicting severity and 3-month mortality in acute PE in the emergency department (ED).
Material and Methods: All ED patients older than 18 years who were confirmed to have acute PE within six hours of diagnostic work-up were enrolled and prospectively screened. Risk stratification was made according to the 2014 European Society of Cardiology guideline on PE. The study endpoints were defined as 3-month mortality, presence of non-low risk PE, and presence of right ventricular (RV) dysfunction. The Mann-Whitney U test was used for the comparison of medians. Receiver operating characteristic curves were generated and the area under the curve (AUC) was calculated to determine the best cut-off values of copeptin and NT-proBNP. A P value < 0.05 was considered statistically significant.
Results: The study enrolled 82 patients. Twelve patients who died during 3 months had higher concentrations of NT-proBNP and copeptin, but not troponin I. The AUCs of NT-proBNP and copeptin to accurately predict the 3-month mortality were 0.73 ± 0.09 (95% CI, 0.62 – 0.82; p = 0.013) and 0.78 ± 0.09 (95% CI, 0.68 – 0.86; p = 0.003), respectively. Low-risk patients, according to Pulmonary Embolism Severity Index, had lower concentrations of copeptin and NT-proBNP compared to intermediate-high risk patients. All three markers discriminated the presence of RV dysfunction truly.
Discussion: Copeptin correlates with NT-proBNP and appears beneficial for early risk stratification of acute pulmonary embolism in the ED.
Keywords: Acute Pulmonary Embolism; Copeptin; Emergency Department; N-Terminal Probrain Natriuretic Peptide; Troponin I
Introduction
Acute pulmonary embolism (PE) is a catastrophic cardiovascular diagnosis in emergency departments (EDs) with high mortality and morbidity rates. The aim of the emergency physician (EP) is to diagnose the disease as soon as possible, as well as to assess the risk stratification to guide the management and make treatment decisions, including the appropriate type and site of treatment. The European Society of Cardiology (ESC) classifies hemodynamically unstable patients with shock or hypotension as patients with a high risk of 30-day mortality. In these unstable patients, normal right ventricular (RV) function excludes PE as the cause of hemodynamic instability [1,2]. Therefore, after the diagnosis of PE, in hemodynamically stable, non-high risk patients, RV function is assessed by echocardiography or computed tomography angiography. Then cardiac biomarkers, such as N-terminal probrain natriuretic peptide (NT-proBNP) and cardiac troponins, are measured and a Pulmonary Embolism Severity Index (PESI) was calculated for further risk stratification [1-5]. When at least one of these factors is positive, the patient is classified as intermediate risk. If all these are negative, then the patient is classified as low risk [1,2]. Intermediate and high-risk PE patients have increased 30- day mortality compared to low-risk patients. Low- risk patients are considered for outpatient treatment.
All medical patients are under stress. The body responds to stress via activation of the hypothalamo-hypophyseal-adrenal axis. Arginine-vasopressin (AVP) is a component of this axis. Thus, copeptin, a C-terminal fragment of provasopressin, is an emerging marker and reflects the individual stress level [6]. It is used not only for diagnostic purposes but also for risk stratification of emergent cardiovascular conditions, including acute coronary syndromes and pulmonary embolism [7-13]. Copeptin levels have been shown to increase during 0-4 hours of acute myocardial infarction, when troponin T still remained undetectable [9]. This early increase appears to be an advantage of copeptin over other biomarkers.
In this study, we aimed to compare copeptin with NT-proBNP and cardiac troponin I for predicting the severity and 3-month mortality in acute PE in the ED.
Material and Methods
This prospective cohort study was conducted from June 2014 to May 2016. The local institutional ethics committee approved the study protocol (2014/99) and written informed consent was obtained from the participants prior to enrollment. The study complied with the international guidelines, the “Regulations on Pharmaceutical Research,” enforced by the Ministry of Health of Turkey published in the 27089 numbered Official Journal dated 23 December 2008 and also with other regulations published at a later date. All patients older than 18 years who were admitted to the ED and were confirmed to have acute PE within six hours of diagnostic work-up, regardless of symptom duration, were enrolled and prospectively screened. The exclusion criteria included delayed diagnosis of more than six hours, lack of echocardiography, inability to provide consent, or patients with one of the following clinical states: pregnancy, renal insufficiency or dialysis, hypophysial tumor, steroid treatment, decompensated heart failure, acute coronary syndrome, or known chronic pulmonary hypertension.
The diagnosis of acute PE was confirmed via computed tomography (CT) angiography performed with a 16- slice multidetector-row scanner (Toshiba AlexionTM/ Advance, Toshiba Medical Systems Corporation, Nashu, Japan) following the intravenous administration of 100 mL non-ionic iodinated contrast reagent. Clinical data regarding age, sex, comorbid diseases, vital signs and routine blood count, blood chemistry, and arterial blood gases were recorded on every patient chart. When the diagnosis was confirmed within six hours, two tubes, each containing 3 milliliters (mL) of blood samples, were collected. One tube was for cardiac troponin I and was investigated in a routine laboratory during an emergency room visit. The other tube was centrifuged within 1 hour at 1000 g for 15 minutes, and the serum was isolated and stored at -80 °C until analysis.
Serum levels of human NT-proBNP and human copeptin were quantified via an enzyme-linked immunosorbent assay (ELISA) using commercially available matched antibodies (Eastbiopharm, Hangzhou, China). The intra-assay and inter-assay coefficients of variation were <10% and <12%, respectively. The sensitivity was calculated as 2.49 ng/L for NT-proBNP and 0.024 ng/mL for copeptin.
Within one hour after the diagnosis, all patients underwent transthoracic echocardiography in the ED to assess RV function by a cardiologist (VingMed Vivid 5S, GE Healthcare, Waukesha, USA). Unstable high-risk patients were hospitalized in the intensive care unit for thrombolysis, and the remaining intermediate and low-risk patients were treated in the clinic of chest diseases with low-molecular-weight heparin and warfarin. The study endpoints were defined as 3-month mortality, presence of non-low risk PE and presence of RV dysfunction. Two emergency residents, who were blinded to the laboratory measurements, assessed outcomes of the measurements of the discharged patients via telephone interview.
Statistical Analysis
All statistical analyses were performed using the Statistical Package for the Social Sciences version 17.0 (IBM Corp. Armonk, NY, USA) and MedCalc Statistical Software version 16.1 (MedCalc Software bvba, Ostend, Belgium). Categorical data are presented as frequencies and percentages. Normality analysis was done using the Kolmogorov-Smirnov test. Continuous data were non-normally distributed; thus, they are presented as medians with interquartile ranges (IQRs). The Mann-Whitney U test was used to compare the medians of the two groups.
Receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) and Youden’s Index were calculated to determine the effectiveness of copeptin and NT- proBNP in determining the best cut-off values with the highest sensitivity and specificity to predict mortality, severity and RV dysfunction. A p-value < 0.05 was considered statistically significant.
Results
Ninety-eight consecutive patients were diagnosed with acute PE during the study period. Sixteen of the patients were excluded. Finally, 82 patients were enrolled. The most common presenting symptoms were dyspnea (67.07%), syncope (17.07%) and chest pain (9.75%) and others (6.09%), respectively. Twenty (24.39%) patients were candidates for thrombolysis; however, only 11 of these could receive. During hospitalization, six of the intermediate-risk patients developed hemodynamic decompensation and received thrombolysis, too. Twelve patients died within the 3-month follow-up period due to PE and related complications (all-cause mortality: four in the first week, five in the first month, one in the second month, and two in the third month). Clinical characteristics of the patients are presented in Table 1.
According to the PESI, there were 64 patients in the high- intermediate risk group (49 in high and 15 in intermediate risk groups) and 18 patients in the low-risk group. Patients in the high-intermediate risk group had higher plasma concentrations of NT-proBNP and copeptin, but not troponin I (Table 2). Among the 82 patients, 48 patients had RV dysfunction during the echocardiographic examination. Patients with RV dysfunction had higher concentrations of troponin I, NT-proBNP and copeptin (Table 2). ROC curves and related AUCs of three markers for predicting RV dysfunction are shown in Figure 1A. The AUC of troponin I was 0.66 ± 0.06 (95% CI, 0.55 – 0.77; p = 0.006) with a sensitivity of 75% and a specificity of 53%. The AUC of NT-proBNP was 0.79 ± 0.05 (95% CI, 0.69 – 0.87; p <0.001) with a sensitivity of 81% and a specificity of 73%. The AUC of copeptin was 0.71 ± 0.06 (95% CI, 0.60 – 0.81; p <0.001) with a sensitivity of 52% and a specificity of 88%. The optimal cut-off values for troponin I, NT-proBNP and copeptin were 0.04 ng/mL, 376.21ng/L and 6.63 ng/mL for the presence of RV dysfunction, respectively.
The patients who died at the end of the 3-month had higher concentrations of NT-proBNP and copeptin but not troponin I (Table 2). The AUCs of NT-proBNP and copeptin to accurately predict the 3-month mortality were 0.73 ± 0.09 (95% CI, 0.62 – 0.82; p = 0.013) with a sensitivity of 75% and a specificity of 84% and 0.78 ± 0.09 (95% CI, 0.68 – 0.86; p = 0.003) with a sensitivity of 83% and a specificity of 84%, respectively. There was no statistical difference between the ROC curves of NT- proBNP and copeptin (p = 0,632). The optimal cut-off values for NT-proBNP and copeptin were 609.64 ng/L and 7.34 ng/ mL, respectively. ROC curves and related AUCs of three markers for predicting 3-month mortality are shown in Figure 1B. There was a moderate correlation between copeptin and NT-proBNP (r = 0.478, p < 0.001).
Discussion
The main findings of the present study are that higher copeptin levels have prognostic significance for the prediction of 3-month mortality, as well as the severity of acute PE and the presence of RV dysfunction. Copeptin, obtained within six hours following presentation to the ED, shows better performance than troponin, regardless of symptom duration. Copeptin and NT-proBNP exhibit a moderate correlation to predict the severity of acute PE in the ED.
Biomarkers that identify the RV dysfunction and contribute to risk stratification are crucial, especially when echocardiographic assessment is not available. In these circumstances, biomarkers appear to be the only marker of risk stratification. As for many other biomarkers, there is an inevitable diagnostic gap in the initial hours after the onset of symptoms of acute PE. Several hours are required for the cardiac troponins and BNP levels to increase in the blood following the onset of acute myocardial stretch. Newer biomarkers that minimize or narrow this gap or require shorter time periods for testing are of clinical importance.
Cardiac troponins (I and T) comprise widely used markers of myocardial damage; however, they require 6-12 hours to rule out myocardial necrosis. Highly sensitive troponins have been developed to increase their diagnostic performance that identifies myocardial necrosis in 1-3 hours [14]. Cardiac troponins have also been well-studied for the risk stratification of acute PE, and increased levels have been associated with the RV strain, a complicated clinical course, and mortality [5,15]. In our study, patients with RV dysfunction had higher levels of troponin, although median troponin level was below the laboratory cut-off level of 0.1 ng/mL. Troponin levels did not differ between 3-month survivors and non-survivors. This discrepancy may be explained by the fact that in the previously described studies, the blood samples for troponins were collected at any time within 24 hours of symptom onset, which is sufficient for troponins to increase in blood; however, in our study, blood samples were acquired within six hours of diagnostic confirmation, regardless of symptom onset.
BNP and NT-proBNP are released from cardiac ventricles in response to ventricular strain. Both BNP and NT-proBNP have been suggested as reliable markers for identifying RV dysfunction and predicting mortality and serious adverse events [5,15]. For this purpose, the ROC curve analysis indicated a cut- off value of 600 or 1000 pg/mL for NT-proBNP [5,15,16]. This value was higher than our cut-off value (1 pg/mL = 1 ng/L). The exact times of blood sample collection regarding the symptom onset were not provided in these studies. An early collection of samples may be the reason for lower cutoff values in our study. Copeptin, the C-terminal part of AVP prohormone, is a promising marker. AVP is co-secreted with copeptin and neurophysin II from neurohypophysis in response to hemodynamic or osmotic stimuli, as well as endocrine stress [17]. It is not a disease or a single organ specific marker. It reflects an individual’s overall stress level rather than only cardiovascular stress because it has a more central role in the stress response This role enables it to be a more generalized marker for disease severity rather than for diagnosis. Copeptin results are available within one hour, which makes it an attractive biomarker in the ED [4,17]. It is also stable in both serum and plasma at room temperature for one to two weeks, making it suitable for retrospective analysis [17].
Because RV dysfunction indicates a poor prognostic factor, early detection with a simple blood test in acute stages, especially when echocardiography is not available, is essential. PE patients with RV dysfunction were found to have increased serum copeptin levels [10,11,13]. The result of the present study is similar with the literature in this aspect.
Liebetrau et al. demonstrated that copeptin concentrations began to increase at 30 minutes and peaked at 90 minutes following the induction of myocardial infarction in patients with hypertrophic obstructive cardiomyopathy undergoing transcoronary ablation of septal hypertrophy. The concentration returned to baseline after 24 hours [18]. In a similar model, the authors also examined NT-proBNP and demonstrated that it began to increase at 45 minutes after the induction of myocardial infarction and decreased after 76 minutes. The concentration returned to baseline after 8 hours [19]. Previously, it has been demonstrated that the copeptin levels decreased following the initiation of proper therapy for pulmonary hypertension. Thus, increased levels of copeptin suggest that the AVP system is also activated due to RV strain in acute PE [8]. Normotensive PE patients with a 30-day unfavorable outcome had increased copeptin levels compared with patients with a favorable course [10]. However, the increased copeptin levels were not associated with 30-day mortality. This finding may be explained by the exclusion of high-risk patients in their study in contrast to our study. Usul et al. also did not find any relation between copeptin levels and 30-day mortality, but in their study, copeptin had an AUC of 0.82 with a sensitivity of 69% a specificity of 83% in patients with RV dysfunction [13].
Deveci et al. found that high-risk PE patients according to a simplified PESI score had higher copeptin levels compared to low-risk patients and controls [12]. This is similar with the result of the present study. In a multicenter validation study, Hellenkamp et al. showed that copeptin might enable identifying normotensive PE patients at high risk [20].
A recent study conducted with 107 acute PE patients and 64 controls demonstrated that the copeptin levels were increased in the diseased patients compared with the controls [21]. The authors also stated that the low-risk patients’ plasma copeptin concentrations were lower than the intermediate/high-risk patients. The non-survivors within 30 days had higher copeptin levels than survivors. However, there were only four non- survivors in their study. Their study reported that the patients with a complicated clinical course had higher copeptin levels than the patients with a benign clinical course. However, they did not state the accurate time for blood sample collection. Most of our results are similar to this study; however, we have more patients who reached the study endpoints despite a lower number of included patients.
Limitations
First, because of institutional reasons, more patients were included in the intermediate-high risk group. The geriatric patients in these groups had more comorbidities that may influence the copeptin levels to some degree. Second, as a result of the limited number of patients who reached the primary endpoint, we did not perform regression analysis because reliable results would not be attained. Third, copeptin and NT- proBNP were studied using ELISA. The use of commercially available automated assays with fast turnaround time may give faster results.
Conclusion
When time is crucial, in patients with acute PE, copeptin, obtained within six hours following presentation to the ED, regardless of symptom duration, shows better performance than troponin, possibly due to delayed increase of troponin in the serum. It moderately correlates with NT-proBNP and appears beneficial for early risk stratification of acute PE in the ED. It also precisely discriminates low-risk patients with the same accuracy as NT-proBNP who are candidates for outpatient treatment.
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.
Funding: None
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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Özcan Yavaşi, Kamil Kayayurt, Özlem Bilir, Gökhan Ersunan, Songül Özyurt, Aynur Kırbaş, Erhan Uğraş. Correlation of Copeptin with N-terminal pro-brain natriuretic peptide in predicting the severity and prognosis of acute pulmonary embolism. Ann Clin Anal Med 2021;12(Suppl 4): S472-477
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Effectiveness of a clinical pilates program in women with chronic low back pain: A randomized controlled trial
Ozden Baskan 1, Ugur Cavlak 2, Emre Baskan 3
1 Physical therapist, İstanbul Rumeli University School of Physical Therapy and Rehabilitation, Istanbul, 2 Physical therapist, Avrasya University School of Physical Therapy and Rehabilitation, Trabzon, 3 Physical therapist, Pamukkale University School of Physical Therapy and Rehabilitation, Denizli, Turkey
DOI: 10.4328/ACAM.20648 Received: 2021-04-13 Accepted: 2021-06-24 Published Online: 2021-07-20 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S478-482
Corresponding Author: Ozden Baskan, Istanbul Rumeli University School of Physical Therapy and Rehabilitation, Istanbul, Turkey. E-mail: ozden.baskan@rumeli.edu.tr P: +90 2128660101 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1549-4838
Aim: The aim of this study was to show the effects of clinical Pilates program in women with chronic non-specific low back pain (CNLBP).
Material and Methods: Forty volunteer women aged 30-45 years with CNLBP for three months were included in this study. They were randomized to either a Pilates (n= 20) or a home exercise group (n= 20). Both groups participated in a 2- hour back-school education program. Pain intensity, muscle strength, pulmo- nary function, balance ability, and disability level were measured before and after the program (eight weeks). Participants in the Pilates program attended an 8-week Pilates regime (3 times in a week, for 45 min) supervised by an experienced physiotherapist. Home exercise group participants were advised doing a selected exercise program by a physiotherapist 3 times a week.
Results: Pilates participants showed significant improvements in pain intensity, muscle strength, pulmonary function, disability level, and balance ability (p≤ 0.05). There was no superiority for trunk flexion strength and pulmonary function between clinical Pilates and home exercise groups (p>0,05). Clinical Pilates is more effective than home exercises for CNLBP in terms of pain, muscle strength, balance ability and disability level (p≤0,05).
Discussion: We recommend using clinical Pilates exercises in clinics instead of the home exercise program for chronic nonspecific low back pain. The recom- mendation and application of clinical Pilates by physiotherapists will be beneficial in the treatment plan for patients with CNLBP more.
Keywords: Low Back Pain; Clinical Pilates; Pain Intensity; Disability
Introduction
Factors affecting pain severity of nonspecific back pain; sociodemographic characteristics, physical and psychosocial factors, lifestyle, repetitive activities, repulsion and withdrawal activities, static work posture [1,2]. Nonspecific low back, pain caused by pathologies related to the spine, sacroiliac joints, ligaments and paraspinal muscles, dura, spinal cord, and nerve roots is defined as mechanical low back pain [3,4].
Pilates exercises, which have become popular in recent years, strengthen the abdominal back muscles, and contribute positively to the lumbar spine posture. Clinical Pilates is a further modification of this method adapted for therapeutic use concentrating on core muscles [5,6]. In the literature, there are several studies evaluating Pilates but the results are conflicting [7]. Although there is a large number of researches on this subject, a stronger evidence about the effectiveness of Pilates is needed. Strengthening and stretching exercises are widely used in home exercise programs.
The purpose of our study was to examine the effectiveness of clinical Pilates in women with chronic nonspecific low back pain. However, we compared the effects of clinical Pilates training versus home exercise program on pain, muscle strength, pulmonary function, balance ability and disability level in women with chronic nonspecific low back pain.
Material and Methods
Forty women between the ages of 30-45 were included in our study. According to the power analysis, it has been calculated that when 40 people were included in the study (20 people in each group), 90% power would be obtained with 95% confidence. The participants were randomly divided into two groups as Pilates group and a control (home exercise) group. A computer-aided block the randomization method was used for randomization of cases.
Our study was conducted with the approval of Pamukkale University Faculty of Medicine Ethics Committee (60116787\020\44903). Initially, all participants gave written consent. This study was carried out in accordance with the Principles of Helsinki Declaration.
Individuals who have been diagnosed with mechanical low back pain at least 8 weeks ago, who had mechanical low back pain for at least 3 months and female participants were included in the study. Simple analgesia was permitted, but participants were requested to refrain from seeking other forms of treatment during the trial.
The exclusion criteria were pregnancy, radicular back pain, previous spinal surgery, orthopedic and neurological diseases. Before the start of the training, all participants were given a 2-hour training of Back School by the physical therapist. In this training, the anatomy of the lumbar region, muscle structure, neutral spine position, proper lumbar posture, protection methods of the low back during daily works, office ergonomics for individuals with low back pain were discussed.
Participants performed 45 minutes of clinical Pilates exercises with a physical therapist 3 times per week for a total of 8 weeks. Forty cases were divided into two groups as Pilates group (n=20) and home exercise group (n=20). Home exercise program which is widely used in clinics was recommended to the second group.
The participants performed the home exercises in their own homes. To get informed about the continuity of the exercise program, a phone dial was made with the participants once a week. Forty participants completed the study as the clinical Pilates group and the home exercise group. The participants were evaluated before and after the training.
Home exercise program
Home Exercise Program consists of the following exercises:
1. Participant in a hooked position, reaching to the knees with her hands, head raised.
2. Posterior pelvic tilt exercise in the supine position.
3. Stretching the lumbar extensors by pulling the knees to the chest in the supine position.
4. Stretching both hamstring and lumbar extensors by touching the toes with hands in long sitting position.
5. Stretching the hip flexors by springing forward in a half kneeling position.
6. Strengthening the M. Quadriceps femoris by squatting and standing up, in standing position.
7. Strengthening the back extensors while lying down in the prone position with both arms on the sides of the body, asking them to lift their head and upper body backwards [8].
Each exercise was performed with 10 repetitions.
Clinical Pilates program
The 5 key elements, consisting of centering, breathing, head and neck placement, shoulder placement, chest wall placement were taught to the Pilates group before the first session. The Pilates exercise program included warm-up and cool-down exercises, and each exercise was repeated 7-8 times [9].
1. Warm-up (foot series, roll up, chest stretching, upper body warming exercises, upper body series, side plie with stretch, walking)
2. Roll down, Roll down with push up, shoulder bridge, hip twist, abdominal preparation, oblique preparation, breaststroke preparation, swan dive, single leg kick, clam, single leg circle, swimming, arm opening, spine twist
3. Cool down (spine stretch, the saw, mermaid, piriformis stretches, hamstring stretch)
Questionnaires and scales used in the evaluation of participants: Demographic data form: Age, smoking, marital status, number of childbirths, type of childbirth was questioned.
Assessment of pain severity: The Visual Analogue Scale (VAS) was used for the intensity of low back pain [10].
Strength assessment: Participants’ trunk flexion, trunk extension, hip flexion, hip extension, hip abduction, hip adduction, knee flexion and extension muscle strength were assessed with digital force meter (Power Track). “Make test” was used as the measurement technique and the maximum power application protocol for the device was used while the meter kept the dynamometer constant. After completing the desired movement, the participant was asked to continue the maximum isometric contraction for 5 seconds. Averages of the 3 consecutive maximum contractions were measured with intervals of 30 seconds [11,12].
Pulmonary function: During the test, forced expiratory flow rate (FEV1%), forced vital capacity (% FVC), FEV1 / FVC] were measured in the first second. During the test, the participant sat down, and his\her nose was closed with a plastic latch. The patient was asked to breathe very deeply, exhale very quickly and completely, or to hold his\her breath for a short time [13]. Balance Assessment: Static balance was evaluated by flamingo balance test. [14]. The dynamic balance was assessed by functional reaching test. [15].
Observed Oswestry Pain Scale: It consists of 10 items questioning daily life activities. These are; pain severity, personal care, lifting, walking, sitting, standing, sleeping, social life, travel and pain. There are 6 options between 0-5 points for each item. Zero indicates worst case, 5 indicates worst case, 0-14 weak, 15-29 moderate, 30 above the functional limit [16]. SPSS for Windows 22.0 computer package program was used for all statistical analyzes. Descriptive statistical data were given as mean ± standard deviation (X ± SD) or %. In all statistics, the p-value was accepted as 0.05. In the study, the Wilcoxon test was used to determine the differences before and after treatment in the study, and the Mann-Whitney U test was used for the differences between the groups [17].
Results
There was no difference between the groups in terms of age, weight, height, body mass index (Table 1). When analyzing pain severity, trunk and lower extremity muscle strength measurements, balance levels and disability levels of the groups, there was no significant difference between the groups (p> 0.05). In the clinical Pilates group, when comparing pain severity before and after training, there was a significant decrease in pain severity after training (p <0.05).
When trunk flexor and extensor muscle strength were compared, it was seen that muscle strength significantly increased after the clinical Pilates training (p≤0.05). Bilateral hip flexion, extension, hip abduction and adduction, knee extension muscle strength were also significantly increased following the clinical Pilates training (p≤0.05). When the flamingo balance test and functional reaching test results were compared, a significant increase was determined after the training for the clinical Pilates group (p <0,05). There was also a significant decrease on the Oswestry pain scale in participants attending clinical Pilates training (p <0.05) (Table 2).
There was no significant change in the pain severity in the home exercise group, which was measured by the VAS (p>0,05). When measuring the trunk and lower extremity muscle strength, there was no statistically significant improvement in the home exercise group.
Both methods were not superior to each other in the respiratory functionality, although the clinical Pilates FVC results were improved (p = 0.09 for FVC; p = 0.32 for Fev1 /FVC). There was no significant improvement in balance levels and Oswestry pain scale measurements in the home exercise group (p> 0.05).
In our study, we determined that clinical Pilates was more effective than home exercise group in reducing pain severity in patients with mechanical low back pain (Figure 1).
When the clinical Pilates group and the home exercise group were compared, there was a statistically significant increase in measurement results related to the trunk flexion muscle strength of the clinical Pilates group after training (p <0,05). However, intergroup differences were not shown (p = 0.27). When clinical Pilates and home exercise training were compared for trunk extension, hip flexion, extension, abduction, adduction, knee extension muscle strength, the clinical Pilates group showed a statistically significant improvement in muscle strength (p≤0.05).
When the flamingo balance test and the functional reaching test results of both groups were examined, there was a statistically significant superiority compared to the home exercise program of clinical Pilates method. Clinical Pilates training was found to be more effective than home exercise program in improving static and dynamic balance. When the results of the Oswestry pain scale of the clinical Pilates and home exercise program participants were compared, we can say that clinical Pilates is more effective in reducing the level of disability than the home exercise program.
Discussion
Our purpose was that clinical Pilates training in women with chronic nonspecific low back pain would provide more favorable improvements in muscle strength, pain, balance and disability compared to the home exercise program. The purpose of this study was to compare the effectiveness of clinical Pilates program on nonspecific low back pain with an exercise program consisting of flexibility exercises and strengthening abdominal and back muscles, which are commonly used in clinics.
We found a significant decrease in pain intensity in the Pilates group. There was no significant change in pain intensity in the home exercise group. When both methods were compared, it was seen that clinical Pilates more effective than a home exercise program in decreasing pain. The literature review shows that clinical Pilates reduces chronic mechanical low back pain. In a meta-analysis study, Owen et al. stated that Pilates, stabilization\motor control, aerobic and resistant exercise programs are the most effective treatment methods in individuals with chronic nonspecific low back pain [18]. Chronic back pain and muscle weakness developing over time leads to postural disorders. Over time, decreasing in movement and mobility leads to muscle weakness. We think that this situation also negatively affects the balance. Therefore, we think that clinical Pilates exercises have positive effects on muscle weakness and body inhalation in chronic low back pain and should be included in the physical therapy and rehabilitation program.
There was a statically significant increase in the levels of the body and lower extremity muscular strength in the clinical Pilates training group compared to the home exercise group. We can say that the clinical Pilates training is a more effective method than the home exercise program especially for improving hip flexion and extension muscle strength. The clinical Pilates program is a more effective method to improve muscle strength except for body flexion than the home exercise program. However, none of the methods are superior to the other in terms of enhancing body flexion muscle strength. In the Pilates program, a person is worked on by increasing the level of difficulty of movement with his / her body weight and the auxiliary tools used. All the body-oriented exercises are controlled under the supervision of a physiotherapist in the Pilates program, while working individually against body weight at home in the home exercise program. We think that the difference is caused by this situation. Our study has similar results with the literature. Tozim et al. showed an improvement in the isometric strength of the trunk extensor muscles as evaluated with a lumbar dynamometer when they compared Pilates method with other exercise methods [19].
Roşu et al. investigated the effects of Pilates, McKenzie and Hecksher training on pulmonary function in patients with ankylosing spondylitis. As a result, in their study of 96 participants, it was seen that this training had a positive effect on pulmonary functions [20]. In our research, there was a significant increase in FVC values in the clinical Pilates group, while there was no significant change in Fev1 / FVC values. No significant change in FVC and Fev1 / FVC values was observed in the home exercise group. We can say that clinical Pilates increases vital capacity in participants with mechanical low back pain.
There are a limited number of studies evaluating the static and dynamic balance in patients with nonspecific low back pain in the literature. Yalfani et al found that mat Pilates exercise program had beneficial differences on static balance for chronic low back pain [21]. Its effect on dynamic balance was not statistically significant. In our study, we found significant improvement on static and dynamic balance in patients with chronic low back pain. We need more investigation on Pilates exercises for balance.
In a meta-analysis conducted in 2020, they investigated the effect of Pilates exercises on disability in patients with low back pain. The results of meta-analysis showed that Pilates exercises had a significant positive effect on disability improvement in the Pilates group compared with other types of exercise methods [22]. Another review article suggested that, the Pilates method has demonstrated excellent results in pain perception and intensity, functional capacity, fear of movement, and the idea that movement can worsen the health perception, muscle strength, and flexibility [23].
As a result, it was concluded that Pilates is an effective method on pain and disability, Core weakness is very important in patients with low back pain [24]. Axial extension and stabilization principles are applied throughout Pilates exercises. Studies show that Transversus Abdominis, Multifidus, diaphragm, pelvic floor muscles and abdominal oblique muscles are the muscles which are key to movement in healthy people in terms of low back pain [24,25].
A limitation of this study was that long term effects of exercise programs have not been investigated. The strength of this study was that two exercise programs that affect such parameters as strength, balance, pulmonary functions were investigated in patients with chronic low back pain. Blinded assessments were done by a independent physiotherapist. Both interventions were delivered by the same physiotherapist to minimize differences. This study showed that clinical Pilates exercises are more effective than home exercise program in reducing pain, disability and improving strength, balance for patients with chronic nonspecific low back pain. Physiotherapists should use clinical Pilates exercises in the treatment plans of patients with nonspecific low back pain.
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.
Funding: None
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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6. Muscolino JE, Cipriani S. Pilates and the ‘‘powerhouse’’-1. J Bodywork Movement Ther. 2004;8:15–24.
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8. Otman S. Egzersiz Tedavisinde Temel Prensipler ve Yöntemler (Basic Principles and Methods in Exercise Therapy). Ankara: Pelikan Yayınları; 2014.
9. Lee CW, Hyun J, Kim SG. Influence of pilates mat and apparatus exercises on pain and balance of businesswomen with chronic low back pain. J Phys Ther Sci. 2014; 26(4): 475-7.
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11. Kolber MJ, Cleland JA. Strength testing using hand-held dynamometry. Phys Ther Rev. 2005; 10(2):99-1124. DOI: 10.1179/108331905X55730
12. Telci Aslan E, Aslan Baş U, Cavlak U. Sağlıklı quadriseps femoris kasında handheld dinamometrenin intrarater ve interrater güvenirliği: Kas kuvvetinin etkisi (Intrarater and interterrater reliability of handheld dynamometer in healthy quadriceps femoris muscle: The effect of muscle strength). Clinical and Experimental Health Sciences. 2011; 124-8.
13. Waked IS, Osman EM, Deghidi AHN. Efficacy of Pilates Exercises in Improving Pulmonary Functions and Quality of Life after Renal Transplantation: A Randomized Controlled Trial. International Journal of Health Sciences and Research. 2016, 6(1): 246-53.
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Ozden Baskan, Ugur Cavlak, Emre Baskan. Effectiveness of a clinical pilates program in women with chronic low back pain: A randomized controlled trial. Ann Clin Anal Med 2021;12(Suppl 4): S478-482
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AIMS65 score and shock index in predicting mortality in patients with acute upper gastrointestinal bleeding
Fatih Doğanay 1, Erdal Yılmaz 2
1 Specialist of Emergency Medicine, Department of Emergency Medicine, Edremit State Hospital, Balıkesir, 2 Specialist of Emergency Medicine, Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20803 Received: 2021-07-28 Accepted: 2021-08-21 Published Online: 2021-08-23 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S483-487
Corresponding Author: Fatih Doğanay, Cennet Ayağı Mahallesi, 781. Sokak No:7, 10300 Edremit, Balıkesir, Turkey. E-mail: drdoganay@gmail.com P: +90 535 600 2600 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4720-787X
Aim: The aim of the study was to investigate the effectiveness of the shock index (SI) and the AIMS65 score in predicting mortality in patients with upper gastrointestinal bleeding (UGIB) who presented to the emergency department (ED)
Material and Methods: The files of all patients with a diagnosis of UGIB over the age of 18 who visited ED during the study period were scanned from the hospital archives, taking into account the International Classification of Diseases (ICD) codes. Receiver operating characteristic (ROC) analysis, the area under the curve (AUC) and Youden Index J (YJI) was performed to analyze the performance of AIMS65 and SI in predicting in-hospital mortality.
Results: This retrospective observational study was conducted using data from 394 patients. The median age of the study population was 68 (81-54). Sensitiv- ity, specificity, PPV, NPV, AUC and YJI values for the AIMS65 score were calculated as 100%, 64.21%, 17.60%, 100%, 0.917, 0.642, respectively (P < 0.001). The same values for the shock index were calculated as 71.43%, 88.80%, 32.8%, 97.6%, 0.807, and 0.602, respectively (P < 0.001).
Discussion: In this study, the AIMS65 score was found to be more successful than SI in predicting mortality in UGIB patients. We suggest that the AIMS65 score, which is an easily calculated score in emergency departments, should be used to predict mortality in UGIB patients.
Keywords: Gastrointestinal diseases; Gastrointestinal hemorrhage; Risk scores; Shock
Introduction
Acute upper gastrointestinal bleeding (UGIB) which originates proximal to the ligament of Treitz is a serious disease that can result in mortality [1]. This disease, which affects 48-160 out of 100,000 adults per year, can lead to poor outcomes such as recurrent UGIB (reach to 26%) and death (2%-12%) [2, 3]. Therefore, early identification of critically ill patients who will require early invasive procedures is important.
International guidelines recommend the use of risk scores at the time of the first admission to the emergency department (ED) of UGIB patients [4, 5]. However, most of these scores include endoscopic data [6-8]. These scores are useless for emergency departments, given that endoscopy is difficult to access in many emergency departments. In 2011, Saltzman JR et al. reported a simple score to assess the prognosis of patients with UGIB. This score has five variables that do not include endoscopic data: age, systolic blood pressure (SBP), altered level of consciousness, international normalized ratio (INR), and albumin. The patient will receive one point for the presence of each variable. As a result, the mortality rate is 0.3% for 0 points, 1.2% for 1 point, 5.3% for 2 points, 10.3% for 3 points, 16.5% for 4 points and 24.5% for 5 points. Those who score zero or one on the AIMS65 score are classified as low-risk in terms of in-hospital mortality risk, while those with a score of two to five are classified as high-risk. In the same study, the AIMS65 score was reported to be beneficial in reducing the length and cost of hospital stay as well as in-hospital mortality in patients with UGIB [9].
The shock index (SI) is a practical risk predictor, calculated as the ratio of heart rate (HR) to SBP. SI has been shown to increase with acute hypovolemia and left ventricular dysfunction [10]. The UK National Confidential Inquiry into Patient Outcome and Death (NCEPOD) report, published in 2015, recommended the use of the SI to identify patients with UGIB at high risk of poor outcome and the possible need for early intervention (available at: http://www.ncepod.org.uk/2015gih.html).
The aim of this study was to investigate the efficacy of SI and AIMS65 score in predicting mortality risk in patients with the diagnosis of UGIB.
Material and Methods
This retrospective observational study was carried out in the ED of a tertiary care hospital between January 1, 2020, and June 1, 2020. The institutional review board approved the analysis and issued a waiver of consent (Ethics Committee Ruling number: 2021/514/204/6, date: 22.06.2021). The files of all patients with a diagnosis of UGIB over the age of 18 who visited ED during the study period were scanned from the hospital archives, taking into account the International Classification of Diseases (ICD) codes. Patients transferred from another hospital, patients who refused to be hospitalized, patients with varicose bleeding, patients whose shock index and AIMS65 score could not be calculated, and patients whose in-hospital mortality status could not be reached were excluded from the study. Vital signs, physical examination findings, consciousness status, laboratory values, and comorbidities of each patient at admission were recorded in an Excel dataset ((Microsoft Inc., Richmond, WA). The shock index was calculated as the ratio of heart rate (HR) to SBP. In calculating the AIMS65 score, one point was given to each of the five variables: less than 3 g/dL for serum albumin, older than 65 for age, less than 90 mmHg for SBP, higher than 1.5 for INR and altered level of consciousness. The primary outcome of the study was in-hospital mortality. Statistical analysis was performed using IBM SPSS Statistics Version 26.0 and MedCalc Statistical Software Version 19.0.6 software. The Mann-Whitney U test was used for continuous data analysis, the Chi-square test and Fisher’s Exact test were used for the analysis of categorical data. Continuous data were reported as medians and interquartile ranges (25th-75th). Categorical data were given as frequency and percentage (Tables 1 and 2). A p-value less than 0.05 was considered statistically significant.
Receiver operating characteristic (ROC) analysis was performed using the DeLong method to analyze the performance of AIMS65 and SI in predicting in-hospital mortality for UGIB patients [11]. The area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Youden index J (YJI) were calculated to analyze the predictive performance of in-hospital mortality. In addition, YJI analysis was used to determine the ideal threshold values for predicting in-hospital mortality of AIMS65 and SI scores [12].
Results
After applying the exclusion criteria, this study was conducted using data from 394 patients. The number of patients in the groups was 366 for the survivors group and 28 for the non- survivors group. Among the patients included in the study, 147 were females and 247 were males. There was a statistically significant difference in favor of males between the groups in terms of genders (Table 1).
The median age of the study population was 68 (81-54) years, and the median age of the groups was calculated as 67 (53- 80.25) years for the survivors group and 74 (67.5-84.75) years for the non-survivors group. A statistically significant difference was found between the groups in terms of age (Table 2).
When the effects of chronic diseases on mortality in UGIB patients were analyzed, there was a statistically significant difference in terms of mortality between the survivors and non- survivors groups for liver disease (LD), ischemic heart disease (IHD), and congestive heart failure (CHF). (Table 1).
When the effects of vital parameters on mortality were analyzed, there was a statistically significant difference between the groups for SBP, DBP, HR and spO2 (Table 2).
When the effects of symptoms on mortality were analyzed, there was a statistically significant difference between the groups for hematochezia, hematemesis, syncope and unconsciousness, while there was no statistically significant difference for melena (Table 2).
When the effectiveness of laboratory parameters in relation to mortality was analyzed, there was a significant difference between the groups for hemoglobin, urea, creatinine, INR, and albumin, while there was no significant difference between the groups for platelet count (Table 2).
The accuracy of the AIMS65 score and SI in predicting in- hospital mortality was analyzed by ROC analysis. Sensitivity, specificity, PPV, NPV, AUC and YJI values for the AIMS65 score were calculated as 100%, 64.21%, 17.60%, 100%, 0.917, 0.642, respectively (P < 0.001) (Table 3). The same values for the shock index were calculated as 71.43%, 88.80%, 32.8%, 97.6%, 0.807, and 0.602, respectively (P < 0.001) (Table 3). The ideal threshold values for predicting in-hospital mortality in UGIB patients were calculated as “≥2” for the AIMS65 score and “>0.967” for the shock index (Table 3). When the ROC curves of the AIMS65 score and the shock index were compared, it was seen that there was a statistically significant difference between the two curves (p=0.0289).
Discussion
Early diagnosis of UGIB patients with a high risk of poor prognosis will reduce morbidity and mortality. Likewise, classifying UGIB patients at a low risk may lead to the safe and early discharge of these patients, resulting in the appropriate use of healthcare resources.
In this study, the performances of SI and AIMS65 scores in predicting mortality in patients with UGIB were examined. Although the results of both prediction models were found to be satisfactory, the AIMS65 score demonstrated the best accuracy at predicting mortality with AUROC [95% CI]: 0.917 [0.885-0.942].
Patients presenting to ED with UGIB have a high risk of morbidity and mortality. In the USA, more than one million patients are admitted annually due to GI bleeding [13]. Numerous risk assessment scores have been developed for these patients, but most of the scores include endoscopic data and do not seem useful for ED [14]. Saltzman et al. created the AIMS65 score with pre-endoscopic data, which was validated using 2 optimal cut-off points in a retrospective cohort of 32,504 patients. This study reported sensitivity and specificity of 0.79 and 0.61, respectively, for predicting mortality [9].
In Yaka et al.’s cohort of 254 patients, the AIMS65 score was successful in predicting mortality with an AUC of 0.81 [15]. In prospective observational study by Chang et al., AIMS65, Glasgow-Blatchford, and Rockall scores were compared, and the AIMS65 score was found to be superior to other scores with an AUC of 0.747 in estimating mortality [16]. In another study comparing AIMS65, Glasgow-Blatchford, and Rockall scores, AIMS65 was found to be the most successful scoring system with an AUC value of 0.91 in mortality prediction [17].
SI has attracted the attention of researchers since the first day it was defined and has been studied in many different diseases such as hypovolemia, sepsis, and myocardial infarction [18-20]. Similarly, there are studies on SI in predicting the prognosis of patients with UGIB. In a study examining the relationship of SI with poor prognosis in patients with UGIB, it was reported that shock index values greater than 0.7 were effective in predicting the need for intensive care, blood transfusion and endoscopic treatment [21]. In another study, it was reported that high SI values were associated with angiographic extravasation in patients with UGIB [22]. In the newly developed scoring system of Horibe et al., SI was used as a variable of the score, and they reported that this score was successful in determining the endoscopic intervention [23]. However, there are also studies reporting that SI is not a useful prediction tool. In the study by Saffouri et al., SI, Glasgow Blatchford, AIMS65, ABC, and admission Rockall scores were compared to predict the prognosis of patients with UGIB. In terms of major transfusion, endotherapy, and 30- day mortality, the SI was found to be unsuccessful compared to other scores. The authors reported that the patients in this study were younger, had less cardiovascular comorbidity, and were using less antihypertensive medication. They emphasized that these factors may explain why SI is less useful in predicting the outcome of patients with UGIB [24].
There are some limitations in our study. First, this is a single- center retrospective study conducted on a relatively small population and should be validated in a larger, multi-center cohort. In addition, it should be kept in mind that the presence of underlying comorbidities such as hypertension, diabetes mellitus, or coronary artery disease may suppress the predictive value of SI.
Conclusions
In this study, the AIMS65 score was found to be more successful than SI in predicting mortality in UGIB patients. We suggest that the AIMS65 score, which does not require endoscopic data and patients’ comorbidity information and can be easily calculated in emergency departments, should be used to estimate mortality in UGIB patients.
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.
Funding: None
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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Comparison of eosinophilic cationic protein, adiponectin and leptin levels in patients with allergic rhinitis and local allergic rhinitis
Emel Atayık 1, Gokhan Aytekın 1, Oznur Abadoglu 2
1 Department of Allergy and Clinical Immunology, University of Health Science, Konya City Hospital, Konya, 2 Private Office of Pulmonary and Allergic Diseases, Istanbul, Turkey
DOI: 10.4328/ACAM.20627 Received: 2021-03-30 Accepted: 2021-08-14 Published Online: 2021-09-07 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S488-493
Corresponding Author: Emel Atayık, Department of Allergy and Clinical Immunology, University of Health Science, Konya City Hospital, Konya, Turkey. E-mail: emelakinci@yahoo.com P: +90 545 300 31 97 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7011-7752
Aim: Local allergic rhinitis (LAR) is a type of rhinitis with unclear treatment and unknown incidence and mechanism, which is characterized by perennial rhinitis complaints. A nasal provocation test (NPT) is recommended in the diagnosis of LAR. Eosinophil cationic protein (ECP), leptin, and adiponectin tests are mark- ers reported to be used in the diagnosis and treatment of many allergic diseases. In this study, we aimed to investigate whether there is a difference in serum adiponectin, leptin, and ECP levels between patients with allergic rhinitis (AR) and LAR.
Materials and Methods: Adult patients aged 18-65 years, who had been complaining of rhinitis for at least two years, had perennial rhinitis complaints were included in the study.
Results: NPT was positive in 30% of the patients; 30% (9 patients) of the patients who had non-allergic rhinitis and underwent NPT were found to have a posi- tive nasal provocation test. A significant difference was determined between the groups in terms of ECP and adiponectin levels (p: 0.001 and p: 0.007). There was a significant difference between the patients with AR and NPT (-) LAR in terms of ECP levels (p: 0.001). Furthermore, a significant difference was deter- mined between patients with NPT (+) LAR and NPT (-) LAR and patients with NPT (+) LAR and the control group in terms of ECP levels (p: 0.001 and p: 0.001).
Discussion: Although ECP and adiponectin levels differ between patient groups, it is obvious that larger studies are needed to evaluate the correlation of these parameters with the severity of rhinitis in patients with rhinitis.
Keywords: Local Allergic Rhinitis; Leptin; Adiponectin; Nasal Provocation Test; Eosinophil Cationic Protein
Introduction
Local allergic rhinitis (LAR) is a type of rhinitis with unclear treatment and unknown incidence and mechanism, which is characterized by perennial rhinitis complaints. LAR is included in the non-allergic rhinitis group and is diagnosed with the exclusion of other causes of rhinitis. It is thought to result from nasal local immunoglobulin (Ig) E (entopy) response, despite similar symptoms to AR and negative allergy skin tests and/or negative allergen-specific IgE levels in the blood [1].
In patients with suspected LAR, a nasal provocation test (NPT) is recommended to be beneficial for diagnosis. NPT is a method demonstrating the function and immune response of the nasal mucosa, and provocation tests can be performed using allergens, lysine-aspirin, and nonspecific stimulants (methacholine, capsaicin, cold air, etc.).
NPT is recommended in the diagnosis of LAR; however, this method is difficult to apply in routine practice and, thus, studies on markers, which may be beneficial in the diagnosis of LAR, are easy to apply and can be recommended for every patient, continue. Nasal eosinophil cationic protein, nasal specific IgE, basophil activation tests are markers reported to be used in the diagnosis and treatment of many allergic diseases [2]. Adiponectin and leptin are protein-nature hormones released by adipocytes [3]. There are studies suggesting that serum leptin and adiponectin levels are correlated with the severity of allergic rhinitis and may be used in the determination of the severity of AR [4]. Eosinophil cationic protein (ECP) level is an indicator of eosinophil inflammation. In many studies, ECP was reported to be higher in patients with AR compared to the control group [5]. However, there is no sufficient literature data on the use of leptin, adiponectin, and eosinophil cationic protein, which have been studied in allergic rhinitis and were found to be correlated with disease severity, in local allergic rhinitis.
In this study, we aimed to investigate whether there is a difference in serum adiponectin, leptin, and ECP levels not only between patients with AR and LAR, but also between patients with NPT (+) LAR and NPT (-) LAR, and to demonstrate a potential correlation between these parameters and severity of rhinitis.
Material and Methods
Adult patients aged 18-65 years who admitted to Cumhuriyet University Faculty of Medicine Outpatient Clinic of Immunological and Allergic Diseases, had been complaining of rhinitis for at least two years, have had perennial rhinitis complaints, whose rhinitis complaints emerge in domestic and dusty environments, who had not received treatment for rhinitis in the last six weeks were included in the study. The patients with a history of anaphylaxis with any of the allergens to be used, history of oral/oropharyngeal angioedema, and a history of taking medicines that may exacerbate lower respiratory tract complaints (ACE inhibitors, β-blockers, etc.) or influence test results (antihistamines, allergen-specific immunotherapy, etc.) were excluded from the study.
The patients were divided into three groups based upon allergy skin test results: allergic rhinitis (AR), non-allergic rhinitis (NAR), and control group. The patients included in the non- allergic rhinitis group were further grouped based upon nasal provocation test results: NPT (+) LAR and NPT (-) LAR.
Each case was subject to an allergy skin test with standardized inhalant allergens (ALK, Madrid, Spain). Skin prick test was performed using general inhalant allergens, house dust mite (Dermatophagoides (D) farinae, D. pteronyssinus), cat (Felis domesticus), dog (Canis familaris), cockroach (Blatella germanica), fungi (Alternaria, Cladosporium, Aspergillus), and pollen mixtures (tree, weed, grass). It was carried out in all patients in which systemic atopy could not be demonstrated with skin prick tests and specific IgE.
The patients were asked to evaluate their rhinitis symptoms quantitatively and to display their responses to the question “how much does your rhinitis complaints bother you?” on a 0-10-cm scale. As reported in the literature, <5 cm values on the scale were evaluated as mild rhinitis and ≥6 cm values as moderate-severe rhinitis [6].
The nasal provocation test (NPT) was performed for qualitative measurement of nasal reactivity against an allergen. Thusly, a mixture of house dust mite was selected as a suspected allergen in patients who have complained of perennial rhinitis in domestic and dusty environments. NaCl (0.9%) was used as a control step. In addition, a nasal allergen provocation was performed with a mixture of house mite dust (D. pteronyssinus, ALK, Madrid, Spain). Dusty allergens were diluted to 1 BU/ mL, 2 BU/mL, 4 BU/mL, and 10 BU/mL. The house dust mite solution was applied into two nostrils with a metered-dose pump spray by spraying upwards and towards the concha. Firstly, a non-allergenic and neutral pH solution was applied in order to determine the response to nonspecific stimulants. When no symptoms developed, a nasal provocation test with an allergen was performed. Following each allergen application, symptom scoring and visual analog scale were filled. The nasal provocation test was completed in a total of 75 minutes at 15-minute intervals using 0.9% NaCl and allergens (1, 2, 4, 10 BU/mL).
Serum ECP levels were measured using Unicap ECP FEIA kits (Pharmacia & Upjohn Diagnostics AB Uppsala, Sweden) with a CAP System on an automated device.
Leptin (Leptin sandwich DRG, DRG Instruments, Marburg, Germany) was measured quantitatively using the sandwich enzyme immunoassay technique and expressed as nanogram/ milliliter.
Serum adiponectin (Assay Max Human Adiponectin ELISA Kit, Missouri USA) levels were measured using “The enzyme- linked immunosorbent assay (ELISA)” method and expressed as microgram/milliliter.
The study was carried out with financial support granted by the Scientific Research Unit following the decision of the ethics committee (Decision No: 2010/99) dated 07.07.2010 (CUBAP Number: T-459). Written informed consent was obtained from each patient.
Statistical evaluation was performed using the SPSS (Statistical Package for the Social Sciences)-16 program. Normally distributed parameters were presented as mean ± standard deviation, and data that were not normally distributed were expressed as median (minimum-maximum). Nominal (unclassified) variables between the AR, NAR, and control groups were analyzed using the χ2 independence test. The normality Comparison of adipokin levels in patients with allergic rhinitis and local allergic rhinitis of numerical data was firstly evaluated with the Shapiro-Wilk test. Variance analysis was performed using one-way ANOVA for normally distributed data and Kruskal-Wallis test for non- normally distributed data. For inter-group comparison, post hoc analysis was performed with the Tukey-ANOVA test. Changes in symptom scores of the groups were compared with the Kruskal-Wallis test, as they exhibited abnormal distribution. For nonparametric data, the Kruskal-Wallis independent samples test was used for multiple comparisons, and the Mann-Whitney U independent samples test was used for paired comparisons. For parametric data, the Levene test was used for multiple comparisons, and the Student T-test was used for paired comparisons. A p<0.05 was considered statistically significant.
Results
A total of 90 cases, 30 patients with allergic rhinitis (patients with sensitivity to D. pteronyssinus and/or D. farinea detected in the skin test), 30 patients with non-allergic rhinitis (patients without sensitivity to D. pteronyssinus and/or D. farinea detected in skin prick and intradermal tests). Thirty cases (33.3%) weres male and 60 (67.7%) were females (Figure 1) (Table 1).
There was no difference between patients in the AR and NAR groups in terms of duration of rhinitis and the severity of rhinitis symptoms (p: 0.688). When rhinitis was classified in both groups according to the ARIA (Allergic Rhinitis and its Impact on Asthma) classification, frequencies of all four groups of rhinitis severity were observed to be similar (p: 0.460 and p: 0.220, respectively).
NPT was positive in 30% of the patients; 30% (9 patients) of the patients who had non-allergic rhinitis and underwent nasal provocation test with D. pteronyssinus antigen were found to have a positive nasal provocation test.
The mean ECP, leptin, and adiponectin levels in patients in all 4 groups included in the study are summarized in Table 2. A significant difference was determined between the groups in terms of ECP and adiponectin levels (p: 0.001 and p: 0.007, respectively). There was no significant difference in terms of leptin levels (p: 0.142).
As a result of post hoc analyses, a significant difference was determined between the patients with allergic rhinitis and the control group in terms of ECP levels (p: 0.001). There was a significant difference between the patients with allergic rhinitis and NPT (-) LAR in terms of ECP levels (p: 0.001). Furthermore, a significant difference was determined between patients with NPT (+) LAR and NPT (-) LAR, and patients with NPT (+) LAR and the control group in terms of ECP levels (p: 0.001 and p: 0.001, respectively). There was no significant difference between the patients with allergic rhinitis and NPT (+) LAR in terms of ECP levels (p: 0.540). It was shown that there was no significant difference between patients with NPT (-) LAR and the control group in terms of ECP levels (p: 0.937) (Table 2).
As a result of post hoc analyses, a significant difference was determined between patients with allergic rhinitis and the control group in terms of adiponectin levels (p: 0.003). It was demonstrated that there was no significant difference between the patients with allergic rhinitis and NPT (+) LAR (p: 0.740), patients with allergic rhinitis and NPT (-) LAR (p: 0.185), patients with NPT (+) LAR and NPT (-) LAR (p: 0.963), and patients with NPT (-) LAR and the control group (p: 0.618) in terms of adiponectin levels (Table 3).
When the severity of rhinitis and serum ECP levels were evaluated in the LAR group, no significant association between the severity of rhinitis and serum ECP levels was determined in the NPT (+) and NPT (-) LAR groups (r: 0.283, p: 0.460 and r: 0.135, p: 0.230, respectively).
When the severity of rhinitis and serum leptin levels were evaluated in the LAR groups, no significant association between the severity of rhinitis and serum leptin levels was determined in the NPT (+) and NPT (-) LAR groups (r: 0.025, p: 0.949 and r: 0.322, p: 0.155, respectively).
When the severity of rhinitis and serum adiponectin levels were evaluated in the AR and LAR groups, no significant association was determined (r: -0.095, p: 0.808 and r: -0.274, p: 0.230, respectively) (Figure 2).
Discussion
In this study, we investigated whether there is a difference between AR, LAR, and the control groups in terms of ECP, leptin, and adiponectin levels, and the correlation of these parameters with the severity of rhinitis. ECP was found to be increased in both patients with allergic rhinitis and NPT (+) local allergic rhinitis compared to the control group. Furthermore, ECP was shown to be increased in patients with NPT (+) LAR compared to the patients with NPT (-) LAR. Adiponectin levels were determined to be significantly higher in patients with AR compared to the control group. No correlation was determined between all 3 parameters and the severity of rhinitis.
In our study, early allergic responses that developed within the first one hour after the nasal provocation test were evaluated.
After exposure to an allergen or provocation with allergens, an early response develops due to mast cell, and a late response develops due to IL-13, and neurogenic pathway leads to only early response. In the literature, 30-62.5% of positivity after provocation with tree or grass pollen, 54% of positivity after provocation with house dust mite were reported in patients with local allergic rhinitis, whereas positivity after provocation with any allergen was reported to be 62% [7]. In our study, the NPT response, determined by the total symptom score and VAS was found to be positive in 30% in the local allergic rhinitis group.
It has been suggested that ECP may lead to the development of local allergy via some mechanisms, including the induction of mast cell granulation, the involvement of lymphocytes, and the stimulation of tissue “remodeling”. Bellussi et al [8] reported that serum ECP levels were higher in patients with NPT-positive non-allergic rhinitis. It was also suggested that ECP and IgE measurement in nasal lavage fluid of patients with non-allergic rhinitis and rhinosinusitis is a useful marker for determination of entopy [9]. Tomassini et al. [10] reported that serum ECP levels significantly increased in patients with AR during the pollen season. However, Rondon et al. could not find a significant difference between patients with persistent rhinitis with positive NPT with Dermatophagoides pteronyssinus antigen and patients with NPT- negative persistent rhinitis in terms of serum ECP levels [11]. ECP levels in nasal lavage fluid were significantly higher in both groups compared to the control group, whereas serum ECP levels were higher in patients with persistent allergic rhinitis, although similar to the NAR group [12]. As a result of our study, similar to Rondon et al., we did not determine a significant difference between patients with NPT (+) and patients NPT (-) local allergic rhinitis in terms of ECP levels.
Sin et al. [13] reported that serum ECP levels were associated with the severity of rhinitis. Especially when serum IgE, ECP, and eosinophilia are evaluated together, it is emphasized that this association is more significant. In patients with suspected AR with high serum ECP levels, although it is emphasized that other clinical and laboratory examinations should be performed, low serum ECP levels alone do not exclude entopy [14]. However, in our study, due to the relatively low number of patients with NPT (+) local allergic rhinitis and, probably, the asymptomatic course of patients in our study, we could not determine such a correlation in our study.
Leptin has been shown to play a role in both innate and adaptive immunities and allergic sensitization. Ciprandi et al. [15] found that outside pollen season serum leptin levels in patients with seasonal AR were similar to healthy individuals. When serum leptin levels of the same patients were evaluated during pollen season, they determined higher leptin levels compared to both the values outside pollen season and healthy controls. On the contrary, in a study by Erel et al. [16], in which they compared serum leptin levels of 43 patients with AR and healthy controls, no difference could be demonstrated between both groups. In our study, no significant difference was determined between all 4 groups in terms of serum leptin levels. The fact that some patients were evaluated during the asymptomatic period was thought to cause a lack of difference.
In other studies, evaluating the association between severity of airway disease and leptin, it was suggested that there was a positive association between severity of asthma and serum leptin levels in both adults and children, and leptin was suggested to play a role as an inflammatory mediator [17]. However, there also are studies revealing no correlation between the severity of symptoms and serum leptin levels in patients with seasonal allergic rhinitis [18].
In a study by Hsueh et al. [19], conducted with 97 pediatric patients with AR, a positive correlation was shown between serum leptin levels and severity of allergic rhinitis, and it was suggested that leptin may have a predictive value in predicting the severity of allergic rhinitis. In contrast to these aforementioned studies, such a correlation could not be shown in our study, probably as our study included an adult age group. Adiponectin plays a regulatory role not only in glucose and energy metabolism, but also in the immune system and allergic inflammation. It is well known that adiponectin is associated with sensitization and its levels are influenced by allergic diseases [20]. Ciprandi et al. [21] reported higher serum adiponectin levels in patients with seasonal allergic rhinitis compared to those outside pollen seasons. In another study conducted with 103 patients with seasonal allergic rhinitis, in the same group, serum adiponectin levels were significantly higher compared to the control group [22]. In another study, although higher serum adiponectin levels were found in 41 patients with pollen- sensitive allergic rhinitis compared to the control group, this difference was reported to be insignificant [23]. Although the difference was determined between the patients with AR and the control group in terms of adiponectin levels, this situation was not detected in patients with local allergic rhinitis. These results suggest the idea that serum adiponectin has pro- inflammatory effects, and its levels increase in allergic diseases, although examination and measurements of cytokines that are the regulator of expressions of genes related particularly to body weight and human serum adiponectin levels are needed for corroboration of this assumption.
Hsueh et al. [24] showed a negative correlation between serum adiponectin levels and the severity of allergic rhinitis. Ciprandi et al., [21] however, did not determine any correlation between the severity of rhinitis and serum adiponectin levels in patients with seasonal allergic rhinitis. Similarly, in our study, no correlation was observed between the severity of allergic rhinitis and adiponectin levels.
In our study, responses that developed within the first one hour after the nasal provocation test were considered to be the early responses. The first limitation of our study is the inability to perform NPT with other indoor allergens that play a role in perennial rhinitis in patients. Nevertheless, the incidence of LAR due to isolated sensitivity to other allergens is lower compared to local sensitivity to Dermatophagoides pteronyssinus (sensitivity to Dermatophagoides pteronyssinus 60%, Alternaria alternata 17.3%, cat dander 2.7%) [25]. In addition, among other limitations, there is a small population and the inclusion of only one center.
Conclusion
In conclusion, our study is important due to the very limited number of studies investigating serum ECP, leptin, and adiponectin levels in patients with AR, NPT (+), and NPT (-) LAR. Although ECP and adiponectin levels differ between patient groups, it is obvious that larger studies are needed in order to evaluate the correlation of these parameters with the severity of rhinitis in patients with rhinitis.
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.
Funding: None
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.20627
Emel Atayık, Gokhan Aytekın, Oznur Abadoglu. Comparison of eosinophilic cationic protein, adiponectin and leptin levels in patients with allergic rhinitis and local allergic rhinitis. Ann Clin Anal Med 2021;12(Suppl 4): S488-493
Citations in Google Scholar: Google Scholar
Persistent asymptomatic microscopic hematuria in childhood: A single-centered experience
Tülin Güngör 1, Evrim Kargın Çakıcı 1, Fatma Yazılıtaş 1, Deniz Karakaya 1, Evra Çelikkaya 1, Mehmet Bülbül 1, 2
1 Department of Pediatric Nephrology, 2 Department of Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20764 Received: 2021-06-29 Accepted: 2021-08-19 Published Online: 2021-09-10 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S494-497
Corresponding Author: Tülin Güngör, Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey. E-mail: tulingungor84@gmail.com P: +90 505 521 49 50 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5881-1565
Aim: This study aimed to evaluate the demographic, clinical, and laboratory findings and prognoses of patients who were followed in a pediatric nephrology department with persistent asymptomatic microscopic hematuria (PAMH) with or without mild proteinuria.
Material and Methods: This retrospective, single-center observational study included 136 patients with PAMH who were referred to our hospital from 2015 to 2020.
Results: The study included 136 children (72 male and 64 female) with PAMH and the mean age at diagnosis was 8.13±3.17 years. The mean follow-up period of the patients was 4.24±2.16 years. The patients were divided into two groups as 107 patients (78.68%) with asymptomatic isolated microscopic hematuria (AIMH) and 29 patients (21.32%) with asymptomatic microscopic hematuria and mild proteinuria (AMHP). No significant difference was determined between the two groups in terms of age, estimated glomerular filtration rate, or family history of renal disease (p>0.05 for each). The male sex ratio was significantly higher among patients in the AMHP group (p=0.005). Glomerular hematuria was detected in 32 patients (23.5%), and 22 of those patients (68.75%) had mild proteinuria accompanying asymptomatic microscopic hematuria at baseline and/or follow-up. The most common histopathological diagnosis was IgA nephropathy. Glomerular pathologies were found to be significantly more common among the AMHP group compared to AIMH (p=0.00). Patients who developed chronic kidney disease (CKD) and hypertension (1.47%) were in the AMHP group.
Discussion: Proteinuria accompanying microscopic hematuria might be a risk factor for the development of CKD. Meticulous long-term follow-up must be performed for isolated microscopic hematuria and renal biopsy should be conducted in selected cases.
Keywords: Isolated Hematuria; Proteinuria; Renal Biopsy; Genetic
Introduction
Hematuria is one of the most common symptoms among children and is defined as the detection of more than 5 red blood cells in the urine. Hematuria in childhood may be macroscopic or microscopic, and patients may be asymptomatic or symptomatic due to serious renal pathologies [1-4]. Among asymptomatic cases with microscopic hematuria, 50-75% are observed as benign recurrent or persistent hematuria. Persistent asymptomatic microscopic hematuria (PAMH) is a common presenting symptom of renal disorders among children, with a prevalence of 1% to 2%, often being benign and rarely a sign of serious disease. Of this group, as many as one in four will have a normalization of urinalysis in 5 years [3-7]. The most common causes of persistent asymptomatic microscopic hematuria include glomerulopathies (thin basement membrane disease and Alport syndrome), hypercalciuria, and nutcracker syndrome. Most of the time, a detailed medical history, physical examination, and simple laboratory tests facilitate the diagnosis. Kidney biopsy may be required for the early diagnosis of asymptomatic patients with unknown etiology who are at risk of progressive renal disease [1, 3, 8, 9].
In this study, it was aimed to evaluate the demographic, clinical, and laboratory findings and prognosis of patients who were followed in a pediatric nephrology clinic with PAMH.
Material and Methods
In this study, 136 patients aged under 18, who had at least 1 year of follow-up at Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Department of Pediatric Nephrology, between January 2015 and January 2020 and were detected to have microscopic hematuria in 3 consecutive examinations with intervals of 4 weeks or longer were evaluated. The presence of 5 or more erythrocytes in the high magnification field in centrifuged urine examination repeated at least 3 times was considered as hematuria [1]. The presence of a urinary protein creatinine ratio of >0.2 mg/ mg or a 24-h protein excretion of >4 mg/m2/h in at least two consecutive evaluations was considered as proteinuria [10]. Patient data were obtained retrospectively from medical records and included clinical and demographic data of the patients, such as age and sex; laboratory findings, such as serum creatinine and albumin; autoimmune screening (anti-nuclear antibody (ANA), anti-double-stranded (ds) DNA antibodies, complement factor 3 (C3) and C4) levels); urinalysis, urinary calcium-to- creatinine ratio or 24-h urinary calcium excretion, and urinary protein-to-creatinine ratio or 24-h urinary protein excretion level; abdominal ultrasonography (USG) findings; renal biopsy findings; and treatment of the disease. Estimated glomerular filtration rate (eGFR) was computed according to the Schwartz formula [11].
Based on the presence of proteinuria, all 136 patients were divided into two groups as 107 patients with asymptomatic isolated microscopic hematuria (AIMH), no proteinuria or macroscopic hematuria, and 29 patients with asymptomatic microscopic hematuria and mild proteinuria (AMHP) (<0.5 g/ m2/24 h). Patients who also had severe proteinuria (>0.5 g/m2/24 h), acute or chronic glomerulonephritis, renal insufficiency, a known bleeding diathesis, hypertension, or chronic systemic illness were excluded from the study. In our clinic, kidney biopsy is performed in patients with PAMH in the presence of a history of microscopic hematuria for at least 2 years, a family history of kidney disease, hypocomplementemia, and/or accompanying proteinuria. No patient received any specific treatment before the renal biopsy. During follow-up, the patients were evaluated in terms of eGFR values, hematuria, proteinuria, and hypertension.
The study protocol was approved by the Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital Ethics Committee (Number: E-21/02-102).
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows 22.0 (IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was used to determine the normality of the distribution of the study variables. Parametric variables are presented as mean±SD and nonparametric variables are presented as median and interquartile range. Categorical variables are presented as numbers and percentages. Student’s t-test was conducted to compare parametric variables and the Mann-Whitney U test was conducted to compare nonparametric variables. The chi-square test or Fisher’s exact test was used to compare categorical variables. The results were considered statistically significant at p<0.05.
Results
The study included 136 children (72 male and 64 female) with PAMH and the mean age was 12.36±3.56 years. The mean age at diagnosis was 8.13±3.17 years and 39% of the patients had a family history. The mean follow-up period of the patients was 4.24±2.16 years. Of the patients, 25% had a family history of kidney stones, 12.5% had a history of hematuria, and 1.5% had a history of chronic kidney disease (CKD). Hypercalciuria was detected solely in one patient and this patient had a family history of stone disease. The mean creatinine level at diagnosis was found to be 0.53±0.1 mg/dL and the mean eGFR level was 114.25±14.02 mL/min/1.73 m2. Two patients had reduced serum C3 concentration and ANA and anti-dsDNA were not positive in any patient.
The patients were divided into two groups as 107 patients (78.68%) with AIMH and 29 patients (21.32%) with AMHP. No significant difference was determined between the two groups in terms of age, eGFR values, or family history of renal disease (p>0.05 for each). However, the rate of family history of microscopic hematuria unrelated to stone disease was significantly higher in the AMHP group (p=0.01). Patients in the AMHP group had a significantly higher male sex ratio (p=0.005) and their creatinine values were significantly higher (p=0.01). Thirty-two patients underwent kidney biopsy; 22 of these patients were in the AMHP group and 10 patients were in the AIMH group. Glomerular pathology was detected in 28 (21.21%) patients, whereas kidney biopsy was normal in three patients and nonspecific in one patient. The most common histopathological diagnosis was IgA nephropathy (IgAN). Histological findings revealed 10 (31.25%) with IgAN, five (15.62%) with thin basement membrane nephropathy (TBMN), four (12.5%) with mesangial proliferative glomerulonephritis (MsPGN), four (12.5%) with normal biopsies/minor lesions, three (9.37%) with Alport syndrome, two (6.25%) with focal segmental glomerulosclerosis (FSGS), two (6.25%) with C3 glomerulopathy, one (3.12%) with membranoproliferative glomerulonephritis (MPGN), and one (3.12%) with diffuse proliferative glomerulonephritis. Genetic analyses were performed for nine patients to detect hereditary nephritis; three patients were diagnosed with Alport syndrome by genetics alone and one patient was diagnosed with Alport syndrome by genetics while the kidney biopsy was normal. Hence, glomerular hematuria was detected in 32 patients (23.5%), and in 22 of those patients (68.75%), mild proteinuria was accompanied by asymptomatic microscopic hematuria at baseline and/or follow- up. Glomerular pathologies were found to be significantly more common among the AMHP group compared to AIMH (p=0.00). A comparison of the patients with and without proteinuria is shown in Table 1. No significant difference was determined between the two groups regarding the frequency of histopathological diagnoses (p>0.05). The most common USG finding in patients was stone disease (30.14%), which was present in 41 patients, followed by nutcracker syndrome (10.3%).
Two patients with the histopathological finding of FSGS and COL4A5 mutation who had been diagnosed with Alport syndrome were being followed for stage 2 CKD. In the other patients, no impairment of kidney functions was observed throughout the follow-up period and hypertension was detected in 2 patients. Patients who developed CKD and hypertension were in the AMHP group. None of the patients received any special treatment before the kidney biopsy. Following the renal biopsy, 21 patients with AMHP and six patients with nutcracker syndrome received angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker for proteinuria. None of the patients received immunosuppressive therapy.
Discussion
Hematuria is one of the most common symptoms of urinary system diseases among children and is rarely a sign of a serious disease [12, 13]. It has been revealed in numerous studies that the incidence of glomerular pathology increases and it has a worse prognosis in the presence of proteinuria in patients with PAMH. Likewise, in our study group, glomerular hematuria was detected in approximately one-fourth of the patients during a mean follow-up period of 4.24±2.16 years. Mild proteinuria accompanied asymptomatic microscopic hematuria at baseline and/or in follow-up in 68.75% of patients in this group. Persistent asymptomatic microscopic hematuria is mostly detected in children aged between 9 and 9.5 years old and the male/female ratio was reported to range between 0.5 and 1.7 [9, 12]. In our study, the median age at diagnosis was 8.13±3.17 years and the male/female ratio was 1.1. No significant difference was determined between patients with AIMH and patients with AMHP in terms of age (p=0.36); however, the male sex ratio was significantly higher among patients in the AMHP group (p=0.005). Urolithiasis is one of the frequently detected ultrasound findings in pediatric patients presenting with gross or microscopic hematuria with or without coexisting abdominal pain, flank pain, or vomiting [14]. Similarly, in our study, the most common USG finding in patients was stone disease (30.14%).
Since hereditary nephropathies can only present with microscopic hematuria in the early stages of the disease, periodic follow-up of PAMH patients for proteinuria is recommended [15, 16]. Considering the data from seven studies involving 1092 children, it was noted that more than 40% of patients with AIMH and more than 80% of patients with AMHP had underlying pathologies. While a limited assessment is reasonable for a child with AIMH, it was underscored that a comprehensive medical history and laboratory examination may be necessary for a child with AMHP. Meticulous long-term follow-up and the scheduling of renal biopsy in selected cases are recommended for these patients [3, 12, 13]. On the other hand, there is no definite consensus on when kidney biopsy should be performed in children with PAMH [13, 15]. In our study, mild proteinuria was detected in 29 patients (21.32%). In some studies, a family history of kidney disease was determined to be significantly more common among patients with AMHP compared to AIMH [9, 12]. However, in our study, no difference was found between patients with AIMH and AMHP regarding family history of kidney disease (p=0.57), although a family history of microscopic hematuria unrelated to stone disease was significantly more common in the AMHP group (p=0.01). These differences may be due to the varying numbers of patients included in the studies and the number of patients with a family history of kidney disease.
Histopathologically, normal biopsies, minor lesions, IgAN, and non-IgA MsPGN accounted for the majority of patterns in PAMH, followed by TBMN, Alport syndrome, MPGN, and FSGS. However, the histopathological diagnoses were different between the AIMH and AMHP groups. Normal biopsies or minor lesions were the most common findings among the AIMH group, whereas IgAN was the most common finding among the AMHP group, which indicates a positive correlation between the severity of clinical characteristics and the histopathological pattern [9, 12, 16, 17]. In our study, glomerular hematuria was detected in 32 patients (23.5%), while three patients were diagnosed only through genetic examination and one patient was diagnosed via genetic examination though kidney biopsy was normal. The most common histopathological diagnosis was IgAN.
The relationship between microhematuria and negative renal outcomes has been reported in several studies [7, 12, 13]. Lin et al. [18] analyzed 573 school-age children in Taiwan and demonstrated that 46.4% of children had persistent AIMH while 14.3% of children had AMHP; they also suggested that children with AIMH are at the same risk for significant glomerulopathies as children with proteinuria. In addition, several studies suggest that long-term outcomes in AIMH are associated with an unfavorable prognosis and that kidney biopsy should be performed at an early stage, and the urinary albumin/creatinine ratio has been shown to be a good predictor for identifying patients at high risk for glomerulopathies [19, 20]. Lee et al. [21] found a relatively high rate of pathological abnormalities on kidney biopsy in a group with microscopic hematuria combined with AMHP compared to the AIMH group. Consistent with this finding, in our study, glomerular pathology was found to be significantly more common in the AMHP group (p=0.00). Two patients with the histopathological finding of FSGS and COL4A5 mutation who had been diagnosed with Alport syndrome were being followed for stage 2 CKD. In the other patients, no impairment of kidney functions was observed throughout the follow-up period and hypertension was detected in 2 patients. Patients who developed CKD and hypertension were in the AMHP group. Thus, our findings are favorable in terms of not performing an early biopsy in the course of AIMH. The main limitations of this study were that it had a retrospective design, reflected the data from a single center, and enrolled a limited number of patients.
Conclusion
Proteinuria may be a significant risk factor for the occurrence of CKD when it is accompanied by microscopic hematuria. As the prognosis of AIMH patients is favorable, a kidney biopsy can be scheduled in the future depending on the follow-up of the patients. However, an early kidney biopsy may be considered when hematuria is accompanied by proteinuria and has a family history.
Acknowledgment
The authors gratefully acknowledge Lexicon tercüme for English language editing.
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.
Funding: None
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.20764
Tülin Güngör, Evrim Kargın Çakıcı, Fatma Yazılıtaş, Deniz Karakaya, Evra Çelikkaya, Mehmet Bülbül. Persistent asymptomatic microscopic hematuria in childhood: A single-centered experience. Ann Clin Anal Med 2021; DOI: 10.4328/ ACAM.20764
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Is the symptom correctly interpreted by patients who apply to a neurology practice with the complaint of dizziness?
Hikmet Saçmacı 1, Gül Ferda Cengiz 2
1 Department of Neurology, 2 Department of psychiatry, Yozgat Bozok University, School of Medicine, Yozgat, Turkey
DOI: 10.4328/ACAM.20771 Received: 2021-07-01 Accepted: 2021-08-19 Published Online: 2021-09-13 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S498-502
Corresponding Author: Hikmet Saçmacı, Department of Neurology, Yozgat Bozok University, School of Medicine, Yozgat, Turkey. E-mail: hsacmaci@hotmail.com P: +90 354 212 62 01 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1480-0562
Aim: Patients with subjective dizziness usually interpret their symptoms as occurring as a result of a physical disorder and put the psychological dimension of their complaints in the background. In this study, it was aimed to help vertigo patients interpret their symptoms correctly, to examine the relationship between these symptoms and various other factors, and to investigate the effects of the handicap of vertigo.
Material and Methods: Our cross-sectional, randomized, and controlled study included 45 patients with normal cognition and 41 healthy controls in the age range of 18-50 years. Detailed analysis was performed for those suffering from complaints of dizziness and to exclude an organic pathology for these patients. All participants were administered the Dizziness Handicap Inventory (DHI) and the Symptom Interpretation Questionnaire (SIQ) was used to assess the quality of life of the patients.
Results: In patients (women/men: 36/9), the DHI score was 44.16±20.89 (mean±SD), and the group consisted of moderately handicapped individuals at a rate of 44%. Symptom interpretation was dominant in the patients with normalizing, psychological, and somatizing styles (p<0.05). Somatizing and normalizing styles were shown to correlate with impaired quality of life due to dizziness (p=0.001, rho=0.512 and p=0.008, rho=0.408, respectively).
Discussion: Our findings indicate a close relationship between vertigo and somatization. In patients who describe nonspecific dizziness, the possibility that a tendency of corporatization may mask the underlying psychological disorder should be taken into consideration, and the diagnosis and treatment of these patients should be carried out with a multidisciplinary approach.
Keywords: Dizziness Handicap Inventory, Psychogenic Dizziness, Vertigo, Disability Due to Dizziness
Introduction
Vertigo or dizziness is not a disease in itself; it is a leading symptom of various diseases of different etiologies [1]. Etiological causes are quite extensive, from peripheral, central, and vestibular disorders and other organic causes to somatoform disorders and their various combinations [2]. Complaints may be associated with psychiatric disorders in about 30-50% of patients [3]. These disorders were defined as anxiety/phobic (45.5%), somatoform (41.4%), or depressive disorders (13.1%) [3].
Psychiatric comorbidity accompanying subjective vertigo is a risk factor for a chronic poor course in these patients and is responsible for an increase in handicap [4]. This condition is often called psychogenic or psychiatric or functional dizziness. Some patients have both organic and non-organic disorders at the same time. In this combined association, the assessment of symptoms becomes more complex and their clinical repercussions vary depending on the individual’s personality and lifestyle [5].
Furman et al. discussed the importance of neuroanatomic connections between vestibular stimuli and the emotional response processing system to explain the comorbidity of vertigo and psychiatric disorders [6]. Such a distorted awareness of somatic sensory stimuli (somatosensory amplification) may contribute to the links between vertigo/ dizziness and somatoform disorders and anxiety disorders [7]. Somatosensory amplification shapes the aspects of cognitive processing rather than just internal perception sensitivity [8]. However, the specific mechanisms related to the connection pathways remain unclear. Regardless of the causal relationship between dizziness and psychiatric findings, this symptom is a major problem for vertigo clinics in terms of diagnosis and differential diagnosis [5].
On the basis of the importance of vertigo in possible psychiatric disease symptomatology, the main purpose of our work is to assess how accurately the patients admitted to our clinic with dizziness can interpret their symptoms and to what extent the symptoms of dizziness and psychological disorders appear as interchangeable symptoms. The hypothesis that we tested was that high rates of frequent visits to neurology clinics are due to the perception that an organic pathology has occurred as a result of individuals having somatic psychopathology under the mask of dizziness.
Material and Methods
Study design and participants
A cross-sectional study was conducted to evaluate the relationship between somatosensory, motor, and psychological variables and disability levels in patients with dizziness. The study included 45 patients with dizziness in the age range of 18-50 years and 41 individuals without dizziness as a control group. Written informed consent was obtained from all participants before inclusion. All participants were provided with a description of the study procedures, which were planned according to the ethical standards of the Declaration of Helsinki and approved by the Bozok University Clinical Research Ethics committee.
The inclusion criterion for the study was the application of individuals to our outpatient clinic for etiology investigation due to dizziness. Exclusion criteria were as follows: (a) presence of neurological symptoms (strength deficit in the extremities, gait disturbance situations); (b) vertebrobasilar insufficiency, dizziness, types of dizziness due to causes such as cardiovascular dizziness or migraine, or neurodegenerative diseases such as cervical spinal cord pathologies, stroke, epilepsy, multiple sclerosis, or Parkinson disease; (c) patients who were treated for vertigo in the last 3 months and required medication at their last admission; (d) patients with cognitive impairment or mental retardation; (e) patients with insufficient language understanding to follow the measurement instructions; (f) patients with impaired hearing and balance, pregnant women and nursing mothers, and patients with visual pathologies. Neurological and clinical assessment
Medical specialists performed complete neurological, neuro-otologic, and neuro-ophthalmological examinations of all patients, as well as subjective measurements for vestibular testing and head impulse testing. Laboratory tests including blood count, plasma glucose, lipid profile, and electrocardiography were examined at the stage of etiological diagnosis, and individuals with normal findings were invited for scale evaluation. Organic exclusion was achieved using magnetic resonance imaging when necessary, depending on the severity of the patient’s complaints. The head impulse test was performed when peripheral vertigo was negative and the patient did not have nystagmus. In addition, the patient group was composed of individuals whose otological examinations and tests were negative in terms of the possibility of peripheral vertigo. If there were no structural disorders that explained the symptoms of the patients, functional/psychiatric symptoms were assessed by a psychiatrist and neurologist in a preliminary interview and the patients were evaluated.
Self-reported questionnaires
Sociodemographic data form: After agreeing to participate in the study, a sociodemographic form prepared by the researchers was given to all patients to be filled out together with the scales on the same day. The sociodemographic form included brief anamnesis information such as age, gender, education level, marital status, and complaints (duration of symptoms, accompanying treatments and comorbidities, etc.).
After that, patients completed self-reported scales that measure dizziness-induced disability and symptom interpretation skills. Dizziness Handicap Inventory (DHI): The DHI is a scale that is not difficult for patients to complete and understand, which shows the degree of impact, emotional status, and functionality of the quality of life of patients who suffer from dizziness [9]. Although this personal questionnaire has been developed to measure the effect of dizziness complaints in diseases of the vestibular system, it can also be used with other dizziness problems not of vestibular origin. The validity and reliability studyoftheTurkishversionwasconductedbyEllialtıoğluetal. in 2001 [10].
The DHI contains 25 points that assess problems with dizziness. Nine questions address the functional, nine questions address the emotional, and seven questions address the physical state. Each question has the possible answers of “no” (0 points), “sometimes” (2 points), and “yes” (4 points), and the highest score is 100. High values indicate that the disorder is more severe. Points between 0 and 30 indicate mild severity of the disorder, points between 31 and 60 indicate moderate severity, and points between 61 and 100 indicate severeness.
Symptom Interpretation Questionnaire (SIQ): The SIQ is a scale investigating the three dimensions of somatization, psychologization, and normalization to attribute symptoms used when interpreting common somatic symptoms as bodily causes.
The SIQ records the presence of 13 common somatic symptoms, such as headache and fatigue. For each symptom, patients are asked to consider whether they would interpret the symptom as the result of emotional stress (psychological attribution style), an environmental factor (normalizing attribution style), or physical predisposition (somatizing attribution style). Each association is scored from “not at all” to “very much” on a 4-point Likert scale. The SIQ has been verified in terms of its reliability and test-retest correlation, and the validity and reliability of the Turkish version were confirmed [11, 12]. The four-point Likert-type scale was converted to a five-point Likert-type scale because of its more common usage in Turkish measurement tools. In a study conducted by Mirdal, the total number of items was increased to 14 by adding the symptom of “chest tightness,” which is commonly seen among Turkish immigrants and may be unique to Turkish culture [12]. Statistical analysis SPSS 22 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Median values, lowest and highest values, and interquartile range values were used for descriptive statistics in nonparametric tests, while mean±standard deviation (SD) values were used in parametric tests. To test for differences in self-reported questionnaire scores between vertigo/dizziness subgroups, we calculated descriptive statistics and performed chi-square tests for gender, age, and vertigo/dizziness duration. Age averages were compared with independent t-tests.
The relationship between psychological and physical variables and disability related to dizziness was analyzed using the Pearson correlation coefficient. A Pearson correlation coefficient of >0.60 showed a strong correlation, a coefficient between 0.30 and 0.60 showed moderate correlation, and a coefficient of <0.30 showed low correlation. Values of p<0.05 at a 95% confidence interval were considered statistically significant.
Results
In our study, there were 36 women and 9 men in the patient group and 25 women and 16 men in the control group. The groups were similar to each other in terms of gender (p=0.052). The ages and interquartile range values of the individuals in the patient group varied by 29 (22-37.81) years, with an average age of 30.57±10.10 years. The ages of the individuals in the control group also varied by 29 (24-38) years and their average age was 30.47±7.58 years. In the patient group, the DHI score was 44.16±20.89 (mean±SD) and 14 (31%) individuals experienced a mild handicap, 20 (44%) individuals experienced a moderate handicap, and 11 (25%) individuals experienced a severe handicap due to dizziness. In the patient group, the participants were mostly students (16 volunteers, 36%) and housewives (16 volunteers, 36%), while in the healthy control group, there were also students (14 volunteers, 35%) and civil servants (16 volunteers, 40%) (p=0.001). All demographic characteristics of the groups are presented in Table 1.
When the distribution of subgroup test analysis of the SIQ scale was examined in groups, an average of 9.61±2.49 individuals evaluated their symptoms as positive in the patient group, while 5.26±2.68 individuals in the control group completed the scale with positive symptoms. Mean±SD and median (IQR) values obtained for the SIQ subgroup scores, which are evaluated as somatizing, psychologizing, and normalizing styles, were higher in the patient group and the statistical difference was p<0.05 (Table 2).
In addition, when correlation analyses between the groups’ ages, symptom duration of vertigo, and subgroup scores of the SIQ and DHI were performed, no significant correlations were found for age and symptom duration. With rho=0.512, p<0.001, there was a moderate positive correlation between the DHI and somatizing style, and with rho=0.408, p=0.008, a significant correlation was found between the DHI and normalizing style (Table 3).
Discussion
The aim of this study was to determine the differences in somatosensory, motor, and psychological variables and to examine the relationship between these variables and disability due to dizziness in patients with the complaint of dizziness who were admitted to our referral clinic. The results of this study showed that general and specific psychological factors of dizziness in admission to a neurology clinic were strongly associated with somatization and normalization findings and dizziness, handicap, and somatization in a representative sample of patients.
It is known that there are numerous and various physical complaints in balance disorders. Psychological dizziness is a diagnosis made only when no organic disorder causing vertigo/ dizziness is detected and positive responses are given in neuropsychiatric questionnaires [13]. In recent years, emphasis has been placed on research and analysis of the psychiatric component of vertigo in both the elderly and young people [14- 16]. Ardic et al. showed with a psychiatric screening scale that somatization scores were higher in patients with vertigo [5]. Studies have also reported psychogenic dizziness progression in a wide range of 9-50% [3, 15]. This psychological dimension of dizziness has been investigated in a variety of studies, from the neuroanatomic background to behavioral perspectives [15]. In previous studies in the literature, cases in which the psychogenic component was identified as chronic subjective dizziness and persistent postural-perceptual dizziness included cases of persistence of complaints for at least 3 months. In the cases included in this study, the ability of individuals with shorter symptom duration to correctly define and observe their complaints were investigated. In our study population, with patients for whom an etiological cause could not be found with comprehensive questionnaires, it was observed that individuals tended to somatize their complaints. In our study, patients who went to the doctor’s office were significantly more likely to exhibit psychological and normalizing qualities of common somatic symptoms. This is probably due to the fact that patients referred to hospital clinics have more severe health-related anxiety or a lower likelihood of accepting psychological or normalizing explanations of unexplained symptoms. In addition, in the patient group, the majority of participants were students and housewives, while the control group included students and civil servants. The working life of individuals contributes to satisfaction in life and increased problem-solving skills and ultimately the increase of quality of life as well as the continuity of cognitive functions [17]. As a result, we believe that an individual who is more skilled at expressing himself or herself can describe and convey symptoms more correctly.
Patients with acute dizziness are more often referred to the emergency department. However, there are functional disorders that can be defined as psychogenic, non-organic, or conversion disorders among the patients who are most frequently referred to clinical neurologists [18]. Correct diagnosis of these patients is very important for successful treatment and for the prevention of socioeconomic losses, healthcare costs, and losses in the workforce. Research has shown that, in the treatment of psychological vertigo, patient education, psychological counseling, and mental health education can be important steps in therapeutic processes besides medication [19].
Some studies investigating psychiatric predisposition in vertigo observed the coexistence of psychiatric comorbidities in some groups of organic vertigo and dizziness patients, such as Meniere’s disease and vestibular migraine [20, 21]. Therefore, the prognosis and course of the disease is poor and anxiety/ panic-related cognition or incompatible coping strategies develop along with these complaints. Psychiatric tendencies emerge because of the negative beliefs that develop in these patients [22]. It was found that chronic stress processes contribute significantly in a recent study investigating risk factors for various types of vertigo in young people [23]. Even though disorders of the vestibular system are observed to be rarer in young people, stress is seen at the forefront in etiological research [24]. In dizziness-related handicap formation, the worst combination has been seen to occur in cases where non-organic vertigo/dizziness and psychiatric comorbidity are intertwined [22]. If the vertigo/dizziness attacks of the patients cannot be controlled, individuals may develop anxiety and panic-related behaviors and this can sometimes lead to the development of avoidance behavior [25]. In our study, the tendency to somatize symptoms was observed via the SIQ in relatively younger individuals with dizziness with good cognition levels. They also had high psychological and normalizing tendencies. Normalized styles correlated with the DHI, as well. The inability of individuals to define their complaints objectively disrupts effective treatment and causes serious socioeconomic burdens. In order for physicians to quickly treat the patient with an appropriate treatment strategy, it is important that they first examine the patient thoroughly and therefore make the correct diagnosis. Accordingly, it is very important to be able to define and interpret the symptoms correctly.
This study has some limitations that need to be taken into account. Given that this is a cross-sectional study, one of its main limitations is its inability to thoroughly investigate etiological causes. We were also unable to provide long-term observational follow-up and expand our findings objectively. If we had utilized more detailed psychiatric interviews to analyze the psychopathologies underlying the etiology in this age group, we would have been able to collect more detailed data. More detailed interviews with the patients over a fairly long period of time would also be helpful. It is important to perform analysis of educated versus uneducated patients or patients with different cultural or religious beliefs to evaluate the effects of social structures. Detailed psychological analyses could also be paired with hormonal and biochemical laboratory parameters with larger samples in future studies. In this study, we established our hypothesis using a scale that has not been tested in cases of vertigo before.
Conclusions
The results of this study show that psychosomatic variables are present in patients with dizziness of unknown etiology and that the effect of these variables leads to an increase in the perception of disability due to dizziness. Based on these results, we think that disability related to dizziness can be deeply affected by emotional factors and can therefore play a similar role in the perception of disability. When we consider the state of anxiety that real vertigo can cause, the anamnesis to be taken from the patient in the outpatient clinic becomes very important.
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.
Funding: None
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.20771
Hikmet Saçmacı, Gül Ferda Cengiz. Is the symptom correctly interpreted by patients who apply to a neurology practice with the complaint of dizziness? Ann Clin Anal Med 2021; 12(Suppl 4): S498-502
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How did changes in medical education during the COVID-19 pandemic affect students’ learning and study approaches?
Zerrin Gamsızkan
Department of Family Medicine, Düzce University, Medical Faculty, Duzce, Turkey
DOI: 10.4328/ACAM.20772 Received: 2021-07-01 Accepted: 2021-08-19 Published Online: 2021-09-08 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S503-507
Corresponding Author: Zerrin Gamsızkan, Department of Family Medicine, Düzce University, Medical Faculty, Duzce, Turkey. E-mail: zgamsizkan@yahoo.com P: +90 532 723 0232 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8677-4004
Aim: Medical education is undergoing a transformation with the COVID-19 pandemic. The aim of this study is to examine the levels of adaptation and flexibility of medical students within an educational system changing due to the pandemic.
Material and Methods: This descriptive cross-sectional study was conducted in the Düzce University Faculty of Medicine. Students were asked to complete the VARK (V: Visual, A: Aural, R: Read-write, K: Kinesthetic) learning preferences inventory and the Two-Factor Study Process Questionnaire (R-SPQ2F).
Results: In this study, 671 students, with 318 (47.39%) male students and 353 (52.61%) female students, were included. It was found that 25.04% (n=168) of these students participated in lessons via distance learning, while 43.67% (n=293) of them stated that they preferred face-to-face learning and 31.30% (n=210) stated that they preferred mixed learning. The mean visual score of the students who attended lessons via distance learning was found to be higher compared to those who attended face-to-face lessons and those engaged in mixed learning (p=0.0001), while the mean visual score of the mixed learning group was higher compared to the face-to-face group (p=0.002).
Discussion: The blended education model, which allows students to choose the most suitable model according to their own learning style, seems to be helpful in challenging periods like the COVID-19 pandemic.
Keywords: COVID-19, Distance Learning, Blended Learning, VARK, R-SPQ2F
Introduction
The COVID-19 pandemic has fundamentally affected the lives of people all around the world in many areas such as health, economy, and education [1]. First restrictions in travel and social settings were implemented, and then face-to-face work and training activities were canceled or postponed in all institutions [2, 3, 4]. Parallel with these developments, faculties of medicine also interrupted face-to-face education and started to implement changes in education, such as giving only online courses for preclinical classes, interrupting small group studies, and canceling some elective clinical courses [5, 6]. However, medical education includes the development of skills and attitudes as well as professional knowledge. The fact that the appropriate skills and attitudes of candidate physicians cannot be developed by online education alone raised some concerns in the education environment. In Turkey, in a report published by the Association for the Evaluation and Accreditation of Medical Education Programs (TEPDAD), it was suggested that blended learning is the most appropriate educational approach in medical education during a pandemic [7].
It is obvious that physicians should be equipped in terms of patient approach before they graduate regardless of the conditions. For this reason, in our medical faculty, it was aimed to train students in terms of clinical approach skills while the necessary preventive measures were taken and a training program within the framework of the blended education model was prepared. It has been reported that blended learning is favorable and welcomed by students [8]. The blended learning model has been rapidly implemented in many countries during the pandemic with its wide choice of options [9, 10].
The aim of this study is to examine the levels of adaptation and flexibility of medical students within an educational system changing due to the pandemic. In addition, it was aimed to investigate whether there is a relationship between learning methods and study approaches of the students and their educational preferences and to discuss alternative methods of education appropriate for both the characteristics of the students and possible threats.
Material and Methods
The study was carried out by the Department of Medical Education with the guidance of the Education Commission. The universe of the study consisted of students enrolled in the Faculty of Medicine. In the 2020-2021 academic year, when the study was planned, a total of 987 students were studying in all years of the medical school. Some exclusion and inclusion criteria were determined for the study sample. Having at least 6 months of experience in medical education during the pandemic period was determined as an inclusion criterion. Students who had a diagnosis of anxiety disorder were excluded because that might affect their participation in their courses. Ethical approval for the study was obtained from the Düzce University Ethics Committee (Protocol Number: 2020/112). Students were reached by student representatives and advisors and data collection tools were sent. A consent form was obtained from the students who participated in the study.
Study Procedure
A questionnaire was prepared for the study, measuring the
level of adaptation and problems of the students regarding the medical education applied during the pandemic period and their educational experiences. In addition, the participants were asked to complete the VARK (V: Visual, A: Aural, R: Read-write, K: Kinesthetic) learning preferences inventory and the Two-Factor Study Process Questionnaire (R-SPQ2F) in order to determine the relationship between learning styles and study approaches. Finally, two open-ended questions were asked to the students so that they could express their thoughts and expectations about the applied education model.
VARK Learning Preferences Inventory
The VARK Learning Preferences Inventory was developed by Fleming in 1987 and adapted to Turkish by Mustafa Kalkan; it was used to determine the dominant learning preferences of the medical students [11, 12]. The VARK Inventory consists of visual, auditory, literacy, and tactile perception categories. With this inventory, the ways in which individuals exchange information, their preferences for processing information, and their learning preferences are evaluated.
Two-Factor Study Process Questionnaire (R-SPQ2F)
This scale was developed by Biggs and then revised with two factors including 20 questions. The final form of the questionnaire has 4 subscales, namely deep motivation, deep strategy, superficial motivation, and superficial strategy, and it includes two basic approaches including the deep approach and superficial approach [13].
Statistical Analyses
Statistical analyses were performed using NCSS (Number Cruncher Statistical System) 2007 statistical software (Kaysville, UT, USA) software. Descriptive statistics were expressed as mean±SD and percentages. Normality of distribution was tested with the Shapiro-Wilk test. Comparisons of normally distributed data between the groups were performed with one-way ANOVA tests. Tukey’s test was used for multiple comparisons, t-tests were used for binary comparisons, and Pearson’s correlation test was used to examine the relationships between variables. Values of p<0.005 were accepted to be statistically significant.
Results
In this study, 671 students, with 318 (47.39%) male students and 353 (52.61%) female students, were included. It was found that 25.04% (n=168) of the students included in the study participated in lessons by distance learning, while 43.67% (n=293) of them stated that they preferred face-to- face learning and 31.30% (n=210) stated that they preferred to receive some courses face-to-face and some courses by distance learning (mixed preference). Furthermore, 35.92% (n=241) of the students stated that they were satisfied with distance education. When the students were asked what kind of education they would like to receive in the post-pandemic period, while 26.08% (n=175) of them stated that they would prefer to continue distance learning, 39.49% (n=265) stated that they would prefer face-to-face learning more. Some sociodemographic characteristics of the students and their educational behaviors in the pandemic period are shown in Table 1.
There were no significant differences between students according to year of study in terms of visual (p=0.076), auditory (p=0.123), reading/writing (p=0.614), and kinesthetic (p=0.614) learning styles. When the study approaches of the students were compared according to year of study, the mean superficial approach score of the second-year students was found to be statistically significantly higher compared to students in the first, fifth, and sixth years (p=0.011, p=0.009, and p=0.002, respectively), while there were no statistically significant differences between the groups in terms of mean in-depth approach scores (p>0.05). The distributions of the answers given by the students about their thoughts on the advantages and disadvantages of distance and blended learning methods are shown in Figure 1.
Significant differences between students’ preferences for attending lessons and their learning styles and study approaches were found. The mean visual score of the students who attended lessons by distance learning was found to be higher compared to those who attended lessons face-to-face and those educated by the blended method (p=0.0001), while the mean visual score of the blended method group was found to be higher compared to the face-to-face group (p=0.002). The mean aural score of the group of students preferring blended education was found to be higher compared to the distance learning and face-to- face learning groups (p=0.045, p=0.0001, respectively), while the mean aural score of the distance learning group was higher compared to the face-to-face learning group (p=0.0001). The mean reading/writing score of the distance learning group was lower compared to the face-to-face and blended learning groups (p=0.014, p=0.0001), whereas the mean reading/writing score of the face-to-face learning group was lower compared to the blended learning group (p=0.025). The mean kinesthetic score of the face-to-face learning group was found to be significantly higher compared to the distance and blended learning groups (p=0.009, p=0.0001), while the mean kinesthetic score of the blended learning group was higher compared to the distance learning group (p=0.0001, Table 2).
We found a statistically significant negative correlation between the mean visual scores and the deep motivation scores (r=- 0.108 p=0.005), a statistically significant negative correlation between the mean visual scores and deep strategy scores (r=-0.164 p=0.0001), and a statistically significant negative correlation between the mean visual scores and deep approach scores (r=-0.147, p=0.0001, Table 3).
Discussion
In this study, students’ compliance, satisfaction, and future expectations in blended education were investigated based on its application in our faculty during the pandemic. In addition, it was sought to determine whether students’ learning styles and study approaches were effective on adaptation to this period. According to the results of the study, approximately half of the students attended classes face-to-face and one-third preferred to attend classes in a mixed format. It was determined that one-fourth of the students attended lessons only by distance education. Their education preferences for the future were found to be at similar rates. There may be many reasons why face-to-face learning was the most preferred method among these students. In studies evaluating feedback from students during the pandemic period, contradictory results have been reported. In the study conducted by Torda et al., it was found that although the students adapted to distance learning, half of them still preferred face-to-face learning [14]. When evaluated in the context of satisfaction with distance education, some of our students stated that although they were satisfied with distance education, they did not prefer to continue it in the future. This may be associated with the dynamics of medical education itself. A student who thinks that he or she cannot fully learn his or her professional skills by distance learning will prefer on-site and face-to-face training. Similarly, it was reported that compulsory distance learning affects students negatively due to lack of suitable learning materials and a well- defined learning environment [15]. It was observed that many students had some concerns about the education they received. These concerns can be accepted as inevitable. Medical students in different regions of the world stated that they could not acquire the necessary professional skills online [16].
According to the results of the present study, although face- to-face education seems to be indispensable, the number of students who want to continue to have distance and blended learning options in the future after the pandemic is not negligible. There are other studies supporting these findings with reports that distance and blended education can be associated with some educational opportunities and can create satisfaction among students [17, 18]. The most frequently stated advantage of distance learning is the flexibility of time that it provides to students [19]. Similarly, in this study, the advantages of distance learning were stated to be flexibility of time, the perception that online learning is a more technological and modern method, and the ability to manage the study process more freely. The most frequently expressed disadvantages of online learning sessions applied during the pandemic period included technical problems, economic inadequacy in access to the internet, and insufficient interaction with lecturers and peers. The statements of the students suggesting that the distance learning materials were inadequate or of low quality and that their interactions with the instructor were also inadequate should be emphasized. In studies from other faculties experiencing similar problems, recommendations regarding the development of distance learning and improvement of problematic aspects were suggested. Enhancing interaction by increasing student participation, measures against technical problems, and appointment of a facilitating moderator can be listed among those recommendations [20, 21]. It is especially emphasized that in low- and middle-income countries, where opportunities for digital education may be limited for both students and instructors, distance learning can usually be of poor quality and inadequate. Therefore, new educational opportunities should be developed urgently [22].
In this study, it was found that students with higher visual and auditory scores preferred distance learning more frequently, whereas students with higher kinesthetic scores preferred face- to-face learning. In medical faculties, various visual materials have been developed and used in distance learning since the beginning of the pandemic [23]. In this respect, students with higher visual and auditory skills seem to be a relatively more advantaged group in terms of distance learning. In order to understand the real impact of this situation, studies are needed to evaluate these factors together with student outcomes.
It was found in the present study that medical faculty students have tried to adapt to this new process by choosing the models most suitable for their own learning styles in the blended learning model during the pandemic period. In this context, blended learning can be considered a helpful education model in terms of providing options suitable for the learning preferences of the students. However, when we evaluated the results of the study approaches scale, we observed that the students who preferred distance learning also focused on superficial learning. This preference may be a natural consequence of distance learning. The prolongation of the pandemic period and the evolution of education into distance learning may have changed the study approach of the students. Students who prefer a superficial learning approach usually depend on their instant memory instead of understanding the subject in depth [24]. On the other hand, the deep learning approach provides permanent knowledge that enables the students to combine information to create new inferences and hypotheses [25]. Discontinuation of the deep learning approach, which is required for the permanent knowledge necessary for medical practice, may compromise medical education. However, despite the reported problems, medical education has to continue to supply personnel to meet the health needs of society.
Limitations
Since this study was carried out in only one medical school, the results cannot be generalized to all medical school students. Another limitation of this study is that the learning and studying approaches of the students before the pandemic were not evaluated. However, we aimed to evaluate the learning approaches of students that were transformed due to the pandemic with open-ended questions. Since the open-ended questions provided qualitative responses, they are valuable in terms of reflecting the views of the participants directly. This can be considered a strength of the study.
Conclusions
The results of this study show that students prefer education models appropriate for their learning styles. We found that students with visual and auditory learning skills preferred distance learning, while students with kinesthetic learning skills preferred face-to-face learning. This shows that students are adapting to dynamic changes in ways appropriate for their skills and appropriate for the situation. Since every clinician who will serve in medical practice should be sufficiently equipped, the results and suggestions of this study should be discussed in a detailed manner.
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.
Funding: None
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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Zerrin Gamsızkan. How did changes in medical education during the COVID-19 pandemic affect students’ learning and study approaches? Ann Clin Anal Med 2021;12(Suppl 4): S503-507
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The role of computed tomography hounsfield unit values in the differentiation of benign and malignant cavitary lung lesions
İlyas Dündar 1, Mesut Özgokçe 1, Fatma Durmaz 1, Veysel Atilla Ayyıldız 2, Hanifi Yıldız 3, Ensar Türko 1, Cemil Göya 1
1 Department of Radiology, Faculty of Medicine, Van Yuzuncu Yil University, Van, 2 Department of Radiology, Faculty of Medicine, Suleyman Demirel University, Isparta, 3 Department of Chest Medicine, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
DOI: 10.4328/ACAM.20783 Received: 2021-07-13 Accepted: 2021-08-20 Published Online: 2021-09-08 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S508-512
Corresponding Author: İlyas Dündar, Department of Radiology, Van Yuzuncu Yil University, Faculty of Medicine, 65080, Campus, Tusba, Van, Turkey. E-mail: dundarilyas262@hotmail.com P: +90 432 215 04 70 F: +90 432 216 85 19 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1429-077X
Aim: This study aims to investigate the role of Hounsfield unit (HU) values measured by contrast-enhanced computed tomography (CT) in the differentiation of benign and malignant cavitary lesions (CLs), which are frequently encountered in the lung parenchyma.
Material and Methods: In this retrospective descriptive study approved by the relevant ethics committee, thoracic CT records taken for various reasons between 2019 and 2021 were scanned from the hospital database. According to the demographic characteristics and histopathological results, the patients were divided into benign and malignant groups. The HU values of 24 patients with CLs were measured by CT and the averages were calculated. HU values were compared by independent t-test.
Results: Of the 24 patients, 20 were male (83.3%) and 4 were female (16.7%), and the mean age was 59.98±16.65 (22-78) years. There were a total of 34 cavitary lung lesions in these 24 patients, including 18 benign (52.94%) and 16 malignant (47.06%) lesions. The mean age of 13 patients (54.17%) with benign etiology was 51.62±18.79 (22-78) and the mean size of all benign lesions was 30.05±9.51 (16-53) mm. The mean age of the 11 patients (45.83%) with malignant etiology was 68.55±6.56 (57-78) and the mean size of all malignant lesions was 39.25±23.45 (13-95) mm. The mean HU values of the 18 benign and 16 malignant CLs were 32.11±12.25 (15-60) and 63.88±24.5 (15-109), respectively, representing a statistically significant difference (p=0.001). In receiver operating characteristic curve analysis, the area under the curve was 86.8%, and when the cut-off was determined as 41.5, the sensitivity was 87.5% and the specificity was 88.9%.
Discussion: We think that HU density values measured from the CL wall by contrast-enhanced CT may be useful in the differentiation of frequently detected benign and malignant CLs, which have similar radiological imaging findings.
Keywords: Computed Tomography, Hounsfield Unit, Cavitary Lung Lesion, Benign, Malignant
Introduction
Cavitary lesions (CLs) are defined as gas-filled areas that appear radiologically as radiolucent areas or cavities surrounded by well-defined thick walls of various shapes within a pulmonary parenchymal consolidation, mass, or nodule, usually caused by the connection of necrotic lesions throughout the bronchial structures [1]. A wide variety of malignant and benign lesions may present as CLs, including malignancies, infections, autoimmune processes, and congenital diseases [2].
Although there are several specific guidelines [2, 3] published to date on the appropriate approach to CLs, most studies on radiological diagnostic approaches to CLs have been based on chest radiography [4]. Thoracic multidetector computed tomography (CT) is currently the preferred imaging method for evaluating CLs as it provides accurate information about the dimension, shape, and site of CLs and other features that are not evident on radiographs [2, 3]. Considering these data, with accurate clinical and laboratory results, radiologists can narrow the list of possible diagnoses, including benign and malignant pathologies [1-4]. However, limited data are available regarding the objective assessment of CLs by thoracic CT. There are various imaging findings that have been described to distinguish benign and malignant CLs, such as bronchiectasis and accompanying peripheral small airway disease, “halo” and “reverse halo” signs, inner wall irregularity, outer contour features, associated bronchial wall thickening, satellite nodules, consolidation, and accompanying ground-glass opacities [5]. However, since these findings are not specific, there are difficulties in differential diagnosis. As far as we have seen in the literature, there are no published studies that have focused on measuring density in the CL wall of the lung on CT.
In light of the considerable overlap in imaging findings that exists between the various CLs of the lung, it is important to clarify the thoracic imaging findings of CLs that can help in identifying a systematic clinical approach and complications that may require appropriate management. In addition to the imaging clues that have previously been described, our aim in this study is to determine the role of Hounsfield unit (HU) values measured from the CL wall by contrast-enhanced CT in the differentiation of frequently detected benign and malignant CLs, which have similar radiological appearances.
Material and Methods
Study design
This single-center retrospective observational study was initiated with the approval of the medical faculty’s clinical research ethics committee with ethical approval number 22.05.2020/150.
In our study, thoracic CT records taken in the radiology clinic for various reasons between January 2019 and January 2021 were retrospectively scanned using the picture archiving and communication systems (PACS) archive of the university hospital. Of the 219 patients who had lung lesions as a result of screening, 148 patients without CLs and 41 patients without pathological results or clinical and radiological follow-up were excluded from the study. In addition, patients with CLs and non- contrast thoracic CT (n=6) were not included in the study because of the retrospective nature of the study and the low number of such patients. The study was conducted with 24 patients with contrast-enhanced thoracic CT with pathological results and/or clinical and radiological follow-up. The histopathological results and clinicoradiological follow-up data of the patients were scanned from electronic medical records and the patients were divided into benign and malignant groups.
CT technique
CT scans were taken with a multidetector CT device (Somatom Emotion 16-slice, CT2012E, Siemens AG, Germany). The imaging protocol was as follows: 3-mm slice thickness, 0.777- mm reconstruction, 0.6-s gantry rotation, 120-kV tube voltage, 200-mA tube current, and field of view of 40-50 cm. For routine contrast-enhanced chest CT imaging, 80 mL of non-ionizing contrast agent, iohexol or iopromide, was injected using an automatic injector (CT 9000 ADV, Liebel-Flarsheim, USA) at a rate of 3 mL/s into the forearm vein. For bolus monitoring, a region of interest (ROI) was identified at the descending aorta at the level of the carina starting at 100 HU and scanning was initiated after 10 s. Scanning was performed at 30-40 s in the
arterial phase. Sections from the lower cervical to the upper abdominal level were obtained with a contrast agent, with patients in the supine position during CT imaging. An experienced radiologist (7 years) used a high-resolution and grayscale work station in CT evaluations to independently evaluate axial and multiplane reformatted images in mediastinal and parenchymal windows in terms of size, morphology, and CT-HU measurements of CLs. The radiologist had no previous knowledge of the clinical findings or histopathological diagnoses. Numbers and sizes (maximum diameters) of CLs were calculated for each examination on contrast-enhanced CT. In addition, the HU values were measured from the circular ROI drawn from the place where the thickness and enhancement of the CL wall were the highest, and the results were recorded. The lower limit for the ROI was determined as 32 mm2. When the ROI measurement area was drawn, it was ensured that the ROI was in the central part of the measured wall and did not overflow into the lung parenchyma and the air-containing central part of the adjacent CL (Figures 1 and 2). The averages of the obtained HU values were calculated separately for benign and malignant cases. All malignant lesions had a histopathological diagnosis. Among the benign cases, there was a histopathological diagnosis of tuberculosis in 4 cases and rheumatoid nodule in 1 case, while the diagnosis of other benign pathologies was decided according to the clinical approach and the response of the lesions to treatment or spontaneous regression after radiological follow-up.
Statistical Analysis
Descriptive statistics for the continuous variables of the study were expressed as mean, standard deviation (SD), minimum, and maximum and categorical variables as numbers and percentages. Independent 2-sample t-tests were used to compare mean values of benign and malignant cavitary lung lesions in terms of HU values. The statistical significance level was determined as 0.05 in the calculations and SPSS 21.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Sensitivity and specificity values were calculated and the percentages were obtained. An optimum cut-off value for HU density was determined with receiver operating characteristic (ROC) curve analysis.
Results
Of the 24 patients in our study, 20 were male (83.3%) and 4 were female (16.7%), and the mean age was 59.98±16.65 (22-78) years. There were a total of 34 cavitary lung lesions in 24 patients, with 18 being benign (52.94%) and 16 malignant (52.94%). The average diameter of all lesions was 34.62±17.78 (13-95) mm and 16 of the lesions were detected in the right upper lobe (47.06%), 8 were in the left lower lobe (23.53%), 7 were in the right lower lobe (20.59%), and 3 were in the left upper lobe (8.82%). While benign lesions showed a balanced distribution in the lung lobes, malignant lesions were mostly detected in the right upper lobe. In addition, all lesions detected in the left upper lobe were benign (Table 1).
In a total of 13 patients (54.17%) with benign etiology, there were 6 cases of pneumonic infiltrations (46.16%) (Figure 1), 4 cases of tuberculosis (30.77%), 1 case of rheumatoid nodule (7.69%), 1 case of necrotizing pneumonia (7.69%) and 1 case of pulmonary embolism (7.69%). The mean age of patients with benign etiology was 51.62±18.79 (22-78) years and the mean size of all benign lesions was 30.05±9.51 (16-53) mm. There were 6 CLs in 1 patient with a diagnosis of rheumatoid arthritis. In a total of 11 patients (45.83%) with malignant etiology, there were 5 case of squamous cell carcinoma (SCC) (45.45%) (Figure 2), 3 cases of metastases (27.27%) (2 rectal, 1 lung adenocarcinoma), 1 case of primary lung adenocarcinoma (9.09%), 1 case of small cell neuroendocrine carcinoma (9.09%), and 1 case of unclassified non-small cell lung carcinoma (NSCLC) (9.09%). The mean age of the patients with malignant etiology was 68.55±6.56 (57-78) years and the mean size of all malignant lesions was 39.25±23.45 (13-95) mm. The 2 patients with rectal adenocarcinoma had a total of 7 metastatic cavitary lung lesions (3 in one and 4 in the other).
Mean HU values measured from the wall of 18 benign and 16 malignant cavitary lung lesions by contrast-enhanced thoracic CT were calculated as 32.11±12.25 (15-60) and 63.88±24.5 (15-109), respectively. In G*power (version 3.1.9.4), post hoc analysis of the differences between two independent means (two groups) revealed an effect of 1.64 with mean and SD values. The calculated power (1-beta) was 0.86 considering type I error (alpha) of 0.001, sample size of 34 (group 1: 18, group 2: 16), and effect size of 1.64. A statistically significant difference was found in the independent t-test performed to differentiate benign and malignant cavitary lung lesions (p=0.001). In ROC analysis, the area under the curve was 86.8%, and when the cut- off value was determined as 41.5, the sensitivity and specificity were 87.5% and 88.9%, respectively (Figure 3).
Discussion
CLs in the lungs are frequently encountered in thorax imaging studies and there are various malignant and benign diseases caused by many acquired or congenital pathologies in the differential diagnoses [6, 7]. In the formation of CLs, there are various pathologic processes, such as central necrosis due to insufficient local blood flow, infarction due to obstruction of regional nutrient vascular structures, and obstruction of the bronchus resulting in distal necrosis. Several studies have suggested that primary lung abscess, malignant neoplasm, and secondary tuberculosis are among the most common pathologies underlying CLs in the lungs, followed by metastatic tumors, fungal infections, lymphoma, and vasculitic processes [8, 9]. Malignant conditions and infections are the two main causes of CLs of the lung in adults. CLs are relatively common in primary lung malignancies; the incidence increases up to 11% on chest radiography and 22% on CT [5]. Therefore, it is important to make a differential diagnosis of CLs. The most common primary lung cancer with a cavity is NSCLC, and especially SCC (69-81%). Other types of lung cancers, including adenocarcinomas and small cell carcinomas, are less likely to present with CLs [10]. In our study, among the benign pathologies, the most common cause was pneumonic infection (n=6), followed by post-primary tuberculosis (n=4). Among malignant pathologies, the most common cause was SCC (n=5), followed by metastases (2 rectal, 1 lung adenocarcinoma). Our findings were similar to those available in the literature. Cavitations in metastatic lesions are not as common as in primary lung malignancies, but metastatic CLs have been reported mostly from squamous cell primaries of organs such as the lungs, colon, stomach, head and neck, bladder, and kidneys [9, 11]. In contrast to the literature, all of the cases of cavitary metastases in our study were adenocarcinoma metastases. Conventional chest radiography and CT are the most commonly used imaging methods to evaluate lung diseases. Although ultrasonography is useful in the evaluation of pleural pathologies such as effusion or mass, it is not useful to evaluate parenchymal pathologies due to reverberation artifacts caused by the high air content of the lungs [12]. Despite recent advances, evaluation of the lungs by magnetic resonance imaging is still very limited due to low spatial resolution, high sensitivity, and motion artifacts [13, 14]. Although positron emission tomography is another widely used method to detect or characterize lesions larger than 8 mm, it lacks specificity in distinguishing between inflammatory and neoplastic lesions [15]. CT still continues to be the best and most sensitive method among all imaging modalities. We therefore planned our study with patients with contrast-enhanced CT scans.
Localization can be helpful in the differential diagnosis of CLs, as some disease processes have a preference for certain regions of the lung. For example, CLs due to post-primary tuberculosis are mainly located in the apical posterior segments of the upper lobes [16], while lung abscesses due to aspiration generally tend to occur in the posterior segment of the upper lobes or the upper segment of the lower lobes [17]. In addition, there is generally upper lobe predominance in CLs of the lungs [5]. Of the tuberculosis cases (n=4) in our study, 2 were in the left upper lobe, 1 in the left lower lobe, and 1 in the right lower lobe. In this study, similar to the literature, while upper lobe predominance (55.88%) was present, all CLs were mostly located in the right upper lobe (47.06%). In addition, while the majority of lesions in the right upper lobe (n=16) in our study were malignant lesions (n=11, 68.75%), all lesions in the left upper lobe were benign. Our study showed that the malignancy potential is higher if a CL is located in the upper lobes of the lung, especially on the right side.
In some disease processes, more than one cavity is formed in the lung, while a single cavity is observed in others. While bronchogenic carcinoma and pyogenic abscess are among the differential diagnoses of a single CL in the lung, metastases, tuberculosis, septic embolism, aspergillosis, and autoimmune diseases often cause multiple CLs [18]. In our study, among the patients with malignant etiology, 2 patients with rectal adenocarcinoma had a total of 7 CLs, 3 in one case and 4 in the other; other malignant etiologies had a single CL. Among the patients with benign etiologies in our study, 1 patient with a diagnosis of rheumatoid arthritis had a total of 6 cavitary rheumatoid lesions; others had a single CL. Similar to the literature, our study showed that both benign and malignant cavitary lesions may be multiple.
Different clinical and radiological parameters may be helpful in evaluating lung CLs, such as the duration of symptoms, internal contour features, and location of the lesions. Clinical findings may help narrow the differential diagnosis of pulmonary CLs. Acute onset symptoms with fever and productive cough suggest an infection, while chronic cough and weight loss together with fatigue suggest malignancy or tuberculosis. The patient’s immune status is another factor to consider in determining the cause of cavitation. The radiological approach to a cavitary lung lesion includes the analysis of wall features, intracavitary material, arterial enhancing foci, its relationship with the pleura, environmental changes, and ancillary findings. However, since the specificity of these definitions is low between malignant and benign etiologies, considerable overlap occurs in these clinical and imaging findings [19]. In this study, we have investigated the role of CT-HU density values measured from the CL wall. In the literature, there is no similar study done with CT-HU density, and in our current study, we found that HU values were quite significant in differentiating benign and malignant CLs.
Some studies have explained that CLs with thicker walls and irregular internal contours can help diagnose primary or metastatic lung cancer [8, 9, 20]. It has been reported from chest radiographs that most lesions with a maximum wall thickness of >15 mm are malignant, but most of those with a maximum wall thickness of ≤4 mm are benign [4]. Other studies have suggested cut-off values of 15 and 3 mm, respectively [3]. In another similar recent study with CT scanning of 96 patients, the cut-off values for CL wall thickness were determined as 27 and 7 mm [19]. Another study evaluating cavity maximum wall thickness on thoracic CT did not find any difference between malignant and benign pathologies. In the same study, however, it was reported that malignant cavities were more likely to have an irregular inner wall and an indentation in the outer wall compared to benign cavities [10]. Although there are similar studies on CT series of patients with CLs in the lungs [8, 9], these findings are still insufficient and sometimes show inconsistencies. Although most CLs are still diagnosed by additional invasive methods such as percutaneous biopsies, comprehensive CT characterization will provide a safer approach to the patient in cases of suspicious lesions as well as avoiding unnecessary research on benign lesions. In the current study, as a noninvasive method, HU density values were measured from the walls of CLs by contrast-enhanced thoracic CT and were found to be higher in cases of malignant lesions (p=0.001). The results of our study showed the highest predictive value in the differentiation of benign and malignant CLs in the lungs with 87.5% sensitivity and 88.9% diagnostic accuracy when the threshold HU value was determined as 41.5.
The small number of patients in our study can be considered a limitation. However, we know that it takes quite a long time to build a good series of CLs. Our second limitation lies in the lack of inter- and intraobserver variability and our final limitation is that there were some differences in the protocols applied for the contrast phase due to the retrospective nature of the study. However, in our clinic, although the amount and duration of contrast in all contrast-enhanced thoracic CT scans, except for the pulmonary embolism protocol, are partially dependent on the patient, these scans are performed according to a standard as specified in the Material and Methods section.
Conclusion
Contrast-enhanced thorax CT is a valuable imaging method for the characterization of lung CLs. We think that HU density values measured from the CL wall during contrast-enhanced thoracic CT may be useful in the differentiation of frequently detected benign and malignant CLs, which have similar radiological imaging findings. We also think that multicenter and prospective studies are needed to help us develop a more accurate approach to CLs in the lungs.
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.
Funding: None
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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İlyas Dündar, Mesut Özgokçe, Fatma Durmaz, Veysel Atilla Ayyıldız, Hanifi Yıldız, Ensar Türko, Cemil Göya. The role of computed tomography hounsfield unit values in the differentiation of benign and malignant cavitary lung lesions. Ann Clin Anal Med 2021; 12(Suppl 4): S508-512
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Can immature granulocytes predict mortality in coronavirus disease 2019 (COVID‑19) infection in patients with chronic kidney disease?
Fatih Selvi, Cihan Bedel, Mustafa Korkut, Ökkeş Zortuk
Department of Emergency Medicine, Health Science University, Antalya Training and Research Hospital, Antalya, Turkey
DOI: 10.4328/ACAM.20719 Received: 2021‐05‐29 Accepted: 2021‐08‐19 Published Online: 2021‐09‐12 Printed: 2021‐09‐15 Ann Clin Anal Med 2021;12(Suppl 4): S513‐517
Corresponding Author: Cihan Bedel, Health Science University, Antalya Training And Research Hospital, Kazım Karabekir Street, postal zip code: 07100, Muratpaşa, Antalya, Turkey. E‐mail: cihanbedel@hotmail.com P: +90 507 564 12 54 F: +90 242 249 44 87 Corresponding Author ORCID ID: https://orcid.org/0000‐0002‐3823‐2929
Aim: The association between mortality and comorbid diseases such as cardiovascular disease, chronic kidney disease (CKD), diabetes, and other chronic diseases has been reported in COVID-19 patients. Mortality is 14-16 times higher in patients with CKD. Inflammation plays an important role in the pathophysiology of COVID‐19. Immature granulocytes (IG%) are used to make an immediate diagnosis in cases of severe infections. Therefore, we aimed to investigate whether IG% can be used as a prognostic factor in CKD patients who have contracted COVID‐19.
Material and Methods: All CKD patients admitted to our center in the period between June and December 2020 with a COVID‐19 diagnosis were reviewed. Complete blood count and biochemical tests were performed and the results were recorded. According to the occurrence of in‐hospital mortality, the patients were categorized into groups and intergroup comparisons were conducted.
Results: Our study included 87 patients, 42 (48.3%) of whom were women. The mean age of the patients was 67.07±13.52 years. Of the patients included in the study, 71 (81.6%) were survivors and 16 (18.4%) were non‐survivors. The comparison of the mean IG% between the survivor and non‐survivor groups did not reveal a significant correlation (0.72±0.52 vs. 0.71±0.42; p=0.754). The comparison of disease severity between the groups with high and normal IG% did not reveal a significant difference (24.4% vs. 21.1%; p=0.769).
Discussion: IG% cannot be used as an indicator to predict mortality in CKD patients with COVID‐19.
Keywords: Coronavirus Disease 2019, Chronic Kidney Disease, Mortality, Immature Granulocytes
Introduction
The novel coronavirus disease (COVID‐19), caused by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), first occurred in Wuhan in China at the end of 2019 and caused a global outbreak resulting in seriously devastating socioeconomic effects all over the world [1]. According to the World Health Organization, more than 115 million people have been diagnosed with COVID‐19 and more than 2.5 million have died worldwide [2]. While most patients experience mild symptoms such as fever and dry cough, some may quickly develop shortness of breath or even acute respiratory distress syndrome (ARDS) resulting in death [3]. Studies have shown the relationship between mortality and comorbid diseases such as cardiovascular disease, chronic kidney disease (CKD), diabetes, and other chronic diseases in COVID‐19 patients. Mortality is 14‐16 times higher in patients with CKD [4].
Inflammation plays an important role in the pathophysiology of COVID‐19. It is critical to identify potential risk factors to predict COVID‐19 patients who will likely develop critical conditions [5]. Recent studies have shown that the neutrophil‐ to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and interleukin‐6 (IL‐6) as inflammatory markers may be independent risk factors for death in COVID‐19 patients [3, 6]. Immature granulocytes (IG%) are indicative of increased myeloid cell production and are used to make an immediate diagnosis in cases of severe infections [7, 8]. Recent studies have reported the role of IG% as a predictor of the severity and complications of gastrointestinal system diseases, sepsis, and cardiovascular system diseases [8‐10]. To our knowledge, the benefits of using IG% to predict mortality in COVID‐19 patients with CKD have not yet been studied. Therefore, we aimed to investigate whether IG% can be used as a prognostic factor in CKD patients who have contracted COVID‐19.
Material and Methods
This is a retrospective observational study conducted at a single center. The study was approved by the ethics committee of our institution with decision number 19/12 and study registration number 2020‐362 on December 10, 2020. Data of all patients recorded in the hospital information system were retrospectively reviewed. The patient population consisted of CKD patients who were admitted to a tertiary emergency department and the pandemic triage system due to the presence of COVID‐19 symptoms and who received a confirmed diagnosis of COVID‐19 from among patients with suspected clinical, laboratory, and radiological findings for COVID‐19. Sample selection was not performed. Instead, all CKD patients admitted to our center in the period between June 1 and December 1, 2020, who received a COVID‐19 diagnosis were reviewed. The quantitative reverse transcription‐polymerase chain reaction test (RT‐PCR) was performed with samples taken from the upper respiratory tract (nasopharyngeal and oropharyngeal secretions) to make the diagnosis of COVID‐19. In accordance with the guidance provided in the Republic of Turkey Ministry of Health’s COVID‐19 diagnostic and therapeutic guidelines, the RT‐PCR test was performed with the Coronex COVID‐19 QPCR kit (DS BIO and NANO Tech. Ltd., Ankara, Turkey) as the standard method. Individuals with a positive RT‐PCR test result were accepted as COVID‐19 patients. Patients were examined for the presence of COVID‐19 symptoms including fever, cough, dyspnea, generalized pain, weakness, anorexia, nausea, vomiting, diarrhea, and anosmia and the findings were recorded. When thoracic computed tomography (CT) images were available, the presence of a ground‐glass appearance or pneumonic infiltration on such images was recorded as a positive finding.
Patients with COVID‐19 are considered severely ill if SpO2 is <94% in room air at sea level, respiratory rate is >30 breaths/ min, PaO2¬/FiO2 is <300 mmHg, or lung infiltrates are >50% in room air at sea level. These patients may experience rapid clinical deterioration [5‐7]. Critically ill patients may have ARDS, septic shock representing virus‐induced shock of distribution, cardiac dysfunction, exaggerated inflammatory response, and/ or exacerbation of underlying comorbidities [6, 7]. Venous blood samples obtained at admission were studied using the Sysmex XN‐1000 modular system device (Sysmex Corp., Kobe, Japan). Of the complete blood count parameters, the white blood cell (WBC) count, hemoglobin levels, neutrophil and lymphocyte counts, and IG% were measured and the results were recorded. Of the biochemical parameters, venous blood gas levels, glomerular filtration rate (GFR), and levels of C‐reactive protein (CRP), serum creatinine, blood urea nitrogen (BUN), alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and glucose were assessed. Sociodemographic data and comorbid diseases were recorded. CKD patients included in the study were grouped into 5 categories as defined in the 2002 guidelines of the Kidney Disease Outcomes Quality Initiative (KDOQI) for the evaluation, classification, and stratification of CKD. According to these guidelines, category 1 refers to kidney damage with normal or increased GFR levels of ≥90 mL/min/1.73 m2, category 2 refers to kidney damage with a mild reduction in GFR characterized by GFR values in the range of 60‐89 mL/ min/1.73 m2, category 3 refers to moderate renal impairment characterized by GFR values in the range of 30‐59 mL/min/1.73 m2, category 4 refers to severe renal failure characterized by GFR values in the range of 15‐29 mL/min/1.73 m2, and category 5 refers to end‐stage renal failure characterized by GFR values of <15 mL/min/1.73 m2. The standard treatment protocol administered to the patients was developed in accordance with the current recommendations specified in the treatment guidelines for adult patients issued by the Ministry of Health of the Republic of Turkey. The relationship of IG% with COVID‐19 and in‐hospital mortality was investigated, covering the prognostic processes. According to the occurrence of in‐ hospital mortality, the patients were categorized into groups and intergroup comparisons were performed.
Statistical Analysis
Standard deviation and mean values were calculated for continuous variables. Medians and interquartile ranges were calculated for non‐parametric data. Each independent variable was compared between the groups by either the chi‐square test or the independent t‐test, whichever was suitable. Descriptive statistical analysis of all variables was carried out using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Logistic regression analysis was performed to investigate the factors associated with mortality. Statistical significance was defined at a p<0.05.
Results
Our study included 87 patients who met the inclusion criteria. Of these patients, 45 (51.7%) were men and 42 (48.3%) were women. The mean age of the patients was 67.07±13.52 years. Hypertension, diabetes, and coronary heart disease were the most common risk factors associated with the disease. The mean BUN level was 47.27±25.68 and the mean creatinine level was 2.94±2.14. The mean IG% value was 0.72±0.5. The patients were divided into two groups according to mortality. Of the patients included in the study, 71 (81.6%) were survivors and 16 (18.4%) were non‐survivors. Non‐survivors were older compared to survivors (73.06±9.91 vs. 65.72±13.91; p=0.021). There was a significant relationship between disease severity and mortality. The mortality rate was significantly higher in patients with severe or critical disease (p<0.001). The need for mechanical ventilation was significantly higher in non‐survivors (p<0.001). The comparison of the mean IG% values between the survivor and non‐survivor groups did not reveal a significant correlation (0.72±0.52 vs. 0.71±0.42; p=0.754) (Figure 1). No significant differences were found in other parameters between the groups. The clinical characteristics of the patients included in the study are listed in Table 1.
Patients were classified into two groups as patients with lower (<0.6) and elevated (≥0.6) baseline IG% values. In the groups with normal and high baseline IG% values, there were 46 (52.8%) and 41 (47.2%) patients, respectively. There were no significant differences in age, gender, or disease‐related risk factors between the groups with high and normal IG% levels. Furthermore, laboratory test results were not significantly different between these groups. The comparison of disease severity between the groups with high and normal IG% levels did not reveal a significant difference (24.4% vs. 21.1%; p=0.769). In addition, high IG% values did not correlate with the need for mechanical ventilation for the management of the disease (p=0.959). The demographic, clinical, and laboratory data of the COVID‐19 patients at admission are shown in Table 1 by IG% values. The results of the logistic regression analysis that was conducted to determine the factors that might act on mortality revealed that age [0.295 (0.075-1.152), p=0.079], BUN levels [1.125 (0.359-3.523), p=0.840], CRP levels [0.757 (0.212- 2.706), p=0.688], and IG% [0.945 (0.311-2.874), p=0.920] were not associated with mortality (Table 3).
Discussion
COVID‐19 is spreading rapidly around the world, contributing to the continued severity of the pandemic. Although many cases can be asymptomatic or present with only mild symptoms, COVID‐19 can entail a wide range of clinical symptoms that might progress to severe and fatal pneumonia and multi‐ organ failure [11, 12]. Studies have shown that COVID‐19 and chronic comorbidities such as advanced age, male gender, obesity, cardiovascular disease, diabetes, and kidney failure are associated with poor survival [5, 13]. In patients with COVID‐19, it has been reported that there is a relationship between prognosis and acute phase reactants, including hematological parameters (WBC, platelet, and lymphocyte counts, etc.) and the levels of CRP, lactate dehydrogenase, ferritin, and D‐dimer [14, 15]. In this study, we examined the prognostic value of IG% as an inflammatory marker for the first time in the literature to estimate prognosis in COVID‐19 patients with CKD. We have found that IG% is not a marker of mortality in patients with CKD.
Although the underlying cause of the occurrence of infections with highly contagious SARS‐CoV‐2 has not been fully understood yet, the key role of inflammation in infectious diseases cannot be denied. Studies about the progression of viral pneumonia in COVID‐19 have reported an increase in proinflammatory cytokines [16, 17]. The well‐known inflammatory parameters include the counts of WBCs, neutrophils, lymphocytes, and platelets and their ratios, such as the NLR and PLR. Many studies have shown that the use of such markers is feasible in the diagnosis, follow‐up, and estimation of disease prognosis because the test results can be obtained quickly at low costs [18, 19]. In this study, we examined the association of IG% with mortality in COVID‐19 patients with CKD as a marker that physicians are usually not familiar with.
It has been reported that hematological, biochemical, inflammatory, and immune biomarker abnormalities occur in patients with severe COVID‐19 [20]. In a meta‐analysis performed by Henry et al., it was found that the WBC count is elevated and lymphocyte and platelet counts are low in patients with severe COVID‐19 [14]. Another study reported disorders in the immune response in COVID‐19 patients and showed the relationship of disease severity with elevated leukocyte and low monocyte, eosinophil, and basophil counts [21]. IG% can be easily obtained via complete blood count as an easy‐to‐ perform test available in any emergency department. Because IG% indicates bone marrow activation, it has been stated that it can possibly be used as an indicator of early‐stage inflammation [8, 22]. Many studies have reported that IG% can be used in the diagnosis and estimation of prognosis in many diseases, especially in cardiovascular and gastrointestinal system diseases [23, 24]. In one study, it was shown that IG% could help predict the likelihood of early in acute appendicitis patients as a parameter that can be tested quickly without extra costs [25]. In a study of 301 patients with clinical findings of sepsis, Ayres et al. demonstrated that IG% of <2.0% helped exclude the diagnosis of sepsis with very high specificity and that IG% could be a useful additional adjunctive marker to diagnose sepsis and initiate early treatment [10]. Patients with CKD have increased risk for infections and infection‐related mortality. The increased risk of infections is likely related to a dysregulated immune system. Infections are the second most common cause of death for dialysis patients, and some studies have found an annual death rate of several hundred times higher secondary to sepsis compared to the general population [21‐25]. Therefore, the contribution of parameters such as IG%, which is associated with infection, to early intervention and treatment cannot be denied. To the best of our knowledge, there are no studies in the literature examining the relationship between IG% and mortality in CKD patients with COVID‐19. Our results have shown that IG% is not a parameter that can be used to predict mortality in patients with CKD despite the elevated baseline values observed in approximately half of the patients.
Our study has some limitations. First, the study had a retrospective design and was conducted at a single center. Second, the time from the onset of symptoms to the time of emergency unit admission and the collection of blood samples could not be analyzed. We consider it a limitation that may have affected our results. In addition, only baseline IG% levels at admission could be tested; it was not possible to perform serial IG% measurements in the emergency room. Multi‐center prospective studies with larger patient populations are needed to better interpret the findings of our study.
Conclusion
The results of our study have shown that IG% cannot be used as an indicator to predict mortality in CKD patients with COVID‐19.
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.
Funding: None
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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Fatih Selvi, Cihan Bedel, Mustafa Korkut, Ökkeş Zortuk. Can immature granulocytes predict mortality in coronavirus disease 2019 (COVID-19) infection in patients with chronic kidney disease? Ann Clin Anal Med 2021; 12(Suppl 4): S513-517
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Analysis of laboratory parameters in patients with COVID-19: Experiences from a pandemic hospital
Serdar Özdemir 1, Serkan Emre Eroğlu 1, Abdullah Algın 1, Hatice Şeyma Akça 1, Abuzer Özkan 1, Emin Pala 2, Mehtap Aydın 3, Gökhan Aksel 1
1 Department of Emergency Medicine, 2 Department of Family Medicine, 3 Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences Umraniye Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20678 Received: 2021-04-29 Accepted: 2021-06-24 Published Online: 2021-07-21 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S518-523
Corresponding Author: Serdar Özdemir, Department of Emergency Medicine, Health of Sciences University Umraniye Training and Research Hospital, Site Mahallesi, Adıvar Sokak, No:44 Daire:15 Ümraniye, Istanbul, Turkey. E-mail: dr.serdar55@hotmail.com P: +90(505) 2673292 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6186-6110
Aim: This study aimed to determine the analysis of the laboratory parameters in patients infected with SARS-CoV-2 during the early pandemic period in Turkey.
Material and Methods : This retrospective descriptive study was conducted at a pandemic hospital. All hospitalized patients and outpatients with a positive RT-PCR assay for SARS-CoV-2 were included in the study. Demographics, clinical characteristics, vital parameters on admission, laboratory findings, and drugs used for SARS-CoV-2 infection were obtained from the computer-based patient data system of the hospital and analyzed. The primary outcome of the study was the laboratory parameters of patients with COVID-19. The secondary outcome was 30-day all-cause mortality following emergency department admis- sion.
Results: A total of 2,012 patients were included in study. The rates of hospitalization and 30-day mortality were 24% and 2%, respectively. The most common symptom was cough, and the most common comorbidity was hypertension. The neutrophil count, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio values were elevated in the non-survivor group compared to the survivor group (P = 0.001, P < 0.001, and P = 0.020, respectively). The lymphocyte and platelet counts were elevated in the survivor group compared to the non-survivor group (P = 0.001 and P < 0.001, respectively). As predictors of mortality, the cut-off value for the neutrophil, lymphocyte and platelet counts, and the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios were 5.68, 1.42, 195, 3.09, and 141.8, respectively, and the AUC was determined as 0.704, 0.714, 0.727, 0.745, and 0.610, respectively (P < 0.001, P < 0.001, P < 0.001, P < 0.001, and P = 0.023, respectively).
Discussion: The results of the study demonstrated that the neutrophil count, lymphocyte count, platelet count, neutrophil-to-lymphocyte ratio and platelet-to- lymphocyte ratio are useful in determining prognosis in SARS-CoV-2 infection.
Keywords: SARS-CoV-2; Clinical Characteristics; COVID-19; Mortality; Laboratory Parameters
Introduction
Coronaviruses are single-stranded, enveloped RNA viruses with positive polarity. Although they cause a self-limiting mild infection, which is common in society similar to the common cold, it can also lead to the development of more serious conditions, such as MERS-CoV and SARS-CoV infections [1]. In December 2019, a new type of coronavirus was reported to cause SARS and was named SARS-CoV-2. The respiratory syndrome caused by this virus was termed as coronavirus disease-2019 (COVID-19) [2]. After the emergence of the virus, by September 21, 2020, there have been over 31,000,000 SARS-CoV-2 cases, which were reported from 128 countries, and over 962,000 patients died as a result of this viral infection [3].
In Turkey, the first positive case of COVID-19 was identified on March 11, 2020, and the pandemic continues to spread increasingly [4]. There are many issues related to the COVID-19 disease that have not yet been clarified. In Turkey, there is a need for further research on the COVID-19 pandemic, which has negatively affected the whole world since December 2019. We considered that an analysis of laboratory parameters throughout Turkey might help predict the severity of the disease and clinical characteristics, given the rapid spread of SARS-CoV-2. Therefore, in this study, we aimed to determine the laboratory parameters of patients infected with SARS- CoV-2 during the early pandemic period in Turkey.
Material and Methods
Study design
This retrospective descriptive study was conducted at University of Health Sciences, Ümraniye Training and Research Hospital, a 672-bed tertiary academic hospital with an annual emergency department (ED) census of 438,000. We retrospectively collected the data of the patients who presented to our ED due to COVID-19-related symptoms between March 15, 2020 and April 15, 2020.
Study population
The study population comprised patients with suspected SARS-CoV-2 infection according to the COVID-19 Outbreak Management and Working Guidelines of the Turkish Ministry of Health (available at: https://covid19bilgi.saglik.gov.tr/tr/ algoritmalar). Patients who met the criteria given in these guidelines were tested for SARS-CoV-2, and the diagnosis was made using the real-time reverse transcriptase-polymerase chain reaction (rt-PCR) test. Patients who did not undergo this test or tested negative for SARS-CoV-2 were excluded from the study. All hospitalized patients and outpatients with a positive RT-PCR assay for SARS-CoV-2 were included in the study. Decisions about the necessity of hospitalization were made by the emergency physician, or thoracic surgeon or cardiovascular surgeon in accordance with the same guidelines, independent of inpatient bed availability. Patients requiring hospitalization when no bed was available at our hospital were not transferred to other hospitals and waited in ED until a bed became available.
Data collection
Demographics, clinical characteristics (including travel to an endemic country, medical history, surgery history, exposure history, comorbidities, and symptoms), vital parameters on admission, laboratory findings, and drugs used for SARS-CoV-2 infection (hydroxychloroquine, favipiravir) were obtained from the computer-based patient data system of the hospital and analyzed by four independent researchers.
Comorbid diseases, such as chronic obstructive pulmonary diseases (COPD), diabetes mellitus (DM), hypertension, coronary artery disease (CAD), congestive heart failure (CHF), and active malignancy, chronic kidney disease (CKD), and immunosuppression. Symptoms including fever, cough, sputum, shortness of breath, weakness, muscle-joint pain, loss of taste or smell, headache, sore throat, nausea-vomiting, and diarrhea were recorded. Vital parameters were noted as blood pressure (systolic, and diastolic), heart rate, body temperature, respiratory rate, and oxygen saturation.
Laboratory parameters contained complete blood count [white blood cell count, lymphocyte count, neutrophil count, platelet count, hemoglobin count, hematocrit, mean platelet volume (MPV), mean corpuscular volume (MCV), neutrophil-to- lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR)], renal and liver function, and measures of serum electrolytes, D-Dimer, C-reactive protein, troponin I, ferritin, and fibrinogen. Laboratory tests were conducted within 24 hours of hospital admission. The outcome within 24 hours of ED admission was recorded as discharged, admission to an inpatient clinic, admission to the intensive care unit (ICU), and death in ED. Contact history was defined as being in contact with a confirmed COVID-19 case or travelling to a country where the pandemic was seen within the last 14 days. The primary outcome of the study was the laboratory parameters of the patients with COVID-19, and the secondary outcome was 30- day all-cause mortality following ED admission.
Statistical analysis
IBM SPSS Statistics for Mac, Version 27.0. Armonk, NY, IBM Corp was used to perform statistical analyses. The Kolmogorov- Smirnov test was conducted to evaluate the conformity of variables to normal distribution. The data that matched normal distribution were presented with mean and standard deviation and values, and the remaining data were expressed as interquartile range and median values. Categorical data were presented with the number of cases and percentages. For the comparison of quantitative and qualitative data between two groups, the chi-square and Mann-Whitney U tests were used. We also formed a receiver-operating characteristic curve for 30-day mortality and obtained the area under the curve (AUC) for individual variables. The AUC values of the parameters were calculated and tested mutually for significance with the DeLong equality test. A p-value lower than 0.05 was considered statistically significant in all analyses.
Ethics
The ethical approval for our study was obtained from the Clinic Research Ethics Committee of University of Health Sciences, Ümraniye Training and Research Hospital (approval number: B.10.1.TKH.4.34.H.GP.0.01/97). We retrospectively reviewed the secondary data recorded from the computer-based patient data system of the hospital. The recorded data did not include any personally identifiable information and only contained clinical data; therefore, informed consent was waived.
Results
Among 20,077 patients presenting to our ED during the study period, 6,034 patients had symptoms of SARS-CoV-2 infection. A total of 2,012 patients with a positive RT-PCR assay result for SARS-CoV-2 were included in the final analysis. The study flowchart is given in Figure 1.
The mean age and standard deviation values of the 2,012 patients were 68.27 ± 13.02 years, and 1,166 patients (58%) were male. A total of 41 patients died within 30-day of ED admission. All deaths were in-hospital deaths and were due to COVID-19. The rates of hospitalization and 30-day mortality were 24% and 2%, respectively. Demographic characteristics, comorbid diseases, symptoms, vital parameters on admission, initial laboratory findings, and drugs used for SARS-CoV-2 infection are shown in Table 1-2.
Outcomes
Comparisons of characteristics of the non-survivor and survivor groups are shown in Table 1. Significant differences were detected between the survivor and non-survivor groups in terms of age (40.82 ± 14.3 versus 69.56 ± 12.81, P < 0.001), contact history (816 versus 32, P = 0.012), COPD (36 versus 4, P = 0.008), HT (178 versus 15, P < 0.001), CAD (36 versus 5, P = 0.001), CHF (9 versus 6, P < 0.001), CKD (10 versus 4, P < 0.001), active malignancy (16 versus 3, P = 0.006), cough (1286 versus 19, P = 0.012), sodium (138.94±2.49 versus 136.98 ± 5.82, P = 0.039), potassium (3.75 ± 18.22 versus 4.16 ± 1.08, P = 0.034), glucose [117 (64-355) versus 127 (78-519), P < 0.001], blood urea nitrogen (23.42 ± 14.05 versus 49.14 ± 32.87, P < 0.001), creatinine (0.79 ± 0.35 versus 1.4 ± 1.05, P = 0.001), albumin (4 ± 1.11 versus 3.5 ± 0.85, P = 0.007),
aspartate aminotransferase [28 (8-159) versus 36 (15-454), P < 0.001], troponin [0.05 (0.00-7.85) versus 0.32 (0.05-1.12), P < 0.001], fibrinogen (469.16 ± 140.82 versus 535.09 ± 155.69), P = 0.038], and CRP [1.4 (0.1-21.7) versus 2.3 (0.2- 24.6), P < 0.001]. Significant differences were also identified between the survivor and non-survivor groups in relation to the hematological test parameters: neutrophil count (4.69 ± 2.74 versus 7.29 ± 4.40, P = 0.001), lymphocyte count (2.04 ± 1.08 versus 1.44 ± 1.05, P = 0.001), platelet count (241.60 ± 68.09 versus 181.58 ± 66.5, P < 0.001), hemoglobin count [13.2 (1.3-16.8) versus 13.3 (1.10-17.3), P = 0.027], hematocrit [39.5 (3.9-48.9) versus 39.2 (3.9-52.1), P = 0.007)], MPV (8.83±2.76 versus 9.73±2.36, P = 0.037), NLR [3.32 (0.04-53.14) versus 6.09 (0.03-57.32), P < 0.001], and PLR [147.7 (53.6-1357.1) versus 164.1 (31.7-510.81), P = 0.020].
Table 3 and Figure 2 present the cut-off, sensitivity and specificity and AUC values with a 95% confidence interval of the investigated parameters.
Discussion
In this study, we performed a comprehensive evaluation of 2,012 adult patients with SARS-CoV-2 infection at a pandemic hospital in Turkey to contribute to the limited data on SARS- CoV-2 cases in the country. All the patients in this study were confirmed to have SARS-CoV-2 based on a positive RT-PCR assay.
Some studies have identified an association between the severity of COVID-19 and low lymphocyte count. The literature contains the hypotheses of the possible underlying pathogenesis concerning COVID-19-induced lymphopenia [5-9]. Mazzoni et al. suggested that the massive lymphocyte death that occurred due to an inflammatory cytokine storm might be a possible underlying cause of lymphopenia [6]. In an in vitro study, Xiong et al. showed that SARS-CoV-2 could infect T cells [7]. Ouyong et al. reported that in severe COVID-19 patients, T cell activation and functions were affected by the downregulation of MAP2K7 and SOS1, which, they hypothesized, could be a result of cytokine storm [8]. In another study, Dialo et al. showed an increase in some apoptosis proteins of T cells, such as PD-1 and Tim-3; thus, they suggested that the exhaustion of T cells could be involved in the pathogenesis of lymphopenia [9].
NLR has been investigated as an independent prognostic marker in critically ill patients, as well as in those with severe sepsis, septic shock, and other diseases [10-12]. Yang et al. reported that NLR and PLR might be related to the severity of infection in patients with SARS-CoV-2 [11]. In that study, the cut-off values for NLR and PLR as predictors of severity were determined as 3.3 and 180, respectively in patients with SARS-CoV-2 infection, and their AUC values were 0.743 and 0.784, respectively [11]. In a meta-analysis conducted by Chan et al. examining a total of 20 studies and 3,508 patients, NLR and PLR were suggested to be independent biologic prognostic markers of the severity of SARS-CoV-2 infection [12]. In that study, elevated NLR and PLR values were associated with severe disease (standard mean difference: 2.80 and 1.82; 95% confidence interval: 2.12-3.48 and 1.03- 2.61, respectively; P < 0. 01 for both) [12]. Similarly, the results of the current study showed that NLR and PLR were elevated in the non-survivor group compared to the survivor group.
In recent studies, it was demonstrated that thrombocytopenia might be an indicator of poor outcome and worsening illness [13-16]. Our findings are consistent with those of previous studies. In the literature, several mechanisms have been proposed to explain the pathogenesis of thrombocytopenia. As in other coronavirus infections, SARS-CoV-2 may reduce platelet production by infecting bone marrow cells and abnormal hematopoiesis [14]. Mehta et al. showed that cytokine storm reduces the bone marrow’s ability to make new blood cells, and destroy the hematopoietic progenitor cells, in SARS-CoV-2 infected patients [15]. Xu et al. speculated that the increasing level of immune complexes and autoantibodies could cause immune-mediated thrombocytopenia. SARS-CoV-2 infection causes damage to pulmonary endothelial cells and lung tissues. Endothelial damage results in platelet activation and micro embolisms [16]. Another hypothesis about thrombocytopenia in SARS-CoV-2-infected patients is an increase in platelet consumption due to the formation of microthrombi, and aggregation of platelets [16].
Limitations
The main limitation of this study is its retrospective nature. Secondly, our study was conducted in a single center with an observational design, and therefore the results may not be generalizable to other healthcare institutions. Thirdly, in our study, the survivor and non-survivor groups were not similar in terms of age and gender. In addition, as factors that may have an impact on laboratory parameters, physical activity, alcohol consumption, and BMI, may have led to potential bias. Less biased results can be obtained with prospective studies. Conclusion
The results of this study demonstrated that the neutrophil count, lymphocyte count, platelet count, NLR, PLR and MPV are useful in determining prognosis in SARS-CoV-2 infection. These laboratory parameters can be used as an indicator to help prevent and control the COVID-19 pandemic.
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.
Funding: None
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.20678
Serdar Özdemir, Serkan Emre Eroğlu, Abdullah Algın, Hatice Şeyma Akça, Abuzer Özkan, Emin Pala, Mehtap Aydın, Gökhan Aksel. Analysis of laboratory parameters in patients with COVID-19: Experiences from a pandemic hospital. Ann Clin Anal Med 2021;12(Suppl 4): S518-523
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Our experiences in emergency surgery for proximal aortic diseases
Yılmaz Apaydın 1, Buket Özyaprak 1, Ayşe Neslihan Balkaya 1, Filiz Ata 1, Hakan Özkan 1, Canan Yılmaz 1, Nail Kahraman 2
1 Department of Anesthesiology and Reanimation, Bursa Yüksek Ihtisas Training and Research Hospital, Health Sciences University, 2 Department of Cardiovasculary Surgery, Bursa City Hospital, Health Sciences University, Bursa, Turkey
DOI: 10.4328/ACAM.20806 Received: 2021-08-04 Accepted: 2021-09-10 Published Online: 2021-09-14 Printed: 2021-09-15 Ann Clin Anal Med 2021;12(Suppl 4): S524-528
Corresponding Author: Yılmaz Apaydın, Department of Anesthesiology and Reanimation, Bursa Yüksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey. E-mail: dryilmaza@gmail.com P: +90 224 295 50 00 / +90 224 366 44 34 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0583-8198
Aim: Proximal aortic disease surgery has high morbidity and mortality. In addition, the urgent performance of these operations complicates both surgical and anesthesia management. This study aimed to retrospectively evaluate patients with proximal aortic diseases who were operated on urgently in our cardiovascular surgery department.
Material and Methods: After approval was obtained from the ethics committee, a total of 72 patients who underwent emergency proximal aortic surgery in our clinic between January 2014 and January 2020 were analyzed retrospectively. Demographic data, comorbidities, anesthetic agents administered, mean duration of anesthesia, cardiopulmonary bypass (CPB) time, X-clamp time, intensive care and hospitalization times, mortality, and morbidity were evaluated.
Results: There were 51 (70.83%) male and 21 (29.17%) female patients. The mean age of the patients was 62.31±11.71 years. The most common preoperative risk factor was hypertension (n=60, 83.33%). Mean CPB time was 141.72±25.08 minutes. Fifty-nine patients (81.95%) survived and 13 (18.05%) died. The mean age of non-survivors (69.54±6.04 years vs. 60.71±12.09 years) was higher, and their X-clamp and CPB durations were longer compared to surviving patients.
Discussion: It is essential to determine the causes of mortality, take precautions, and share positive and negative experiences in both anesthesia and surgical management of proximal aortic pathologies that are operated on urgently. Hemodynamic instability, additional surgical procedures, and prolonged operation and perfusion times are key factors affecting mortality and morbidity.
Keywords: Proximal Aortic Diseases, Emergency Surgery, Anesthesia
Introduction
Emergency anesthesia is anesthesia administered in unplanned, non-elective surgical procedures [1]. As in other surgical branches, surgeries that require emergency intervention in cardiovascular surgery are increasing. Anesthesia management of cardiovascular diseases that require emergency intervention necessitates vast knowledge of cardiovascular physiology, as well as how different anesthetic agents affect pulmonary and systemic circulation and myocardial functions. The necessity of urgent operation complicates the management of anesthesia since it also limits the preparations and preoperative evaluation [2, 3].
In addition to the risk of a full stomach in patients undergoing emergency surgery, systemic diseases such as asthma, diabetes mellitus, hypertension, hypovolemia, and electrolyte disorders that cannot be evaluated adequately preoperatively and abnormal laboratory values all increase the risks of anesthesia [1, 4]. These problems should be determined as carefully as possible during the planning phase and precautions should be taken.
The frequency of aortic diseases requiring urgent intervention has increased due to easier access to healthcare services, the development of technology, and the increase in the elderly population [5]. Proximal aortic dissection and aneurysms are aortic diseases that may require emergency intervention by open heart surgery. Despite medical and technological advances, mortality and morbidity rates are also quite high [6, 7].
One of the key factors in increasing the success of these surgeries is the transfer of experience through clinical studies, and another is the protocol-oriented optimization of the results from these experiences specific to aortic surgeries. In this study, we aimed to retrospectively evaluate the results of our patients with proximal aortic dissection and aortic aneurysms who were operated on urgently and hence contribute to the literature.
Material and Methods
Study Plan and Patient Selection
The study was retrospectively performed with 72 patients with proximal aortic diseases who underwent emergency operations between January 1, 2014, and January 1, 2020, after the approval of the local ethics committee was obtained and in accordance with the Declaration of Helsinki. Demographic data, comorbidities, anesthesia, cardiopulmonary bypass (CPB) time, X-clamp time, total circulatory arrest, amounts of blood and blood products transfused, intensive care and hospitalization times, and morbidity and mortality were examined. Patient data were accessed through patient files and the hospital registry. Patients under 18 years of age who underwent elective surgery due to proximal aortic diseases and those who would undergo redo open heart surgery were excluded.
Routine Anesthesia Procedure
The patients were assessed preoperatively with the available data. Intravenous cannulas were placed in the operating room before anesthesia induction. Routine monitoring included electrocardiography with leads D2 and V5, SpO2 measurement with pulse oximetry, and invasive systemic arterial pressure, end- tidal carbon dioxide (ETCO2), esophageal temperature, invasive arterial blood pressure, and right atrial pressure measurement with central venous catheters. In addition, arterial blood gas and urine output were monitored hourly. Anesthesia induction drugs and doses administered according to the hemodynamic status of the patients were as follows:
• 1-2 μg/kg fentanyl (Talinat, Vem Pharmaceuticals, Turkey), 3-5 mg/kg pentothal (pental sodium vial, İbrahim Etem Pharmaceuticals, Turkey), and 0.6 mg/kg rocuronium (Myokron, Vem Pharmaceuticals, Turkey), in hypertensive patients.
• 1-2 μg/kg fentanyl (Talinat, Vem Pharmaceuticals, Turkey), 2 mg/kg propofol (propofol Fresenius vial, Germany), and 0.6 mg/kg rocuronium (Myokron, Vem Pharmaceuticals, Turkey), in hypertensive patients.
• 1 mg/kg ketamine (Ketax, Vem Pharmaceuticals, Turkey), 0.05- 0.1 mg/kg midazolam (Zolamid, Vem Pharmaceuticals, Turkey), and 0.6 mg/kg rocuronium (Myokron, Vem Pharmaceuticals, Turkey), in hypotensive patients.
In the maintenance of anesthesia, in addition to a 50% O2 and air mixture, sevoflurane inhalation anesthesia was administered with a minimum alveolar concentration of 0.5-1.5%, and additional intravenous fentanyl, midazolam, and rocuronium maintenance doses were given (3-5 μg/kg, 0.02 mg/kg, and 0.01 mg/kg, respectively). Furosemide was administered at 0.3 mg/ kg to patients with urine outputs of less than 0.5 mL × weight/ hour. The perioperative hemodynamic findings of the patients and the drugs administered were recorded on anesthesia follow-up charts and perfusionist follow-up slips during CPB. Routine Cardiopulmonary Bypass Management
Priming solution, including crystalloid liquid, mannitol, 8.4% sodium bicarbonate, erythrocyte suspension according to the patient’s hematocrit value, and 150 units/kg of unfractionated heparin (Koparin vial, Koçak Pharmaceuticals, Turkey), was used for extracorporeal circulation. Systemic heparinization was achieved with 300 units/kg of intravenous heparin (Koparin vial, Koçak Pharmaceuticals, Turkey). Activated clotting time (ACT) was measured for anticoagulation assessment. When ACT was >450, CPB was initiated.
Patients underwent either deep (22-25 °C) or moderate hypothermia (25-28 °C) [8, 9]. Age, preoperative kidney function, and aortic pathology were effective in deciding the level of hypothermia. The subclavian, axillary, aortic, and femoral arteries were used for arterial cannulation, the choice of which was influenced by the surgical pathology and the preference of the surgeon. Cardiac arrest was achieved with either crystalloid or del Nido blood cardioplegia. Myocardial protection was accomplished with cold blood cardioplegia in patients receiving crystalloid cardioplegia for cardiac arrest and with del Nido blood cardioplegia solution in those receiving del Nido blood cardioplegia. The pump flow was stopped as necessary for the repair of the aortic arch. At this time, cerebral perfusion was performed for cerebral protection. After the aortic repair, the CPB termination phase was initiated. If necessary, an inotropic agent such as dopamine, dobutamine, adrenaline, or noradrenaline was administered to restart the heart. Nitroglycerin was the vasodilator agent administered to the patients. After the CPB was terminated, anticoagulation was achieved by intravenous administration of protamine at a dose of 350 units/kg (Promin, Vem Pharmaceuticals, Turkey). Routine Postoperative Procedure
After the operation ended, the intubated patients were transported to the intensive care unit, where they were extubated by weaning if their hemodynamics were stable. Statistical Methods
Data were evaluated with SPSS 21.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used for basic statistical analysis and data were presented as mean±standard deviation and percentage. The Mann-Whitney U test was used for intergroup comparisons of non-normally distributed continuous variables and the chi-square test was used for categorical variables.
Results
The files of 72 patients who were urgently operated on by the cardiovascular surgery team were retrospectively evaluated. The number of male patients (n=51, 70.83%) significantly exceeded that of females (n=21, 29.17%) (p<0.05). The mean age of all patients was 62.31±11.71 years. Hypertension was the most common comorbidity in all patients with a rate of 83.33% (n=60). Other comorbidities included diabetes mellitus (n=27, 37.50%), coronary artery disease (n=22, 30.55%), cerebrovascular disease (n=5, 6.94%), and smoking (n=44, 61.11%).
The comorbidities of the survivors and non-survivors were similar (p>0.05) (Table 1). The male gender was significantly more predominant (p<0.05) (Table 1). The mean age of the non-survivors was significantly higher than that of survivors (p<0.05) (Table 1).
General anesthesia was administered to all patients. The pentothal-fentanyl-rocuronium combination was most commonly used in induction (n=42, 58.33%). The propofol- fentanyl-rocuronium combination was administered to 18 patients (25%) and ketamine-midazolam-rocuronium was administered to 12 (16.67%). Midazolam-fentanyl-rocuronium was used for all patients for anesthesia maintenance. Twenty-seven patients (37.5%) underwent isolated aortic repair surgery and 45 (62.5%) underwent an additional surgical procedure (aortic valve repair, mitral valve repair, coronary artery bypass graft surgery) besides aortic repair. The incidence of receiving an additional surgery was significantly higher among non-survivors than surviving patients (p<0.05) (Table 2). Among all patients, the mean duration of anesthesia was 305.75±40.01 min, the mean CPB time was 141.72±25.08 min, and the mean X-clamp time was 95.36±13.45 min. Twenty- nine patients (40.28%) had hemodynamic instability and inotrope infusion was administered to 18 (28%). The mean cardiopulmonary bypass time and X-clamp time, hemodynamic instability, and inotrope infusion administration rates were significantly higher among non-survivors (p<0.05) (Table 2). The mean erythrocyte suspension transfused was 4.29±2.45 units among all patients, being significantly higher among non-survivors compared to those who survived (p<0.05) (Table 2). Moderate and deep hypothermia were administered to 37 (51.39%) and 35 (48.61%) patients, respectively, with no significant differences between the survivors and non-survivors (p>0.05) (Table 2).
All patients were postoperatively transferred to the cardiovascular surgery intensive care unit. The mean length of stay in the intensive care unit was 3.43±2.07 days and the mean hospital stay was 7.93±2.97 days. Neurological complications, bleeding, infection, arrhythmias, and renal failure were observed in 13.89% (n=10), 9.72% (n=7), 6.94% (n=5), 8.33% (n=6), and 4.17% (n=3) of the patients, respectively. Mortality was seen in 13 patients (18.05%), the reasons being low cardiac output in 6 (46.15%), multi-organ failure in 4 (30.77%), bleeding in 3 (23.08%), and febrile reaction in 1 (7.69%) patient.
Discussion
Emergency anesthesia is administered in unplanned, non- elective surgical procedures [1]. These patients cannot be fully evaluated preoperatively due to time constraints [2, 3]. In patients who will undergo emergency surgery, in addition to the risk of aspiration pneumonia that may occur due to a full stomach, the risk of anesthesia increases due to inadequate preoperative evaluation of systemic diseases such as asthma, diabetes mellitus, hypertension, hypovolemia, and electrolyte disorders and laboratory values. These problems should be determined as much as possible during the planning phase and precautions should be taken [2, 4].
Anesthesiologists play a vital role with the surgical team in improving the outcome of high-risk and emergency cases.
For successful anesthesia management and perioperative outcomes, basic knowledge of the surgical procedure, thorough preoperative emergency assessment, early surgical intervention if possible, and careful planning of fluid-electrolyte support and pain management are necessary [3, 4]. Dissection and aneurysms, which are among the proximal aortic diseases, constitute an important part of cardiovascular surgeries in wh