Is histogram analysis useful in the diagnosis of COVID-19 patients?
Seda Nida Karaküçük 1, Murat Baykara 2, Kezban Tülay Yalçınkaya 3, Selçuk Nazik 4, Fatma Gümüşer 4, Kamil Doğan 1, Adil Doğan 1
1 Department of Radiology, Kahramanmaras Sutcu İmam University, School of Medicine, Kahramanmaraş, 2 Department of Radiology, Fırat University, School of Medicine, Elazığ, 3 Department of Molecular Microbiology, Kahramanmaras Sutcu İmam University, School of Medicine, Kahramanmaraş, 4 Department of Infectious Diseases and Clinical Microbiology, Kahramanmaras Sutcu İmam University, School of Medicine, Kahramanmaraş, Turkey
DOI: 10.4328/ACAM.20744 Received: 2021-06-11 Accepted: 2021-08-20 Published Online: 2022-07-27 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):831-835
Corresponding Author: Seda Nida Karaküçük, Department of Radiology, Kahramanmaras Sutcu İmam University School of Medicine, Avşar Mah. West Periphery Blv. No: 251, 46040 Onikişubat, Kahramanmaraş, Turkey. E-mail: email@example.com P: +90 506 380 36 93 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3789-6571
Aim: In this study, we aimed to show the contribution of the chest computed tomography (CT)-based histogram analysis method, which will enable us to make quick decisions for patients who are clinically suspected of having COVID-19 infection and whose diagnoses cannot be confirmed by polymerase chain reaction (PCR) tests.
Material and Methods: A total of 84 patients, 40 in the PCR-positive group (age range: 17-90 years) and 44 in the PCR-negative group (age range: 15-75 years), were included in the study. A total of 154 lesions with ground-glass density, 78 in the PCR-positive group and 76 in the PCR-negative group, were detected in these patients’ thorax CT scans. The region of interest was placed on the ground-glass opacities from the images and numerical data were obtained by histogram analysis. Numerical data were uploaded to the MATLAB program.
Results: The localizations of ground-glass densities in the CT findings of patients with probable and definite COVID-19 diagnoses were similar; 74.7% of the ground-glass areas in both groups showed peripheral distribution. Lesions were frequently observed in right lungs and lower lobes. In histogram analysis, standard deviation, variance, size %L, size %M, and kurtosis values were higher in the PCR-positive than the PCR-negative group. When receiver operating characteristic curve analysis was performed for standard deviation values, the area under the curve was 0.640, and when the threshold value was selected as 123.4821, the two groups could be differentiated with 62.8% sensitivity and 61.8% specificity.
Discussion: The use of histogram-based tissue analysis, which is a subdivision of artificial intelligence, for clinically highly suspicious patients increases the diagnostic accuracy of CT. Therefore, performing CT analysis with the histogram method will significantly aid healthcare professionals, especially in clinics where rapid decisions are required, such as in emergency services.
Keywords: COVID-19, Histogram Analysis, Chest CT
The new coronavirus disease (COVID-19), which was first seen in the city of Wuhan, in China’s Hubei province, spread extremely rapidly, causing a global epidemic in a short time. The causative agent of the disease is a single-stranded RNA virus belonging to the family Coronaviridae and it has been named SARS-CoV-2 [1, 2]. Since the beginning of the pandemic, as of May 10, 2021, the World Health Organization states on its official website that more than 190 million cases have been reported worldwide, and more than 4 million of those cases have resulted in death (https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19).
Early diagnosis of coronavirus infection is very important to alleviate and control the spread of this pandemic. Real-time reverse transcription-polymerase chain reaction (RT-PCR) is considered the gold standard for confirming infection. However, its long turn-around time and relatively low sensitivity limit its use . Sometimes, due to insufficient material, RT-PCR tests can be negative even in positive cases. On the other hand, computed tomography (CT) is used as an auxiliary diagnostic tool with 98% sensitivity among COVID-19 patients [4, 5]. In spite of negative RT-PCR tests, positive CT findings can be seen. In addition, CT can be used in the follow-up of COVID-19 infections .Texture analysis is a new field for the quantitative measurement of density changes and concentration of tissues in CT images that cannot be seen with the naked eye. It helps to make image-based decisions about the underlying pathological processes of tissues . Histogram analysis has been used in the evaluation of many lung diseases such as interstitial disease, nodules, and embolisms [8-11]. In histogram-based measurements, the heterogeneity of the tissue can be distinguished by evaluating the gray levels and pixel distributions in the image.
In our study, we aimed to reveal whether there is a difference in CT images between PCR-negative and PCR-positive patients by using the histogram-based texture analysis method in cases of SARS-CoV-2 infection and to show its contribution to diagnosis.
Material and Methods
Ethical approval (Session: 2020/222, Decision No: 02) was obtained from our hospital’s ethics committee. The study was conducted between June and September 2020.
Our study included patients with diagnoses of possible or definite COVID-19 defined according to the guidelines of the Ministry of Health of the Republic of Turkey (https://covid19.saglik.gov.tr/Eklenti/39061/0/covid-19rehberieriskinhastatedavisipdf.pdf). Patients with fever, headache, sore throat, muscle pain, decrease or loss in taste and/or smell, and a history of contact with a COVID-19 patient or with pulmonary involvement compatible with COVID-19 on CT were considered as possible cases.
The RT-PCR test results were negative in two swab samples taken 24 hours apart in probable COVID-19 patients. Patients with positive RT-PCR test results from swab samples taken by combined nasal/oral method were determined as definite COVID-19 cases. Chest CT scans of patients with probable or definite diagnoses were retrospectively re-evaluated by two radiologists (10 and 11 years of experience). Patients with findings of ground-glass density, which is considered a typical finding for COVID-19 on chest CT, were selected. Eighty-four patients and 154 lesions belonging to these patients were included in the study.
Study Design and Image Processing
Lesions with ground-glass density were determined on the chest CT scans of patients with probable and definite COVID-19 diagnoses and were classified according to their locations. Lesions that had contact with the pleura or did not have contact with the pleura but extended parallel to the pleural surface and had less extension to the parenchyma were called subpleural lesions. Lesions adjacent to the pleura that extended toward the parenchyma and that had a greater parenchymal extension than the pleural extension were termed subpleural-parenchymal. Lesions located far from the pleura and within the parenchyma were termed parenchymal (Figure 1).
The location of the lesion was also defined as right/left lung and upper/middle/lower lobe. A region of interest (ROI) was placed with a manual drawing surrounding the boundaries of each lesion using the ROI form on a 27-inch iMac computer (Apple Inc., Cupertino, CA, USA) (Figures 2 and 3). Lesions far from vascular structures were preferred in patients with multiple lesions.
Chest CT studies without a contrast agent were performed using a 16-detector-array CT device (Alexion Toshiba Medical Systems, Nasu, Japan) with tube voltage of 120 kVp and tube current of 200 mAs. Slice thickness, reconstruction increment, scan field of view, and matrix size were 3 mm, 0.75 mm, 37 cm, and 512 × 512, respectively. CT images were obtained in the supine position at the full inspiration of the patient.
Histogram analysis from the ROIs was performed using a computer program (Matrix Laboratory, MathWorks Inc., Natick, MA, USA). Mean, standard deviation (SD), minimum, maximum, median, variance, entropy (irregularity), uniformity (inhomogeneity), skewness, and kurtosis values were calculated from the ROIs.
Data were expressed as mean±standard deviation. The chi-square test was used to compare genders and the Mann-Whitney U test was used to compare other parameters of the groups. All statistical analyses were performed with SPSS 25.0 (IBM Corp., Armonk, NY, USA). Values of p<0.05 were considered statistically significant.
This study included 40 patients in the PCR-positive group (14 women, 26 men; mean age: 46.4±15.7 years; age range: 17-90 years) and 44 patients in the PCR-negative group (10 women, 34 men; mean age: 43.4±12.6 years; age range: 15-75 years), with a total of 84 patients included. There was no significant difference between the two groups in terms of age or gender (p>0.05).
A total of 78 lesions were detected in the CT images of patients with PCR-positive results. Of these lesions, 60.3% were located in the right lung and 39.7% were located in the left lung. A total of 76 lesions were evaluated in the PCR-negative patient group, 60.5% of which were located in the right lung while 39.5% were located in the left lung.
In the PCR-positive group, 52 of 78 lesions were located in the lower, 6 in the middle, and 20 in the upper lobe, while in the PCR-negative group, 40 were located in the lower, 5 in the middle, and 31 in the upper lobe. In both groups, subpleural-parenchymal and subpleural lesions were observed more frequently (45.5% and 29.2%, respectively), while the frequency of parenchymal lesions (25.3%) was lower. While 73.1% of the lesions in the PCR-positive patient group were located in the peripheral region, 74.7% of all lesions were distributed peripherally.
As shown in Table 1, when comparing the PCR-positive group and the PCR-negative group in histogram analysis, there was no significant difference in mean, entropy, skewness, or uniformity values (p>0.05), while the standard deviation, variance, size %L, size %M, and kurtosis values were statistically significant different (p=0.003, p=0.003, p=0.031, p=0.036, and p=0.002, respectively). When receiver operating characteristic (ROC) curve analysis was performed for standard deviation values, the area under the curve (AUC) was 0.640, and when the threshold value was selected as 123.4821, the two groups could be differentiated with 62.8% sensitivity and 61.8% specificity. ROC analysis was also performed for the kurtosis value, yielding an AUC of 0.648, and when the threshold value was selected as 2.8561, the two groups could be differentiated with 61.8% sensitivity and 61.5% specificity.
In both groups, the lesions’ locations in the right-left lung or upper-middle-lower lobe did not significantly differ in histogram analysis (p>0.05).
Regardless of the location of the lesions, the mean value of the lesions was 377.49±161.03 Hounsfield units (HU) in women and 451.77±171.83 HU in men. When the lesions were examined according to their localization, the mean value was 392.37±164.42 HU for subpleural lesions, 426.17±163.27 HU for subpleural-parenchymal lesions, and 484.34±184.90 HU for parenchymal lesions.
The increasing severity of the pandemic and the serious increase in mortality necessitate the diagnosis of COVID-19 with high accuracy and speed. Although CT findings are typical along with clinical findings, a definite diagnosis of COVID-19 cannot be made from PCR alone as it does not confirm the diagnosis at the time of admission. Therefore, in our study, we hypothesized that we could obtain more data and reduce the contradictions in diagnosis by using a new method, histogram-based tissue analysis, in addition to CT findings in possible and definite COVID-19 cases. Based on our review of the literature, tissue analysis methods have not been used before among COVID-19 patients and our study is the first work in this context.
Chest CT can be used as a screening method to reveal lung findings in potential COVID-19 patients even if the PCR results are negative [12, 13]. In the meta-analysis conducted by Bao et al., examining 13 studies, ground-glass opacities (83.3%) were the most common CT findings of COVID-19. Following this, ground-glass opacities accompanied by consolidation (58.4%), thickening of the adjacent pleura (52.5%), interlobular septal thickening (48.5%), and air bronchograms (46.5%) could be seen. Other CT findings include crazy-paving patterns (14.8%), pleural effusion (5.9%), bronchiectasis (5.4%), pericardial effusion (4.6%), and lymphadenopathy (3.4%) . Although there were different CT findings in our cases, ground-glass density was the most common finding, similar to the literature.
Chen et al. evaluated 216 lesions in 33 patients and determined the distribution of peripheral localization for 85% of the lesions . In the study carried out by Song et al., it was found that 86% of the lesions were peripherally located and 90% of them had lower lobe involvement . In our study, similar to the literature, the distribution of lesions was mostly in the lower lobes and peripheral.
Three different basic methods, statistical, model-based, and transform-based, are used in texture analysis . Although statistical methods are the most common among these, texture analysis can also be performed with the histograms of the intensity values of pixels . In other words, histogram-based texture analysis enables quantitative data to be obtained by evaluating the differences in the background’s gray-level density. Miles et al. demonstrated how histogram parameters are associated with image analysis . The standard deviation tends to increase with heterogeneous distribution in the tissue. Contrarily, kurtosis tends to decrease with heterogeneity in tissue distribution. There was no significant difference in the number of pixels of the lesions included in both groups in our study. In contrast, the ground-glass areas’ gray-level density in the PCR-positive group was observed in a larger area. This led to differences in standard deviation and kurtosis values. On the other hand, this also shows the gray-level changes and the irregularity of the gray-level density in histograms by revealing the relationship of each pixel in terms of entropy and ROI with the neighboring pixels . Another parameter, skewness, shows asymmetry in histograms . The increase in the brightness of pixels shifts the tail of the histogram to the right, causing positive skewness. In our study, the gray-level density of the pixels did not show irregularity or asymmetry in either group. The difference between the size %L and size %M values indicated a difference in the distribution of values in PCR-positive patients.
The limitations of the present study are as follows: As a result of being a single-center study, the number of cases and variety of lesions were low. Also, lung areas with ROIs were not the same in the two groups because the lung area involved was not the same in every individual.
Although chest CT has an important place in diagnosing COVID-19, false-negative PCR results are observed for many patients. The use of histogram-based tissue analysis, which is a subdivision of artificial intelligence, for clinically highly suspicious patients further increases CT’s diagnostic accuracy, making chest CT superior to RT-PCR testing. Therefore, performing CT analysis with histograms will significantly aid healthcare professionals, especially in clinics where rapid decisions are required, such as in emergency services.
Scientiﬁc Responsibility Statement
The authors declare that they are responsible for the article’s scientiﬁc content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientiﬁc review of the contents and approval of the ﬁnal version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20744
Seda Nida Karaküçük, Murat Baykara, Kezban Tülay Yalçınkaya, Selçuk Nazik, Fatma Gümüşer, Kamil Doğan, Adil Doğan. Is histogram analysis useful in the diagnosis of COVID-19 patients?. Ann Clin Anal Med 2022;13(8):831-835
Ghrelin and nesfatin-1 levels and relationship with fertility hormones in obese women
Department of Biochemistry, Health Science Faculty, Cankiri Karatekin University, Cankiri, Turkey
DOI: 10.4328/ACAM.21062 Received: 2022-01-14 Accepted: 2022-05-31 Published Online: 2022-06-03 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):836-840
Corresponding Author: Emrah Caylak, Aksu Mahallesi, Saglık Bilimleri Fakultesi, Karatekin University, Cankiri, 18200, Turkey. E-mail: firstname.lastname@example.org P: +90 544 613 49 99 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0408-9690
Aim: This study aimed to evaluate calorie intake, fertility hormones, ghrelin, and nesfatin-1 levels during the menstrual cycle (MC) in fertile women, and to determine possible the independent relationship between obesity and food intake, and the serum levels of fertility and adipokine hormones.
Material and Methods: Thirty normal weight and 30 obese women, all having apparently normal fertility, were studied. Calorie intake and serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone (fertility hormones), and ghrelin, nesfatin-1 were measured during the follicular (FP), midcycle (MP), and luteal (LP) phases of the MC.
Results: Calorie intakes were significantly higher in obese women compared with controls. Obese women showed lower FSH, LH, estradiol, ghrelin, and nesfatin-1 levels compared with normal women, whereas progesterone levels were similar between the two groups. The levels of ghrelin and nesfatin-1 increased gradually during the menstrual cycle, peaking at MP and declining gradually thereafter. With Spearman’s correlation analyses in obese women, ghrelin showed a negative correlation with calorie intake and a positive correlation with FSH/LH/estradiol, whereas nesfatin-1 maintained a positive association with calorie intake and FSH and LH showed a negative correlation with LH/estradiol.
Discussion: It is not known, whether the fertility hormones in MC are associated with the appetite-regulating hormones, and whether these hormones differ between phases of the MC between obese or non-obese women.
Keywords: Obesity, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, ghrelin, nesfatin-1, menstrual cycle
Obesity is an important health problem among women of childbearing age worldwide and has many harmful effects on women’s reproductive health and system. Menstrual dysfunction, anovulation, and infertility are also common in overweight women. Obesity may change the hormonal balance in the pituitary, ovaries, and endometrium of the reproductive system. Obese women have been reported to have increased insulin, triglycerides, and very-low-density lipoprotein (LDL), FSH, LH, estradiol, progesterone levels and decreased high-density lipoprotein (HDL) levels. Due to these changes, the hypothalamus-pituitary gonadal (HPG) axis is disrupted and different gynecological effects occur. Although adipose tissue is necessary for reproductive and normal developmental functions, in obesity, excessive fat causes significant reproductive disorders . White adipose tissue is an important endocrine organ that regulates energy homeostasis and metabolism by secreting adipokines. Some of those are leptin, adiponectin, ghrelin, and nesfatin-1 . Recently, ghrelin and nesfatin-1 have attracted the interest of many researchers.
Ghrelin is a peptide hormone that was first identified as an endogenous ligand for the growth hormone (GH) secretagogue receptor. It is mostly synthesized by the stomach and expressed at low levels in the pituitary, hypothalamus, pancreas, small intestine, and ovary. Ghrelin was first discovered to stimulate the release of GH in the pituitary, and was later found to affect feeding behaviors and energy metabolism. In addition, a relationship with the HPG axis has been demonstrated, and it is thought to affect the secretion of gonadotropins. Plasma ghrelin levels decrease in humans when obesity and energy intake increase, and increase in fasting state and anorexia nervosa .
Nesfatin-1 was found firstly as a novel satiety anorexigenic factor in areas of eating behavior of the hypothalamus and was shown to induce satiety and inhibit food intake. It is mostly synthesized by the hypothalamus and expressed at low levels in the reproductive organs, adipose tissue, and gastrointestinal tract [2,4]. It is known that nesfatin-1 has a positive correlation with BMI in humans. In most studies to date, serum nesfatin-1 levels were found to be significantly lower in obese individuals [4,5] and higher in very few studies . Nesfatin-1 has been shown to be expressed in the pituitary gland, ovaries, and testicles in the reproductive system . Nesfatin-1 is thought to play a role in fertility, but little is known about its regulatory mechanisms in the reproductive system.
The menstrual cycle (MC) is characterized by monthly rhythmic changes in female hormone secretion and women have different physical and emotional symptoms (e. g. depression, irritability, binge eating, mass gain) . Fertility and adipose tissue hormones have a significant influence on dietary intake and appetite. Recently, an increase in total calorie and carbohydrate intake in women during the MC has been reported . Considering the high energy levels required for reproduction, it is thought that ghrelin and nesfatin-1 may have a role in reproductive physiology. Studies also suggest that ghrelin has important effects on the HPG axis in the release of hormones in the reproductive system. Ghrelin stimulates LH and prolactin release or inhibits the secretion of GnRH, testosterone, and progesterone, as well as induces Leydig cell proliferation and luteal function. On the other hand, nesfatin-1 decreases LH and FSH mRNA expression in the pituitary . It also affects circulating FSH, LH, and estradiol in a dose-dependent manner. Nesfatin-1 can increase and decrease circulating FSH and LH, respectively, when administered high-dose intracerebroventricular (ICV), and low-dose intraperitoneal (IP) [10,11]. In vitro, it increases ovarian progesterone secretion . Circulating estradiol levels are also reduced by IP administration of nesfatin-1 .
With a cross-sectional study, we have tested the hypothesis of a possible independent relationship between fertility and adipokine hormones in normal or overweighted women during MC. These relationships will inform us about the role of adipose tissue hormones in reproduction.
Material and Methods
Sixty healthy women who were admitted to the Clinic of Obstetrics and Gynecology at the Cankiri State Hospital were enrolled in the study. The study was approved by the Ethical Research Committee of the University of Zonguldak Karaelmas/Turkey (2011/07). All individuals were informed about the study and approved consent forms were obtained. Firstly, ages, height, weight, waist circumference widths parameters of the individuals were recorded, and their body mass index and BMI scores were calculated. Women were assigned to the obese group if their BMI were >30 kg/m2, and to the control (non-obese) group >20-24.9 kg/m2. The age range in those groups was 18 – 40 years, and their demographic features are presented in Table 1. Inclusion criteria were no pregnancy, age ≤18/≥45 years, no alcohol or smoke usage, no gynecological treatment with any drugs or contraceptives for the last 6 months, and no disease (such as adrenal hyperplasia, hyperprolactinemia, polycystic ovary disease, hypertension, diabetes mellitus, thyroid/heart disease, and cancers). Blood samples (5 mL) were obtained intravenously between 8 and 11 am after 12 hours of fasting. Ghrelin and nesfatin-1 are peptide hormones that can be broken down by serum proteases; therefore aprotinin (500 Kallikrein units/mL) was put into the blood tubes. The first sampling was done at the follicular phase (1st-3nddays). Subsequent samples were taken mid-cycle at (12th-16th days) and luteal phase (23th-27thday). Then they stored at –70 °C until further analysis of fertility and adipokine (ghrelin and nesfatin-1) hormones.
Normal fasting blood glucose (FBG) and serum insulin (FSI), triglycerides, HDL, LDL, and total cholesterol analysis were performed with Beckman Coulter DX800 auto analyzer (Beckman Coulter, Inc., CA, United States).
In the study, the participants recorded the foods and beverages consumed throughout the day to obtain the daily calorie, carbohydrate, protein, and lipid amounts of the individuals. They were also asked to record attributes such as diet name, amount consumed methods of preparation, and trademarks of existing products in recipes to provide accurate and detailed data. The National Food Composition Database TurKomp was used as the reference table, and DietitianPro® Software was used for calculations.
Serum levels of FSH, LH, estradiol, and progesterone were determined using human enzyme-linked immunosorbent assay (ELISA) kits (Architect, Abbott Laboratories, IL) according to the manufacturer’s instructions. The results were expressed as mIU/mL, pg/mL, and ng/mL, and the lower detection limits were 0.05 IU/L, 0.07 IU/L, 17.9 pg/mL, and 0.2 ng/mL, respectively.
Serum acylated-ghrelin and nesfatin-1 levels were analyzed using commercial human ELISA kits (Cat. No: A05106, SPI-BIO, France; Cat. No. EIA-NES-1, RayBiotech Inc., Georgia). The values were read at 410 nm and 450 nm using a microplate reader (BioTekMicroplate Instruments, USA) and were expressed as pg/ml and ng/ml, respectively (the lower limits 4 pg/mL and 0.1 ng/mL).
While evaluating the findings obtained in the study, the SPSS program (Statistical Package for Social Sciences 20.0, USA) was used for statistical analysis. The Mann-Whitney-U test and Spearman correlation analysis were used to compare differences between groups. The level of significance, p was 0.001 and all data in the tables were mean ± SD.
The demographic features of the individuals are given in Table 1. There were no differences in age and MC duration (days), but were significant differences in BMI and waist circumference between the two groups. As expected, obese women had higher BMI and waist circumference.
Daily calorie intakes, carbohydrate amounts and FBG, FSI, triglycerides, LDL, and total cholesterol were significantly higher and HDL lower in obese women compared to controls. The amount of protein and lipid intake were not significantly different between the groups (Table 2).
In this study, we have determined the changes in fertility hormones and ghrelin, nesfatin-1 levels during the MC. For all women, profiles at the follicular phase (FP), mid-cycle (MP) and luteal phase (LP) were investigated. All determined steroids had the expected trends of menstrual phases in all women. During the menstrual cycle, FSH, LH, and estradiol levels were found lower in obese women than in controls, whereas, progesterone levels were found similar between the two groups.
Table 2 shows the dynamics of ghrelin and nesfatin-1 levels at FP, MP, and LP in participants with obesity and controls. Obese women showed lower ghrelin and nesfatin-1 levels compared with normal women. Their levels increased gradually during the stimulation with LH and estradiol, peaking at MP, and declined gradually thereafter in all women (p<0.001). Spearman’s correlation analyses among variables were conducted for the obese women using ghrelin and nesfatin-1, which are presented in Table 3. When we have compared ghrelin levels and calories at the FP, MP and LP, we have found a significant negative correlation. Also, positive correlations were determined between ghrelin and FSH/LH/estradiol. There was a significant negative correlation between nesfatin-1 levels and calorie intake, positive correlation between nesfatin-1 and LH/estradiol, in the study. No correlations were found between ghrelin/nesfatin-1 and progesterone.
The hormonal changes during the MC have a significant influence on calorie intake and appetite. In normal-weight women, an increase in energy intake and output during the LP of the MC has been reported . In this study, an increase in total calorie and carbohydrate intake was determined in obese women. It was also found that those parameters increased in LP and FP compared to MP in obese women. Due to insufficient intake of micronutrients such as vitamin B6, calcium, magnesium, and potassium, high-energy diet consumption is thought to occur during these phases of menstruation in women . Hormones such as leptin, ghrelin, and nesfatin-1, which regulate energy homeostasis, may also affect this situation .
We found a statistically significant difference between the groups and MC stages in the levels of ghrelin and nesfatin-1, which are the adipokine hormones examined in this study. Serum ghrelin and nesfatin-1 levelswere decreased in MC in obese women and an inverse relationship with calorie intake was observed. Ghrelin has various functions in the regulation of food intake and energy metabolism, and excessive food intake has an appetite-reducing effect by compensating with ghrelin levels . Low levels of ghrelin have been found in obesity and our result is consistent with those [15,16]. It is known that nesfatin-1 levels increase during food intake, thus reducing food consumption and mass gain [2,6]. Studies on circulating nesfatin-1 levels in obese individuals are inconsistent. Abaci et al.  found significantly lower serum nesfatin-1 levels in obese children compared to the control group. Dokumacioglu et al.  showed that serum nesfatin-1 levels were lower in the obesity group compared to the control group. Anwar et al.  found in obese individuals that serum nesfatin-1 levels in the obese group were significantly higher than in the control group.
In this study, we followed changes in fertility and adipokine hormones during the MC. The hormone profiles of obese and non-obese women were compared during the MC at FP, MP and LP. During the MC, a decrease in the levels of FSH, LH, and estradiol and gradual increase in progesterone levels were found in all phases. Changes in ghrelin and nesfatin-1 during the MC were significant. Obese women showed lower ghrelin and nesfatin-1 levels compared with normal women. Their levels increased gradually during the stimulation with LH and estradiol, peaking at MP, and declined gradually thereafter in all women. There is a complex interaction between female reproductive physiology and adipokine hormones that affect the HPA axis . Although adipokines have significant effects on the reproductive system, few studies have evaluated the possible effects of adipokines during MC. Published data on changes in ghrelin levels during MC are inconsistent. Dafopoulos et al.  found no change, but Sramkova et al.  showed a tendency towards a decrease in ghrelin levels in MP. Dafopoulos et al.  reported a significant negative correlation between ghrelin and estradiol levels in FP. In addition, many studies have shown that estrogen plays a role in the regulation of ghrelin secretion. Ghrelin levels have been reported to increase with the use of estrogen-containing oral contraceptives . There are conflicting data in the literature regarding the effect of estrogen therapy on serum ghrelin levels. Di Carlo et al.  administrated exogenous estrogen to postmenopausal women and determined increased ghrelin levels in those. Nevertheless, Chu et al.  have shown significant reductions in ghrelin levels with estrogen treatment in postmenopausal women. In our study, it has been determined the positive correlations between ghrelin and FSH/LH/estradiol, especially in MP. No correlations were found between ghrelin and progesterone. Consistent with our findings, it has been reported that ghrelin stimulates LH and prolactin-releasing in the pituitary .
Animal studies have shown that estrogen/LH plays a role in the regulation of nesfatin-1 secretion. In an experimental study in mice, it was reported that estradiol and progesterone significantly increased/or decreased nesfatin-1 mRNA expression in cultured pituitary tissue, respectively . Similarly, Sun et al.  showed that nesfatin-1 mRNA expression in the ovariectomized mice oviduct was significantly reduced, but the injection of 17β-estradiol increased again its expression. On the other hand, administration of nesfatin-1 decreases the expression of LH and FSH mRNA in the pituitary and also affects circulating FSH and LH in a dose-dependent manner (high/low dose may increase/or decrease) [12,13]. Literature data on nesfatin-1 levels during MC are limited. Demir Caltekin et al.  showed that nesfatin-1 levels were lower in lean women in FP of MC, with a significant negative correlation between nesfatin-1 levels and BMI. However, Ademoglu et al.  found that obese women had higher levels of nesfatin-1 in FP of MC. In addition, in a study conducted in pubertal female rats, it was observed that the expression of nesfatin-1 and LH increased in parallel in the hypothalamus. In our study, we found significant positive correlations between nesfatin-1 levels and LH/estradiol levels. No relationship was found between nesfatin-1 and progesterone.
Our results revealed decreased levels of adipokines in obese women during the physiological menstrual cycle. Their levels increased gradually during the stimulation with LH and estradiol, peaking at MP, and declined gradually thereafter in all women. More research is needed to better understand the reasons for these changes in ghrelin and nesfatin-1 throughout the menstrual cycle . This would also help understand why adipokine levels were increased or decreased during the phases of MC in normal or obese women.
Scientiﬁc Responsibility Statement
The authors declare that they are responsible for the article’s scientiﬁc content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientiﬁc review of the contents and approval of the ﬁnal version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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6. Anwar GM, Yamamah G, Ibrahim A, El-Lebedy D, Farid TM, Mahmoud R. Nesfatin-1 in childhood and adolescent obesity and its association with food intake, body composition and insulin resistance. Regul Pept. 2014;188:21-4.
7. Schalla MA, Stengel A. The role of the gastric hormones ghrelin and nesfatin-1 in reproduction. Int J Mol Sci. 2021;22(20):11059.
8. Saeedian Kia A, Amani R, Cheraghian B. The Association between the risk of premenstrual syndrome and vitamin d, calcium, and magnesium status among university students: A case control study. Health Promot Perspect. 2015;5(3):225-30.
9. McNeil J, Doucet E. Possible factors for altered energy balance across the menstrual cycle: a closer look at the severity of PMS, reward driven behaviors and leptin variations. Eur J Obstet Gynecol Reprod Biol. 2012;163(1):5-10.
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11. Guvenc G, Altinbas B, Kasikci E, Ozyurt E, Bas A, Udum D, et al. Contingent role of phoenixin and nesfatin-1 on secretions of the male reproductive hormones. Andrologia. 2019;51(11):e13410.
12. Ciccimarra R, Bussolati S, Grasselli F, Grolli S, Paolucci M, Basini G. Potential physiological involvement of nesfatin-1 in regulating swine granulosa cell functions. Reprod Fertil Dev. 2020;32(3):274-83.
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14. Vani KR, Veena KS, Subitha L, Hemanth Kumar VR, Bupathy A. Menstrual abnormalities in school going girls – are they related to dietary and exercise pattern? J Clin Diagn Res. 2013;7(11):2537-40.
15. Takagi K, Legrand R, Asakawa A, Amitani H, François M, Tennoune N, et al. Anti-ghrelin immunoglobulins modulate ghrelin stability and its orexigenic effect in obese mice and humans. Nat Commun. 2013;4:2685.
16. Asadi A, Farahani H, Mahmoudi T, Tabaeian SP, Rezamand G, Mohammadbeigi A, et al. Circulating ghrelin levels and susceptibility to colorectal cancer. Arq Gastroenterol. 2021;58(3):316-21.
17. Dafopoulos K, Sourlas D, Kallitsaris A, Pournaras S, Messinis IE. Blood ghrelin, resistin, and adiponectin concentrations during the normal menstrual cycle. Fertil Steril. 2009;92(4):1389-94.
18. Sramkova M, Duakova M, Vitku J, Vcelak J, Matucha P, Bradnova O, et al. (2015) Levels of adipokines and some steroids during the menstrual cycle. Physiol Res. 2015;64:S147-54.
19. Dafopoulos K, Messini CI, Anifandis G, Georgoulias P, Sourlas D, Messinis IE. Blood ghrelin, adiponectin and resistin levels during controlled ovarian stimulation in IVF cycles. Physiol Res. 2016;65(5):809-14.
20. Di Carlo C, Tommaselli GA, Gargano V, Sammartino A, Bifulco G, Tauchmanova L, et al. Effects of estrogen-progestin therapy on serum levels of RANKL, osteoprotegerin, osteocalcin, leptin, and ghrelin in postmenopausal women. Menopause. 2007;14(1):38-44.
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24. Demir Caltekin M, Caniklioglu A, Eris Yalcin S, Aydogan Kirmizi D, Baser E, Yalvac ES. DLK1 and Nesfatin-1 levels and the relationship with metabolic parameters in polycystic ovary syndrome: Prospective, controlled study. Turk J Obstet Gynecol. 2021;18(2):124-30.
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Emrah Caylak. Ghrelin and nesfatin-1 levels and relationship with fertility hormones in obese women. Ann Clin Anal Med 2022;13(8):836-840
Serum AMH and 25 (OH) vitamin D levels in polycystic ovarian syndrome
Department of Obstetrics and Gynecology, Medicalpark Hospital, Samsun, Turkey
DOI: 10.4328/ACAM.21096 Received: 2022-02-02 Accepted: 2022-05-23 Published Online: 2022-06-27 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):841-844
Corresponding Author: Naziye Gurkan, Department of Obstetrics and Gynecology, Medicalpark Hospital, Samsun, Turkey. E-mail: email@example.com P: +90 505 790 79 49 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1088-018X
Aim: In this study, we aimed to investigate the possible relationship between serum 25(OH) vitamin D and AMH levels in patients diagnosed with polycystic ovarian syndrome.
Material and Methods: A total of 42 patients, including 21 patients diagnosed with PCOS and 21 control group patients who did not have clinical and laboratory findings of PCOS, were included. Women were diagnosed with PCOS based on the revised Rotterdam criteria. Patients in the control group were selected from patients with tubal, male factor, endometriosis, or unexplained infertility. All participants underwent venous blood sampling for the determination of AMH and 25-OH vitamin D levels. The primary outcome of the study was investigation of the relationship between 25(OH) vitamin D concentration and serum AMH levels.
Results: Serum LH, total testosterone, HOMA-IR, and fasting insulin levels in PCOS patients were significantly higher than in the control group. The mean age of the participants in both groups was similar (25.8±2.03 vs. 26.5±2.88, p<0.054). BMI values of PCOS patients were significantly higher than of those in the control group (28.02±5.11 kg/m2 vs 26.01±3.09 kg/m2, p<0.04). Serum AMH levels of PCOS patients (6.13±2.11 ng/mL) were significantly higher than in the control group (3.44±0.43 ng/mL, p<0.01). On the other hand, serum 25(OH)D levels of the patients in the PCOS (16.5±4.02 ng/mL) group were found to be significantly lower than in the control group (21.03±2.30 ng/mL, p<0.03). While serum AMH was positively correlated with total testosterone, it was negatively correlated with age in PCOS. Serum AMH levels were negatively correlated with BMI in PCOS. No significant correlation was observed between 25-OH Vitamin D and AMH levels in the PCOS group.
Discussion: While serum AMH levels of PCOS patients increased, 25 (OH) vitamin D levels decreased. AMH and vitamin D levels did not correlate.
Keywords: PCOS, AMH, 25 (OH) Vitamin D, BMI, HOMA-IR
Vitamin D, a steroid hormone, is produced from skin exposed to sunlight and then activated in the liver and kidneys. In addition to its conventional effects on calcium metabolism, the presence of vitamin D receptors in the ovaries, endometrium, placenta, hypothalamus, and pituitary suggests that this hormone also plays an important role in the female reproductive system . In line with this, vitamin D deficiency in animals reduces fertility rates and causes developmental delay in newborn babies . Impairment of follicle development in vitamin D receptor knockout mice  and the development of hypergonadotropic hypogonadism have suggested a link between vitamin D and oocyte developmental capacity. The increase in sex steroid synthesis after the addition of vitamin D to ovarian cell cultures in humans suggested that this vitamin may have a role in folliculogenesis .
Polycystic ovarian syndrome (PCOS) is a common endocrine and metabolic disorder with subfertility, and serum vitamin D levels are low in most cases . An association between serum vitamin D level and anovulation, hyperandrogenism, and insulin resistance has been reported in most patients with PCOS . Anti-mullerian hormone (AMH) is a growth factor produced by granulosa cells and regulates follicle development. It peaks in the early preantral and small antral follicles stage and decreases the FSH sensitivity of the follicles. Since there is little change in levels throughout the cycle and reflects the primordial follicle pool, serum AMH values have begun to be used as ovarian reserve markers in the last decade . The relationship of vitamin D with follicle development and the presence of a vitamin D-response element in the promoter region of the AMH gene indicate that these two molecules are related . For this purpose, many studies have been conducted comparing serum vitamin D levels and AAMH values in PCOS patients. However, the study results showed discordant results unlike experimental models and cell culture studies. Some studies reported a positive relationship between AMH and vitamin D, while others suggested a reverse relationship or no relationship at all . This study was planned to investigate the possible relationship between serum vitamin D and AMH levels in patients diagnosed with PCOS.
Material and Methods
A total of 42 patients, including 21 patients diagnosed with PCOS and 21 control group patients who did not have clinical and laboratory findings of PCOS. Women were diagnosed with PCOS based on the revised Rotterdam criteria, which require two of the following three manifestations: (1) oligo and/or anovulation, (2) clinical and/or biochemical hyperandrogenism, and (3) polycystic ovaries determined by ultrasonography. Patients in the control group had to meet none of the Rotterdam criteria to be included in the study. Patients in the control group were selected from patients with tubal, male factor, endometriosis, or unexplained infertility. Women who had undergone surgical procedures that would affect ovarian reserve, those with a history of chemoradiotherapy, those with endocrine disease including diabetes, and those who received vitamin D supplementation were not included in the study. The study was performed according to the guidelines of the Helsinki Declaration on human experimentation. Patient consent and local ethics committee approval were obtained.
Demographic parameters such as age and body mass index of the patients were recorded. Venous blood samples were obtained after an overnight fasting between the 3rd and 5th days of the natural menstrual cycle for control patients or progestin withdrawal bleeding for PCOS patients. Serum follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and insulin were measured with chemiluminescent enzyme immunoassay. Total testosterone, and dehydroepiandrosterone sulfate (DHEA-S) were measured via the radioimmunoassay method. Insulin resistance was evaluated by calculating a homeostatic model assessment of insulin resistance (HOMA-IR = fasting blood glucose (mg/dL) x fasting insulin (mIU/L)/405). Total plasma 25-OH vitamin D was measured with chemiluminescent enzyme immunoassay and results were given in ng/mL. Serum AMH levels were measured with Gen II Beckman Coulter AMH ELISA kit according to the manufacturer’s instructions. The primary outcome of the study was to investigate the relationship between 25(OH) vitamin D concentration and serum AMH levels.
Analyses of data were performed on SPSS 21 (SPSS Inc., Chicago, IL, USA). To check for normality, the Shapiro-Wilk test was used. Normally distributed variables were analyzed with the independent samples t-test. Non-normally distributed variables were analyzed with the Mann-Whitney U test. Spearman’s correlation coefficients were calculated to evaluate relationships between continuous variables. Data are presented as mean±SD. Differences were considered statistically significant if the p-value <0.05.
Demographic, laboratory characteristics of PCOS and control groups are shown in Table 1. Serum LH, total testosterone, HOMA-IR, and fasting insulin levels of PCOS patients were significantly higher than in the control group. The mean age of the participants in both groups was similar (25.8±2.03 vs. 26.5±2.88, p<0.054). BMI values of PCOS patients were significantly higher than those in the control group (28.02±5.11 kg/m2 vs 26.01±3.09 kg/m2, p<0.04). Serum AMH levels of PCOS patients (6.13±2.11 ng/mL) were significantly higher than in the control group (3.44±0.43 ng/mL, p<0.01). On the other hand, serum 25(OH)D levels of the patients in the PCOS (16.5±4.02 ng/mL) group were found to be significantly lower than in the control group (21.03±2.30 ng/mL, p<0.03).
While serum AMH was positively correlated with total testosterone, it was negatively correlated with age in PCOS. Any correlation was not detected between AHM, HOMA-IR and insulin levels. No significant correlation was observed between 25-OH Vitamin D and AMH levels in the PCOS group. Serum AMH levels were negatively correlated with BMI in the PCOS. As BMI values increased, AMH values decreased significantly. Any correlation was not detected between BMI and 25 (OH) vitamin D levels in PCOS. Negative and significant correlation between AMH and age was noted in the control group.
No significant correlation was found between serum AMH, vitamin D, BMI, other demographic, hormonal, and dyslipidemia
parameters in the control group. Correlation characteristics of PCOS group are shown in Table 2.
The main findings of our study can be listed as follows. Serum AMH levels of PCOS patients were significantly higher than in the control group. This finding is consistent with literature data. Almost all of the studies investigating AMH values in PCOS patients reported that this glycoprotein molecule increased significantly. The fact that AMH was found to be high in PCOS, and this increase was independent of the cycle brought up the suggestion that this molecule should be included in the PCOS diagnostic criteria. However, high AMH does not always indicate the true value of the primordial follicle pool. Elevated AMH is evidence that follicles are arrested at a certain stage rather than ovarian reserve . AMH better represents the response to ovarian stimulation rather than the primordial follicle pool.
As ovarian aging increases with advancing female age, AMH values decrease. We found decreased AMH values in PCOS patients, which correlated with increasing age. The decrease in AMH was not specific to the PCOS group, and AMH values also decreased with age in the patients in the control group. We could not detect a correlation between AMH and 25 (OH) vitamin D levels. In accordance with our findings, serum vitamin D levels in PCOS patients have been reported to be decreased in many studies [4,9]. Vitamin D reduction may cause some clinical manifestations of PCOS. PCOS findings such as anovulation, hyperandrogenism, and insulin resistance are more common in vitamin D deficiency . AMH values may be normalized as these findings are improved in patients who are given vitamin D therapy. A recent meta-analysis reported a decrease in AMH values after vitamin D administration to anovulatory PCOS patients . However, vit D did not have the same effect in ovulatory patients. For this reason, in order to talk about a relationship between AMH and vitamin D in PCOS patients, it is necessary to divide the patients into groups as ovulatory or anovulatory. In addition to studies showing a positive correlation between Vitamin D and AMH values, there are also studies showing a negative correlation . We could not find a significant relationship between AMH and vitamin D levels. While our findings are compatible with some studies, they are inconsistent with others. Since we did not divide our patients into sub-groups according to their ovulatory status, it is not possible to make a clear comment on this issue. On the other hand, grouping patients according to their vitamin D levels and comparing them with AMH could provide more precise data. No correlation was found between AMH and vitamin D in studies that classified patients in the PCOS and control groups with vitamin D levels as deficient or normal . We found a negative and significant correlation between AMH and BMI. There are studies in the literature reporting negative or positive correlations between BMI and AMH. Decreased AMH with increasing BMI may occur due to hemodilution in obese PCOS patients [11-13]. However, we did not divide the patients into groups according to their BMI values. A negative correlation may occur between AMH and BMI, depending on the changes in adipose tissue adiponectin and leptin levels in thin PCOS patients. In order to make a clear comment on this issue, it is necessary to divide patients into groups according to their BMI values and examine their relationship with AMH [14,15]
Our study has some limitations. The small number of patients in the PCOS and control group is an important limitation. Another limitation is that we did not divide patients into subgroups according to their BMI and vitamin D levels. It is also a handicap that vitamin D measurements are not made together with the binding protein. Despite all these limitations, our results are important in terms of comparing the relationship between AMH and 25(OH) vitamin D levels in PCOS patients with demographic and hormonal parameters. It will be possible to reach clearer results with studies that group PCOS patients according to BMI and 25(OH) vitamin D levels and compare AMH values.
Scientiﬁc Responsibility Statement
The authors declare that they are responsible for the article’s scientiﬁc content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientiﬁc review of the contents and approval of the ﬁnal version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
1. Albu D, Albu A. The relationship between anti-müllerian hormone serum level and body mass index in a large cohort of infertile patients. Endocrine. 2019;63(1):157-163.
2. Merhi Z, Buyuk E, Berger DS. Leptin suppresses anti-mullerian hormone gene expression through the JAK2/STAT3 pathway in luteinized granulosa cells of women undergoing IVF. Hum Reprod. 2013;28(6):1661-9.
3. Fauser BC, Tarlatzis BC, Rebar RW. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97(1):28-38.e25.
4. Merhi Z, Doswell A, Krebs K, Cipolla M. Vitamin D alters genes involved in follicular development and steroidogenesis in human cumulus granulosa cells. J Clin Endocrinol Metab. 2014;99(6):E1137-45.
5. Wehr E, Trummer O, Giuliani A, Gruber HJ, Pieber TR, Obermayer-Pietsch B. Vitamin D-associated polymorphisms are related to insulin resistance and vitamin D deficiency in polycystic ovary syndrome. Eur J Endocrinol. 2011;164(5):741-9.
6. He C, Lin Z, Robb SW, Ezeamama AE. Serum Vitamin D Levels and Polycystic Ovary syndrome: A Systematic Review and Meta-Analysis. Nutrients. 2015 8;7(6):4555-77.
7. Tal R, Seifer DB. Ovarian reserve testing: a user’s guide. Am J Obstet Gynecol. 2017;217(2):129-40.
8. Ruiz-Ojeda FJ, Anguita-Ruiz A, Leis R, Aguilera CM. Genetic Factors and Molecular Mechanisms of Vitamin D and Obesity Relationship. Ann Nutr Metab. 2018;73(2):89-99.
9. Moridi I, Chen A, Tal O, Tal R. The Association between Vitamin D and Anti-Müllerian Hormone: A Systematic Review and Meta-Analysis. Nutrients. 2020;12(6):1567-71.
10. Purdue-Smithe AC, Whitcomb BW, Manson JE, Hankinson SE, Troy LM, Rosner BA, et al. Vitamin D Status Is Not Associated with Risk of Early Menopause. J Nutr. 2018;148(9):1445-52.
11. Lambert-Messerlian G, Plante B, Eklund EE, Raker C, Moore RG. Levels of antimüllerian hormone in serum during the normal menstrual cycle. Fertil Steril. 2016;105(1):208-13.e1.
12. Senturk S, Celik O, Dalkilic S, Hatirnaz S, Celik N, Unlu C, et al. Laparoscopic Ovarian Drilling Improves Endometrial Homeobox Gene Expression in PCOS. Reprod Sci. 2020;27(2):675-80.
13. Celik O, Aydin S, Celik N, Yilmaz M. Peptides: Basic determinants of reproductive functions. Peptides. 2015;72:34-43.
14. Pearce K, Gleeson K, Tremellen K. Serum anti-Mullerian hormone production is not correlated with seasonal fluctuations of vitamin D status in ovulatory or PCOS women. Hum Reprod. 2015;30(9):2171-7.
15. Marques-Pamies M, López-Molina M, Pellitero S, Santillan CS, Martínez E, Moreno P, et al. Differential Behavior of 25(OH)D and f25(OH)D3 in Patients with Morbid Obesity After Bariatric Surgery. Obes Surg. 2021;31(9):3990-5.
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Naziye Gurkan. Serum AMH and 25 (OH) vitamin D levels in polycystic ovarian syndrome. Ann Clin Anal Med 2022;13(8):841-844
C-erb-b2 expression in luminal b breast cancer has higher axillary lymph node involvement ratio
Gürkan Değirmencioğlu 1, Mehmet Tolga Kafadar 2, Mehmet Kılıç 3
1 Kırıkhan State Hospital Clinic of General Surgery, Hatay 2 Department of General Surgery, School of Medicine, Dicle University, Diyarbakir 3 Department of General Surgery, School of Medicine, Osmangazi University, Eskisehir, Turkey
DOI: 10.4328/ACAM.21121 Received: 2022-02-20 Accepted: 2022-03-23 Published Online: 2022-04-06 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):845-849
Corresponding Author: Mehmet Tolga Kafadar, Department of General Surgery, School of Medicine, Dicle University, 21280, Diyarbakir, Turkey. E-mail: firstname.lastname@example.org P: +90 412 248 80 01 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9178-7843
Aim: In this study, the effect of c-erb-B-2 (HER-2/neu) expression on axillary lymph node involvement in Luminal- B breast cancer was examined.
Material and Methods: One hundred seven female patients were included in this study who were classified as Stage 1, Stage 2 and Stage 3 pathologically, with positive Estrogen (ER) and Progesterone Receptor (PR) and with the diagnosis of invasive ductal carcinoma with a single focal mass and not a synchronous tumour and received surgical therapy. The lymph node involvement ratio (LNIR) was divided into two groups as over and below 25%. These acquired data were compared with the groups with positive and negative c-erbB-2 gene expression, axillary LNI status, and LNIR separately.
Results: The data of 107 female patients aged between 27 and 87 years were evaluated in this study. The mean age of the patients was 55.69±12.68 years. LNIR was found to be less than 25% in 76.6% (n: 82) of the patients, and over 25% in 23.4% (n: 25) of the patients. The c-erbB-2 positivity was significantly different in the axilla with and without metastatic lymphadenopathy (p =0.026). There was no statistically significant relationship between tumour diameter and metastatic lymphadenopathy. Although axillary metastatic lymphadenopathy positivity was found to be significant in patients with lymphovascular invasion (p<0.001), it was also found to be significant, as in the group with LNIR>25 (p<0.001).
Discussion: This study demonstrated that high expression of c-erbB-2 is associated with poor prognosis of breast cancer by increasing axillary LNI. In hormone (Estrogen and Progesterone) positive patients, if c-erB-2 is also positive, there is greater number of axillary LNI.
Keywords: Breast Cancer, Axillary Lymph Node, Involvement
Breast cancer is the most common cancer among women in Turkey and in the world, and ranks second in cancer deaths after lung cancer. It is considered that one out of eight women will develop invasive breast cancer during their lifetime. This rate is higher in patients with a family history and those with breast cancer-related gene mutations . Breast carcinomas are tumours of different groups with diverse characteristics in terms of histopathological features, hormone receptor levels, clinical and treatment response. The lymph node involvement ratio (LNIR), which indicates the ratio of positive lymph nodes to the total lymph nodes removed, is suggested as an alternative prognostic factor because it offers a more accurate prognostic grouping opportunity and is less influenced by dissection width. C-erbB-2 (HER-2/neu) oncogene is in the form of a single copy in non-pathological cells and is located on chromosome 17. When overexpressed in breast cancer, c-erbB-2 enhances invasion and metastasis, strengthening growth and proliferation . In this study, we aimed to investigate the effect of the increase of c-erbB-2 expression on axillary lymph node involvement and to determine the factors causing axillary involvement, which has the greatest impact on prognosis in patients with invasive ductal carcinoma.
Material and Methods
This study was performed on patients who were admitted to our clinic with the diagnosis of breast cancer and underwent surgical treatment. Of the 309 female breast cancer patients operated between June 2012 and January 2016, 107 patients who met the criteria were included in the study. Among these patients, only Stage 1, Stage 2 and Stage 3 female patients with pathological diagnosis of invasive ductal carcinoma with a single focal mass and not a synchronous tumor, and with positive Estrogen Receptor (ER) and Progesterone Receptor (PR) were included. Information about the patient’s clinical stage and distant metastasis was obtained from the patient files and data processing system in the General Surgery Polyclinic of our hospital, and patients who received neoadjuvant treatment before surgery were not included in the study. From the patient files, ages of patients, histological type, diameter, hormone receptor status, c-erbB-2 expression status (according to immunohistochemical scoring), lymphovascular invasion status of the tumour, localization, axillary lymph node involvement, histological grade of the tumor were determined from the pathology reports.
The cases in the file records were divided into 3 groups according to the tumor size as 2 cm and under, 2 to 5 cm and 5 cm and above reached as a result of pathological examination. Tumor location was divided into 5 quadrants as upper outer quadrant, upper inner quadrant, lower outer quadrant, lower inner quadrant and retroareolar. The cases were divided into two groups as those with and without lymphovascular invasion. c-erbB-2 was divided into 2 groups as negative with score-0, score-1 if no membranous staining is observed in invasive tumour cells or incomplete, indistinct membrane staining is present in cells of 10% or less and positive with values above (score-2, score-3) according to the immunohistochemical (IHC) examination. Two groups were created as the dependent variable; groups with axillary lymph node metastasis and above were identified as positive and those without any metastasis were identified as negative. Tumors staining only -3 positives in IHC were accepted as HER-2 positive. In addition, LNIR, which is frequently used recently and also in the prognosis evaluation with more precision, was divided into two groups as over and below 25%. We used LNIR because of more sensitive prognostic grouping and less effect on dissection width. For LNRI, the purpose of grouping as 25% below and above is to apply the findings according to the percentile values where the cases are partially homogeneously distributed to the groups and transferring the findings to be only 25% below and above for ease of expression since both grouping methods are statistically the same results. Sentinal lymph node sampling was performed in all patients. Patients who were negative as a result of sentinal sampling were included in the group with LNIR less than 25%. Axillary lymph node dissection in patients who were positive for sentinel sampling was completed and LNIR calculation was made according to the pathology result. LNIR is the lymph node involvement rate that expresses the ratio of positive lymph nodes to the total lymph nodes removed.
[LNIR = (positive lymphadenopathy / total number of lymph nodes removed) x 100]
All these acquired data were compared with the groups with positive and negative c-erbB-2 gene expression, axillary lymph node involvement status and LNIR separately. In addition, histological grade, lymphovascular invasion, tumor diameter data, axillary lymph node involvement status and LNIR were compared separately. Immunohistochemical (immunoperoxidase-code: A0485, C-erbB-2 oncoprotein, kid: DAKO LSAB (R) 2 kit-KO675) analysis was performed as a pathological method for c-erbB-2. Values of 50% and above were considered positive in terms of c-erbB-2. Accordingly, those with a fluorescence detection rate of 50% or more were considered c-erbB-2 positive and used within the luminal group classification. Cases in our study consisted of the Luminal B group (Luminal B is considered as ER and/or PR positive, c-erb-B2 negative or positive and Ki-67 proliferation index high patients).
Compliance of quantitative data with normal distribution of the numerical variables were evaluated using the Shapiro-Wilk test, normality test and QQ graphs, and parametric methods were used in the analysis of variables with normal distribution, non-parametric methods were used in the analysis of variables which did not have a normal distribution. Pearson Chi-Square and Fisher’s Exact tests were used to compare categorical data. Quantitative data were expressed as average ± std values in the tables, and categorical data were expressed as n and percentages. Data were analyzed at 95% confidence level and p-values greater than 0.05 were considered insignificant and p-values less than 0.05 were considered significant. p <0.05 was considered statistically significant.
The study was in line with the principles set out in the Declaration of Helsinki. All patients signed informed consent for their data to be used for research purposes after a clear and complete explanation and consent was recorded in the patients’ medical records. The Institutional Review Board of Yıldırım Beyazıt University, Ankara, Turkey approved this study (No: 06.09.2017-161).
In this study, the data of 107 female patients aged between 27 and 87 years were evaluated. The mean age of the patients was 55.69±12.68 years. Fifty-nine (55.1%) tumours were located on the left and 48 (44.9%) were located on the right breast. Fifty-one (47.6%) tumours were in the upper outer quadrant, 16 (15%) in the lower outer quadrant, 17 (15.9%) in the upper inner quadrant, 14 (13%) in the lower inner quadrant, 9 (8.5%) were located in the retroareolar area; 68.2% (n:73) of the patients underwent Modified Radical Mastectomy (MRM) operation, 29.9% (n:32) had Sentinel Lymph Node (SLN) operation together with simple mastectomy or segmental mastectomy, 1.9% (n:2) had axillary dissection with segmental mastectomy. It was detected that in 25.2% (n:27) of patients the tumor size was less than 2 cm, in 58.9% (n:63), the tumor size was between 2-5 cm, and in 15.9% (n:17), the tumor size was over 5 cm. Grade 1 tumor was detected in 18.7% (n:20) of the patients, Grade 2 tumour in 59.8% (n:64) and Grade 3 tumour in 21.5% (n:23) of the patients. When those with score-0 and score-1 in immunohistochemical staining were grouped as negative and those with other scores were grouped as positive, 51.4% (n:55) of the patients were determined as c-erB-2 negative and 48.6% (n:52) were c-erB-2 positive.
According to the pathological TNM staging classification of breast cancer, 13.1% (n:14) of them were found to be Stage-1, 30.8% (n:33) of them Stage-2a, 27.1% (n:29) of them stage-2b, 15% (n:16) of them Stage-3a and 14% (n:15) of them were found to be Stage-3c. While metastatic lymphadenopathy was not detected in the axilla in 36.4% (n:39), metastatic lymphadenopathy was found in 63.6% (n:68) of the patient. LNIR was found to be less than 25% in 76.6% (n:82) of the patients, and over 25% in 23.4% (n:25) of the patients (Table 1). The c-erbB-2 positivity was significantly different in the axilla with and without metastatic lymphadenopathy (p = 0.026) (Table 2).
In the statistical study on whether tumour diameter has an effect on axillary lymph node involvement; the group with LNIR> 25 was found to be higher statistically among patients with tumor diameter of more than 5 cm in pathological measurements (p=0.008), no statistical relation between tumor diameter and metastatic lymphadenopathy was observed.
In the analysis of the effect of lymphovascular invasion on axillary lymph node involvement; although axillary metastatic lymphadenopathy positivity was found to be significant in patients with lymphovascular invasion (p <0.001), it was also found to be significant as in the group with LNIR> 25 (p <0.001) (Table 3). There was no statistically significant correlation between LNIR and c-erbB-2 positivity (p = 0.193) (Table 2).
Various prognostic factors are used to determine the current clinical features and future high-risk group in breast cancer. The most important factor among these is whether the axillary lymph nodes contain metastases, and if so, the number of lymph nodes involved. Tumor diameter, histological grade, histological tumor type, presence of hormone receptor (ER, PR), rate of tumor proliferation (number of mitosis, S-phase reaction Ki-67 proliferation index) and molecular prognostic factors (c-erb-B2, onco-suppressor genes) are other prognostic factors. LNIR, which is suggested as an alternative prognostic factor, can be considered as a prognostic factor [3-6].
In recent years, the increase in recurrence rates, especially among women with negative axillary, has led researchers interested in breast cancer to study new markers, which are also called secondary prognostic factors. This new classification, called the molecular subgroup, was first proposed in 2000 by Perou et al.  in a comprehensive study showing differences in gene expression. Currently, breast cancers are initially classified into five groups as luminal A, luminal B c-erb-B2 (-) and c-erb-B2 (+), non-luminal c-erb-B2 (+), triple negative and Null type according to the applicable molecular classification. The subtypes, which are called luminal, are classified according to ER and PR presence, c-erb-B2 amplification and overexpression Ki 67 proliferation index. Luminal A is considered ER and/or PR positive, c-erb-B2 negative Ki-67 proliferation index low (<15%); Luminal B c-erb-B2 (-) is considered ER and/or PR positive, c-erb-B2 negative Ki-67 proliferation index high (> 15%); Luminal B cerb-B2 (+) is considered ER and/or PR positive Ki-67 proliferation index low and/or high, cerb-B2 positive; non Luminal c-erb-B2 (+) is considered ER and PR are considered negative, c-erb-B2 positive, and Triple negative is considered ER, PR and c-erb-B2 negative. Morphological and molecular studies have shown that these subtypes with different hormonal profiles respond differently to treatment modalities and they are different in prognosis . In a study by Voduc et al.  on 2985 patients with breast cancer, it was revealed that Luminal B group patients showed a poorer prognosis than Luminal A group. However, in the study by Chengshuai et al.  in 814 patients, axillary lymphadenopathy involvement was high in the Luminal-b c-erb-B2 + patient group. Our study is investigated whether c-erbB-2 can be used as a biological indicator showing axillary lymph node involvement in advance or enabling us to make a prediction.
C-erbB-2 (HER-2/neu) is a member of the epidermal growth factor receptor (EGFR) family. It is located on chromosome 17q and acts as a tyrosine kinase receptor protein. C-erbB-2 receptor positivity is seen in approximately 25-30% of invasive cancers. It was found in 50-60% of cases of ductal carcinoma in situ (DCIS). HER-2 positivity was found in 48.6% of the patients with invasive ductal cancer included in our study. There is no clear consensus on the effect of c-erbB-2 on lymph node involvement . In a retrospective study by Tong et al.  on 316 women in 2017, it was detected that increased c-erbB-2 expression increased axillary lymph node involvement. In contrast, it was detected that 18.2% of the cases with SLN positive were HER-2 positive and 81.8% of them were HER-2 negative in the research by Nathanson et al.  on 1063 patients. In this study, it was detected that HER-2 positivity had a negative effect on axillary lymph node involvement. In our study, c-erbB-2 positivity was found to be significantly different in groups with and without metastatic lymphadenopathy in the axilla. Axillary lymph node involvement was found in 75% of the patients with c-erbB-2 positivity. No relationship between c-erbB-2 and LNIR was detected in the study by Akdur et al.  on 150 patients, which is one of the rare studies on the LNIR and c-erbB-2 relationship in the literature. In our study, no statistically significant relationship was found between c-erbB-2 positivity and LNIR.
Lymphovascular invasion is roughly referred to as invasion of tumour tissue and surrounding lymphatic and vascular structures. Lymphovascular invasion is observed in one third of breast cancer patients. The presence of lymphovascular invasion is a negative prognostic factor for locoregional recurrence [15,16]. It was found that peritumoral lymphovascular invasion is an independent risk factor for local recurrence and death in the cohort study of 1704 patients who did not receive any systemic adjuvant therapy . However, it was revealed in the multicentre study by Ejlertsen B et al., published in 2009  on 15.659 patients that when lymphovascular invasion accompanies other poor prognostic factors of breast cancer (tumor size, grade, lymph node involvement, ductal histology, hormone receptor positivity), it acts negatively on the prognosis of the patient but it does not have an effect on the prognosis of the patient by itself. In other words, the presence of lymphovascular invasion alone does not include low-stage breast cancer in the high-stage group. In a study by Ragage F et al. on 374 patients , lymphovascular invasion was found to increase axillary lymph node involvement. However, multivariate models were evaluated in this study and no comparison was made with other factors affecting prognosis. It was shown in the research by He KW et al.  on 255 patients that the presence of lymphovascular invasion increases axillary lymph node involvement when considered with other prognostic factors. In the study by Akdur et al. , it was found that LNIR tended to be higher in cases with lymphovascular invasion. In our study, a significant difference was found between axillary lymph node involvement in patients with lymphovascular invasion and axillary lymph node involvement in patients without lymphovascular invasion. Axillary involvement was not observed in 79.4% of patients without lymphovascular invasion, whereas it was observed in 60.3% of patients with lymphovascular invasion. This result showed that lymphovascular invasion increases lymph node involvement.
This study demonstrated that high expression of c-erbB-2 is associated with axillary lymph node involvement and thus it is a poor prognosis of breast cancer. We thought that c-erbB-2 may be a potential biologic marker for breast cancer prognosis and axillary lymph node involvement and may provide insight for c-erbB-2 expression and axillary involvement at the time of diagnosis for breast cancer in the future. In addition, in the current approach, there are studies suggesting that neoadjuvant systemic treatment can be given primarily in early-stage cancers and patients with axillary lymph node involvement. In this context, since the possibility of axillary lymph node involvement increases in c-erbB-2 positive patients, this should be taken into consideration during the treatment plan.
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Download attachments: 10.4328:ACAM.21121
Gürkan Değirmencioğlu, Mehmet Tolga Kafadar, Mehmet Kılıç. C-erb-B2 expression in luminal B breast cancer has higher axillary lymph node involvement ratio. Ann Clin Anal Med 2022;13(8):845-849
Cystic artery anatomies in laparoscopic cholecystectomy and literature review
Zeliha Turkyilmaz 1, Zeki Hoşcoşkun 1, Oğuz Taşkınalp 2
1 Department of General Surgery, Faculty of Medicine, Trakya University, 2 Department of Anatomy, Faculty of Medicine, Trakya University, Edirne, Turkey
DOI: 10.4328/ACAM.21133 Received: 2022-03-13 Accepted: 2022-05-26 Published Online: 2022-06-18 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):850-853
Corresponding Author: Zeliha Turkyilmaz, Department of General Surgery, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey. E-mail: email@example.com P: +90 532 708 29 44 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0012-2089
Aim: In laparoscopic surgery, knowing the anatomic variations helps to be ready for any possibilities. In this study, it was aimed to evaluate the cystic artery (CA) variations and frequency in patients who underwent laparoscopic cholecystectomy (LC).
Material and Methods: The study was carried out by reviewing retrospectively the reports and movies of 100 LC. The positions of the cystic artery and cystic duct relative to Calot’s triangle (CT) were determined and the frequency of variation was reviewed.
Results: In 82% of our cases, the cystic artery was monitored as a single branch in the CT, whereas two CA were clipped in 12% of cases. In 3 cases in this study, CA went through the caudal of and parallel with the cystic duct, and entered the gall bladder. In one case, the cystic duct passed through the curve formed by the CA. This pattern was named “spiral cystic artery”.
Discussion: The anatomy of the components, which make up a CT has so many diversifications that understanding these variations acts as a key role during LC.
Keywords: Laparoscopy, Cholecystectomy, Arteries
LC is the most common operation of the digestive system, as well as the most common laparoscopic procedure [1,2]. Bleeding complications during LC are the most important non-biliary complications (other than anesthesia) and the most common cause of mortality . Arterial injuries during LC cause approximately 1.9% of cases to convert to open surgery . The inability to perceive the anatomy correctly is an important factor both in the formation of bleeding during dissection and in conversion to open surgery [3,5].
CT is the area between the lower surface of the liver, the cystic duct and the common hepatic duct. During LC, the CA is usually detected and ligated within this triangle . For a reliable LC, it is very important to know the possible variations of this region. When the literature was reviewed, it was noticed that there are few studies on cystic artery variations in LC. In our study, we aimed to define how the CA and CT relationship and how the variations look during LC.
Material and Methods
The study was carried out by reviewing retrospectively the reports and movies of 100 LC operations carried out in the General Surgery Clinic of the Faculty of Medicine at Trakya University. All the operations were carried out by the same surgeon. The patients were positioned slightly deviated to the left and their heads raised approximately 30 degrees. A 0- degree camera was used in the operations.
The study is a retrospective study and Ethics Committee Decision was not required for retrospective studies at the time of the study in our university. Informed consent was obtained from each patient before the operations.
In 82% of the cases, the CA in the CT went through the craniomedial of the cystic duct, and was distributed to the neck or body of the gall bladder. In these cases, the superficial and deep branches of the artery branched from a point close to the gall bladder serosa, and the artery was clamped from a single location in operation. In these cases, when the gall bladder was pulled from its fundus, the distance between the cystic duct and CA widened, and they seemed parallel with each other up to the gall bladder. The CA gave a number of tiny branches into the cystic duct during its course. Since two arteries were seen on the cranial side of the cystic duct in 12 (12%) of our cases, they were clipped separately. While the superficial one was close to the cystic duct, the other was close to the liver.
In one of the two cases with right hepatic artery within the CT, right hepatic artery was found so close to the gall bladder serosa that might nearly be called attached. In this case, when the cystic duct was identified, the first visible structure parallel to it gave the impression of a CA (Figure 1). However, due to the very close location of the vessel, the dissection was proceeded with extreme careб and it was understood that this vessel was not the CA, but the right hepatic artery.
In one of our cases, the CA entered into the CT, but did not show a usual course, passed through the medial side of the cystic duct, passed to the back face of the cystic duct, and made a curve at the caudo-lateral side of the cystic duct. Then the CA passed to the front of the cystic duct and entered the gall bladder. In other words, the cystic duct went through the curve formation that was made by CA. This formation was called the ‘’spiral cystic artery’’ (Figure 2).
In three of our cases (3%), the CA did not seem within the CT. The CA went by the caudal of the cystic duct in parallel with this and entered into the gall bladder at the posteroinferior side of the neck portion of the gall bladder (Figure 3). In these cases, CA was the first formation encountered during the Calot dissection in LC. In the LC, the CA is visible in front of the cystic duct. Therefore, it would be appropriate to call it the “anterior course cystic artery”.
LC has superiorities over open cholecystectomy such as postoperative minimal pain, decreased length of hospital stay, going back to work earlier, and aesthetic results . Even though bile duct injury is one of the most important causes of serious morbidity among LC complications, perioperative bleeding is a complication that cannot be underestimated in terms of its results. Bleeding complications constitute approximately one-third of all major complications in LC. Bleeding remains a frequent reason for conversion to open procedure [2,4,7]. In the study by Sakpal et al, conversion rates due to bleeding constituted 6.4% of all conversion cases . In some studies, the conversion rate from LC to open cholecystectomy has been reported between 2.6% and 8.9% [2,4,9-11]. Uncertain anatomy after adhesions in CT is reported to be the most common cause of conversion with a frequency of 41-42% [9,11].
About 80% of cystic arteries originate from the right hepatic artery. On the other hand, the origins of CA may be the proper hepatic artery, the left hepatic artery, the common hepatic artery, the gastroduodenal artery, celiac artery, and even middle hepatic artery [6,12]. The incidence of a single cystic artery within the CT has been reported with a frequency of 71-76% in various studies. It divides into two branches, one of which is superficial that supplies the ventral side of the gall bladder, and the other is deep that supplies the bed portion between the gall bladder and liver. CA generally branches at the border of the neck or corpus of the gall bladder [3,13-16]. Balija et al. in their study stated that they saw the cystic artery within the Calot’s triangle and behind and deep in the cystic duct in 73.5% of cases. They expressed that this artery appeared within the Calot’s triangle and in a more lateral position to the cystic duct in open cholecystectomy . In our study, CA was in normal condition in 82 cases (82%). In these cases, CA was observed within the CT and parallel with the cystic duct, on its deeper and posterior side, and in the neighborhood of the Sentinel lymph node. Torres et al.  reviewed 88 cases who underwent LC. In cases they named as the standard group, they found out that the cystic artery was located in the anteromedial of the cystic duct and near the sentinel lymph node. The variant group included 32 cases. In 12 of these 32 cases, neither the superficial branch nor the deep branch was dominant. Eight patients had superficial branch predominance. Early division of the cystic artery was observed in 4 patients. Kim et all.  stated that they detected CA originating from the middle hepatic artery (MHA) during LC, and that MHA imitated CA. In one of our cases, the right hepatic artery was found to be almost adherent to the gallbladder serosa and it mimicked CA (Figure1). In such cases, if the artery is ligated without careful dissection, liver supply will be damaged .
Double CA was reported with a frequency rate of 15-25%. These arteries are generally the branches of the right hepatic artery or of its hepatic segments V or VI. The absence of a posterior branch close to the gallbladder may indicate that there are two cystic arteries [4,13]. In another study, it was determined that there was a double artery within the Calot triangle with a frequency of 15.5% . Ding et al. detected a double cystic artery within the Calot triangle with a frequency of 12.2% in their LC operations . In our study, while the Calot’s triangle was explored in 12 (12%) cases, two arteries were determined at the first moment, and these arteries assumed double artery and were clipped separately.
Suzuki et al. , in the series covering 244 cases, reported 6 unusual cystic arteries. These arteries first course in the posterior part of the cystic duct, and then pass to the anterior side of the cystic duct, and enter the gallbladder. They named this variation “Cystic Artery Syndrome”. Similarly, in one of our cases, CA passed through the medial side of the cystic duct, passed to the back side of the cystic duct, and then made a curve at the caudolateral side of the cystic duct, passing to the front face of the cystic duct. We named this anomalous course of CA “spiral cystic artery” (Figure 2). This is a very rare variation.
If the CA approaches the gall bladder from out of the Calot’s triangle, most probably no cystic artery will be observed within the Calot’s triangle upon dissection. In one study, the rate of cystic artery outside the Calot triangle was given as 13.3%. However, in this study, CA (1.67%) arising directly from the liver parenchyma were included in this rate . On the other hand, Balija et al.  identified a CA originating from the arteria gastroduodenalis with a frequency of 4.5% in their study. This type of CA entered the gall bladder from the Hartmann pouch after passing below the cystic duct. In one study, CA was observed both within and outside of Calot’s triangle in 1% of cases, which they called the compound type . In our 3 (3%) cases, the cystic artery was located outside the Calot triangle. It was observed that the CA terminal segment entered into the gall bladder from the lower right of the cystic duct. When dissection was continued, it was observed that the CA went through the caudal side of the cystic duct and parallel with it (Figure 3). In our study, there was no case with double arteries that are observed both outside and within the Calot’s triangle.
A rare anatomical variation of CA can be an entrapment leading to serious complications during LC. To conclude, knowing the laparoscopic appearance of the CA course, the frequency of its possible variations, and its relationship with Calot’s triangle, is extremely important to prevent iatrogenic injuries and perioperative bleeding. Furthermore, prevention of bleeding is extremely important both to reduce the transition to open surgery and to prevent potential iatrogenic bile duct injuries.
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11. Saeed A, Salim M, Kachhawa DS, Chaudhary R. Intra-operative factors responsible for conversion of laparoscopic cholecystectomy to open cholecystectomy in a tertiary care center. Int Surg J. 2020;7(5):1467-72.
12. Kim SH, Park S, Cho J. A cystic artery arising from the middle hepatic artery detected during laparoscopic cholecystectomy: a case report. J Surg Case Rep. 2022; 2022(1): rjab088. DOI: 10.1093/jscr/rjab088.
13. Balija M, Huis M, Nikolic V, Stulhofer M. Laparoscopic visualization of the cystic artery anatomy. World J Surg. 1999; 23(7):703-7.
14. Suzuki M, Akaishi S, Rikiyama T, Naitoh T, Rahman MM, Matsuno S. Laparoscopic cholecystectomy, Calot’s triangle, and variations in cystic arterial supply. Surg Endosc. 2000;14(2):141-4.
15. Singh H, Singh NK, Kaul RK, Gupta A, Tiwar S. Prevalence of anatomical variations of cystic artery during laparoscopic cholecystectomy. Int Surg J. 2019; 6(10):3781-5.
16. Ding YM, Wang B, Wang WX, Wang P, Yan JS. New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy. World J Gastroenterol. 2007; 13(42):5629-34.
17. Torres K, Chroscicki A, Golonka A, Torres A, Staskiewicz G, Palczak R, et al. The course of the cystic artery during laparoscopic cholecystectomy. Folia Morphol. 2009; 68(3):140-3.
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Zeliha Turkyilmaz, Zeki Hoşcoşkun, Oğuz Taşkınalp. Cystic artery anatomies in laparoscopic cholecystectomy and literature review. Ann Clin Anal Med 2022;13(8):850-853
Clinicopathological characteristics and prognostic factors of gastrointestinal stromal tumors treated with curative surgery
Osman Erdogan 1, Alper Parlakgumus 2, Ugur Topal 3, Kemal Yener 4, Zeynel Abidin Tas 5, Oktay Irkorucu 6
1 Department of Surgical Oncology, Konya Numune Hospital, Konya, Turkey, 2 Department of Surgical Oncology, Adana City Training and Research Hospital, Adana, Turkey, 3 Department of Surgical Oncology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey, 4 Department of General Surgery, Adana City Training and Research Hospital, Adana, Turkey, 5 Department of Pathology, Adana City Training and Research Hospital, Adana, Turkey, 6 Department of Clinical Sciences, College of Medicine, Universty of Sharjah, Sharjah, United Arab Emirates
DOI: 10.4328/ACAM.21134 Received: 2022-03-07 Accepted: 2022-04-07 Published Online: 2022-04-08 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):854-859
Corresponding Author: Osman Erdogan, Department of Surgical Oncology, Konya Numune Hospital, Konya, Turkey. E-mail: firstname.lastname@example.org P: +90 332 235 45 00 F: +90 332 235 67 36 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9941-2704
Aim: In this study, we aimed to present our experience with Gastrointestinal Stromal Tumors (GIST).
Material and Methods: All GIST cases in the archived files of the pathology database of Adana City Hospital for the period between January 2010 and December 2019 were reviewed. Patients were grouped according to their mitotic index: Group1: ≤5 and, Group2: >5; the two groups were compared for clinical symptoms, preoperative tests, treatments, pathological characteristics and follow-up data; and univariate and multivariate survival analyses were performed.
Results: This study included 106 patients, who were divided in Group 1 (61 patients) and Group 2 (45 patients). The most common tumor location was the stomach (54.7%), the mean tumor size was 7.45 cm The tumor size was greater in Group 2 (5 vs. 8 cm, p<0.001), the margins were irregular in Group 2 (14.8% vs. 35.6%, p:0.013), the high-risk group according to NIH Guidelines was Group 2 (24.6% vs. 88.9%, p<0.001), and necrosis (p:0.002) and invasion (p<0.001) were more common in Group 2. Among the patients who developed recurrence, the time to recurrence was longer in Group 1 (61 vs. 48 months, p:0.037). The metastatic growth rate was higher in Group 2 (4.9% vs. 24.4%, p:0.003). While disease-free survival was shorter in Group 2 (126 vs. 98, p:0.020). Multivariate analyses showed that emergency operations, a Ki67 index of >5, presence of tumor necrosis, S100 positivity and recurrence at follow-up were all associated with reduced survival.
Discussion: This study provides information on the clinicopathological characteristics and epidemiology of GISTs. Patients with a high mitotic index are associated with poor histopathological and oncological outcomes.
Keywords: Gastrointestinal Stromal Tumors (GISTs), Prognostic Factors, Survival
Gastrointestinal stromal tumors (GISTs) are relatively rare neoplasms that are believed to originate from the mesenchymal elements of the intestines. The GIST histogenesis, diagnostic criteria, prognosis and terminology have been a matter of debate for many years. The current epidemiology suggests that the overall incidence of GIST in the United States is 0.70 per 100,000 people per year, with a tendency to increase each year . Most GISTs originate in the stomach (60%) or the small intestine, including the jejunum or ileum (30%), but may also originate in the duodenum (4–5%), colon and appendix (1–2%), or esophagus (1%), and occasionally outside the gastrointestinal tract [2,3].
The main treatment for primary, localized, resectable gastrointestinal stromal tumors (GISTs) is radical resection with negative margins. That said, almost all GISTs have some degree of recurrence risk. Identifying the risk factors for recurrence after primary surgery is important for the establishment of an appropriate prognosis and follow-up program, and most importantly, to identify patients who will best benefit from adjuvant therapy and thus reduce disease recurrences [4-8]. According to the latest versions of the clinical guidelines, including NCCN, ESMO/EURACAN and the French Intergroup Clinical Practice guidelines, mitotic rate, tumor size and tumor site, including tumor rupture, are all widely accepted prognostic factors. These four established prognostic factors, however, have continued to be researched and improved upon in recent years [3-5]
Extensive experience is required to understand the behavior of tumors and to predict disease outcomes, although this can be difficult due to the low incidence and uncommon locations of GISTs. Furthermore, the rarity of these neoplasms has prevented the adoption of a strong statistical approach in all but a few studies, and series reported in the literature have provided limited information due to the low number of patients [6,7]
Although this issue has been addressed in several studies, the heterogeneity of the patient population and the variety in clinical presentation, anatomical location and morphological characteristics have complicated analyses. We present here the findings of our assessment of the effects of a wide range of factors on survival in those who have undergone curative surgery for Gastrointestinal Stromal Tumors, including patient and tumor characteristics, immunohistochemical results, pathological findings, metastasis or recurrence, and tumor location.
Material and Methods
The study included all cases of GIST retrieved from the pathology database at Adana City Training and Research Hospital between January 2010 and December 2019. Currently, diagnoses of GISTs are based on two factors: a) the presence of spindle, epithelioid, or mesenchymal tumor cells on histopathological examination; and b) CD117 expression with or without CD34 expression via immunohistochemical staining. All patients in the study were diagnosed based on these two criteria. This study was approved by the Adana City Hospital Local Ethics Committee (No 25.03.2020 772/53.).
Data were collected from the individual patient medical case notes, electronic patient records and pathology reports. Gender, age, tumor location, tumor size, presenting complaints, laboratory parameters, type of surgery, mitotic index, Ki67 index, intratumoral necrosis, tumor cell types and borders, National Institutes of Health (NIH) risk category, histological type, and mitotic rate determined by hematoxylin and eosin staining, were recorded. Immunohistochemical analyzes of patients were studied using standard protocols, including CD117, CD34, Desmin, S100, SMA and DOG-1 antibodies. Overall survival (OS) was defined as the time from surgical resection to the date of the last follow-up visit or death. Disease-free survival (DFS) was calculated as the time from the date of surgery to the date of the first evidence of local and/or distant recurrence, or the date of the latest visit for patients lost to follow-up. Progression-free survival (PFS) was first calculated in patients with metastases at the time of diagnosis. The patients were grouped according to their mitotic index: Group 1: ≤5 and, Group 2: > 5, and the two groups were compared. Mitotic activity was assessed by counting the number of cells undergoing mitosis per x 50 high-power fields (HPF). The Ministry of Health Death Notification System was accessed to obtain information about the latest status of the patients.
Surgeons at our institution share the GIST treatment philosophy that emphasizes the complete removal of the tumor. Resections are classified as incomplete if the tumor is unresectable at the time of discovery or if there is substantial residual disease following resection. A complete resection is considered the excision of all gross diseases, regardless of microscopic margins. Resection of metastases is performed in selected patients when the primary tumor has been controlled.
IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp. was used for the statistical analysis of the data. Along with the descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum) for the evaluation of the study data, the Mann-Whitney U test was used for non-normally distributed parameters when analyzing quantitative data. Categorical data were compared using Pearson’s Chi-square test and Fisher’s Exact test, while a multiple logistic regression was used for multivariate assessments. A Kaplan-Meier analysis and a Log-Rank test were used for the analysis of survival. A p-value of <0.05 was considered statistically significant in the analyses.
This study included 106 patients, of which 60.4% were female, and the mean age was 59 years. The most common tumor location was the stomach (54.7%), the mean tumor size was 7.45 cm, and the mean mitotic index was 6.55.
Patients with a mitotic index of ≤5 were classified as Group 1 and those with a mitotic index of > 5 as Group 2. The gender distribution and mean age in the two groups were similar. Patients in Group 2 received neoadjuvant imatinib more frequently (0% vs. 6.7%, p 0.041). The presenting symptom and localization differed between the groups. The results are presented in Table 1.
Tumor size was greater in Group 2 (5 vs. 8 cm, p<0.001), the margins were irregular in Group 2 (14.8% vs. 35.6%, p: 0.013), the high-risk group according to the NIH risk criteria was Group 2 (24.6% vs. 88.9%, p<0.001), and necrosis (p: 0.002) and invasion (p<0.001) were more common in Group 2. The Ki67 index was higher in Group 2 (3 vs. 10, p<0.0001). The results are presented in Table 2.
Concerning immunohistochemical markers, the rate of S100 positivity was higher in Group 1 (50.8% vs. 31.1%, p: 0.042), while other markers were similar in the groups. The results are presented in Table 2.
The length of follow-up was similar in the groups (67 vs. 49 months, p: 0.546). Among the patients who developed recurrence, the time to recurrence was longer in Group 1 (61 vs. 48 months, p: 0.037). In Group 2, all patients received imatinib, and postoperative chemotherapy was administered more frequently in Group 2 (1.6% vs. 15.6%, p: 0.007), and the metastatic growth rate was higher in Group 2 (4.9% vs. 24.4%, p: 0.003). The rate of patients who developed mortality in their follow-up (18% vs 20% p:0.798) and the rate of recurrence (6.6% vs 17% p:0.072) were similar in the groups.
While overall survival was similar in the groups (105 vs. 98 months, p: 0.843), disease-free survival was shorter in Group 2 (126 vs. 98, p: 0.020).
Independent risk factors associated with reduced survival were identified as emergency operations, a Ki67 index of >5, cell pattern, borders, cell type, presence of necrosis, S100 positivity, development of recurrence and postoperative chemotherapy. The results are presented in Table 3.
In the present study, the prognostic factors and survival of a group of patients diagnosed with gastrointestinal stromal tumors who underwent surgery in a Turkish clinic over a 10-year period were assessed retrospectively. Patient survival was associated with the type of surgery, Ki67 index, S100 positivity, postoperative chemotherapy and recurrence, and these findings are largely in agreement with previous studies. In contrast, no association was identified between survival and tumor size or NIH risk in the present study. The evaluation of the factors influencing the prognosis of GISTs is a highly relevant topic, and previous single and multicenter studies have described the association between survival and various factors.
Gastrointestinal stromal tumors are usually asymptomatic and are often detected incidentally, while the most common symptom is abdominal pain. Accompanying symptoms may include non-specific gastrointestinal symptoms such as loss of appetite, early satiety,
weakness, weight loss, abdominal distension, nausea and vomiting. Such tumors, however, may lead to serious gastrointestinal complications with high morbidity and mortality, such as intestinal obstruction, perforation, obstructive jaundice and gastrointestinal bleeding [9,10]. The patient series of our study had symptoms similar to those reported in the literature. Symptoms varied with tumor localization, therefore, despite varying clinical findings, GISTs should be considered in the differential diagnosis, especially in patients with subclinical
Fletcher et al. in 2002 proposed the NIH standard, which is based on two indicators –maximum tumor size, and mitotic figure count – and is used to predict the biological behavior of GISTs, and puts forward four levels of GIST recurrence risk . Most researchers believe that the mitotic count is most accurately expressed as the number of mitosis per 50 HPF, with a mitotic rate of 5 mitoses per 50 HPF being the commonly used limit for tumors with expected benign behavior . Mandrioli et al. reported a mitotic index of >5 to be a strong prognostic factor for disease recurrence , while Park et al. emphasized the prognostic significance of the mitotic index in their study. On this rational basis, we grouped our patients according to a mitotic index of 5 mitoses, and found that a mitotic index of >5 was associated with poor prognostic factors such as tumor size, NIH risk (high), irregular borders, necrosis and an increased KI67 index. Accordingly, patients with a mitotic index of >5 had poor oncological follow-up outcomes, such as reduced time to recurrence, increased metastases and reduced disease-free survival .
The management of GISTs has improved significantly over the past decade. Before the 2000s, the only proven effective treatment was surgery, but with the introduction of TKIs, the management of advanced disease has changed radically, allowing adjuvant or neoadjuvant therapy for locally advanced forms of the disease . That said, surgery still remains the main curative treatment for localized and resectable primary disease. The goal of surgery is to achieve macroscopic resection with a microscopically negative margin (R0) and to avoid tumor rupture (R2). A tumor resection that spares the involved organ (i.e. stomach or intestines) is usually sufficient, although a more extensive resection may sometimes be required for the complete removal of the neoplasm . In the present study, tumor localization served as a guide when determining the type of surgery. An R0 resection was performed in 97% of cases, with anR2 resection performed in the remaining 3% of the patients due to the invasion of various surrounding tissues. The mitotic index was not associated with operative variables. An emergency operation was a prognostic factor for survival, and we believe that morbidity and mortality after emergency operations contribute to this finding.
Ki67, a widely accepted nuclear protein associated with cellular proliferation in malignant tumors, has been reported to be associated with prognosis in GISTs . The study by Zhao et al. of 418 GIST patients established a correlation between an increased Ki67 index and the mitotic index, and the authors further identified Ki67 as an independent prognostic factor for recurrence-free survival . Similarly, our study found the Ki67 index to be associated with the mitotic index and to be an independent risk factor for reduced survival.
Previous studies have concluded that necrosis observed macroscopically in a tumor is associated with overall proliferative activity of the tumor, with necrosis-containing areas being observed macroscopically in the most aggressive GISTs [18,19]. Oliveira et al.  in their study of 54 GIST cases published in 2015, reported that the presence of macroscopic necrosis in the tumor was associated with a poor prognosis. Our study established a significant correlation between macroscopically observed tumor necrosis and the mitotic value. Mitosis index was higher in patients with tumor necrosis. A significant relationship was also found between tumor necrosis and survival in the present study. Radiological and macroscopic observations of necrosis are associated with tumors with high mitotic activity and/or large tumors, which may contribute to treatment planning in such patients, considering the preoperative aggressive course.
Miettinen et al. [20,21] reported S100 expression to be a marker of malignancy, and more common in small intestinal GISTs. They went on to suggest that S100 may be a poor prognostic marker for gastric location, but not for small intestinal location, although the study was limited by a small number of cases. Other studies in the literature, on the other hand, reported no relationship between prognosis and S100 positivity . In the present study, S100 positivity was associated with a low mitotic index and with reduced survival.
Our study has several limitations. First, it was a single-center study with a limited number of patients, although the sample contained a large group of patients considered as having common characteristics, and consistent with the literature. Due to the absence of data from the patient files in the medical records, the use of imatinib could not be analyzed in our patient group.
GISTs are the most common mesenchymal tumors of the gastrointestinal tract, and most commonly arise in the stomach. While surgical resection is the recommended treatment in localized cases, it alone cannot always provide a cure. Recurrence can occur even in cases with complete resection of the primary tumor. Histopathological examinations are of great importance in identifying high-risk patients who will benefit from adjuvant therapy. Preoperative estimation of prognosis in gastrointestinal stromal tumors will give us an idea of postoperative survival, and is important in determining adjuvant therapy. Detecting, reporting and assessing outcomes of rare cancers such as GISTs can be difficult, and the data may be insufficient for population-wide recommendations and interventions. We believe, however, that the data presented here clarify some important points and may help determine future trends.
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3. von Mehren M, Randall RL, Benjamin RS, Boles S, Bui MM, Ganjoo KN, et al. Soft Tissue Sarcoma, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018 ;16(5):536-63.
4. Casali PG, Abecassis N, Aro HT, Bauer S, Biagini R, Bielack S, B et al. ESMO Guidelines Committee and EURACAN. Gastrointestinal stromal tumours: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 ;29(Suppl. 4):iv68-iv78. Erratum in: Ann Oncol. 2018;29(Suppl. 4):iv267.
5. Landi B, Blay JY, Bonvalot S, Brasseur M, Coindre JM, Emile JF, et al. Gastrointestinal stromal tumours (GISTs): French Intergroup Clinical Practice Guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis. 2019 ;51(9):1223-31.
6. Do IG, Jung KU, Koo DH, Lee YG, Oh S, Kim K, et al. Clinicopathological characteristics and outcomes of gastrointestinal stromal tumors with high progranulin expression. PLoS One. 2021;16(1):e0245153
7. Hwang SH, Jung M, Jeong YH, Jo K, Kim S, Wang J, et al. Prognostic value of metabolic tumor volume and total lesion glycolysis on preoperative 18F-FDG PET/CT in patients with localized primary gastrointestinal stromal tumors. Cancer Metab. 2021 ;9(1):8.
8. Rutkowski P. Why We Still Need the Better Risk Classification for GIST. Ann Surg Oncol. 2021;28(5):2425-7
9. Hellara O, Toumi O, Hadhri R, Ben Mansour W, Akkari I, Moussa A, et al. Epidemiological, clinical features, therapeutic results and evolution of gastrointestinal stromal
tumour: about 25 cases. Tunis Med. 2014;92(6):391-8.
10. Caterino S, Lorenzon L, Petrucciani N, Iannicelli E, Pilozzi E, Romiti A, et al. Gastrointestinal stromal tumors: correlation between symptoms at presentation, tumor location and prognostic factors in 47 consecutive patients. World J Surg Oncol. 2011;9:13
11. Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol. 2002 ;33(5):459-65
12. Miettinen M, El-Rifai W, Sobin L HL, Lasota J. Evaluation of malignancy and prognosis of gastrointestinal stromal tumors: a review. Hum Pathol. 2002;33(5):478-83
13. Mandrioli M, Mastrangelo L, Masetti M, Zanini N, Lega S, Nannini M, et al. Characterization of malignant gastrointestinal stromal tumors-a single center experience. J Gastrointest Oncol. 2017 ;8(6):1037-45
14. Park CH, Kim GH, Lee BE, Song GA, Park DY, Choi KU, et al. Two staging systems for gastrointestinal stromal tumors in the stomach: which is better? BMC Gastroenterol. 2017;17(1):141.
15. Raut CP, Ashley SW. How I do it: surgical management of gastrointestinal stromal tumors. J Gastrointest Surg. 2008;12(9):1592-9
16. Rosa F, Alfieri S, Tortorelli AP, Di Miceli D, Papa V, Ricci R, et al. Gastrointestinal stromal tumors: prognostic factors and therapeutic implications. Tumori. 2012 ;98(3):351-6.
17. Zhao WY, Xu J, Wang M, Zhang ZZ, Tu L, Wang CJ, et al. Prognostic value of Ki67 index in gastrointestinal stromal tumors. Int J Clin Exp Pathol. 2014 ;7(5):2298-304.
18. Artigiani Neto R, Logullo AF, Stávale JN, Lourenço LG. Ki-67 expression score correlates to survival rate in gastrointestinal stromal tumors (GIST). Acta Cir Bras. 2012;27(5):315-21.
19. Oliveira RP, Portari Filho PE, Iglesias AC, Basilio de Oliveira CA, Pannain VL. Comparative study of the different degrees of risk of gastrointestinal stromal tumor. Rev Col Bras Cir.2015; 42(1):32-6.
20. Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol. 2005;29(1):52-68.
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Osman Erdogan, Alper Parlakgumus, Ugur Topal, Kemal Yener, Zeynel Abidin Tas, Oktay Irkorucu. Clinicopathological characteristics and prognostic factors of gastrointestinal stromal tumors treated with curative surgery. Ann Clin Anal Med 2022;13(8):854-859
Polyclonal outbreak of bacteremia caused by Burkholderia cepacia in the intensive care unit
Ilkay Bahceci 1, Feray Ferda Senol 2, Aziz Ramazan Dilek 3, Ilknur Esen Yildiz 4, Nuray Arslan 1, Ömer Faruk Duran 1
1 Department of Medical Microbiology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, 2 Department of Medical Microbiology, Elazig Fethi Sekin State of Hospital, Elazig, 3 Department of Medical Microbiology, Faculty of Medicine, Karamanoglu Mehmet Bey University, Karaman, 4 Department of Infectious Diseases, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
DOI: 10.4328/ACAM.21136 Received: 2022-03-10 Accepted: 2022-04-11 Published Online: 2022-04-13 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):860-862
Corresponding Author: Ilkay Bahceci, Department of Medical Microbiology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey. E-mail: email@example.com P: +90 505 713 18 65 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3662-1629
Aim: Burkholderia cepacia is a multidrug-resistant, opportunistic pathogen of humans and outbreaks of infection in hospitals have been described. In this study, we aimed to report an outbreak in patients without cystic fibrosis or chronic granulomatous disease involving different species of Burkholderia cepacia.
Material and Methods: A small outbreak of nosocomial Burkholderia cepacia complex occurred in a 6-bed intensive care unit. We isolated Burkholderia cepacia from blood cultures of the patients admitted to our intensive care unit. All isolates from patients and the environment were identified by standard microbiological techniques and VITEK system. Antibiotic susceptibility testing was performed using Kirby Bauer’s disk diffusion method and the VITEK system
Results: All isolates exhibited identical patterns of antibiotic susceptibility and all isolates were sensitive to trimethoprim-sulfamethoxazole, ceftazidime and meropenem. The isolates were typed using pulsed-field gel electrophoresis using the restriction enzymes XbaI and SpeI. Accordingly, while 4 strains were similar, one was different.
Discussion: The experience from this outbreak reminded us of the importance of outbreak investigation in such small outbreaks and keeping the health care workers educated and constant attention on this issue. The results of this study emphasized once again the necessity to maintain our sensitivity to the basic principles of sanitation and to raise our awareness of such outbreaks.
Keywords: Burkholderia cepacia, Outbreak, Intensive Care Unit
Burkholderia cepacia (BC) is a motile, aerobic, non-fermenting, Gram-negative bacillus, multi-drug-resistant, and more usually a colonizer . Nowadays it is termed as B. cepacia complex (BCC) . Outbreaks of BCC bacteremia are often associated with contaminated intravenous (IV) medications, medical devices, or skin disinfectants. Transmission of BCC by person-to-person contact, contact with contaminated surfaces, or exposure to BCC in the environment have also been reported [3-5]. In the prevention of these outbreaks, the use of personal protective equipment and hand hygiene are of maximum importance. Nosocomial infections and outbreaks are less common in intensive care units where hand hygiene compliance is high . BCC species are particularly devastating pathogens for individuals suffering from chronic lung diseases such as cystic fibrosis, but in the most of the recently reported outbreaks, affected patients had no cystic fibrosis but rather had been affected by hospital-associated and immunocompromised conditions [7, 8].
In this study, we report an outbreak in patients without cystic fibrosis or chronic granulomatous disease involving different species of BCC, despite being a more predominant clone.
Material and Methods
A small outbreak of nosocomial BCC bacteremia occurred in the 6-bed intensive care unit (ICU) of a 516-bed xxxxxxx Training and Research Hospital, xxxx. In this period, Burkholderia cepacia was first isolated from the bronchial alveolar lavage and blood culture of a 72-year old patient with lung cancer. The patient did not suffer from cystic fibrosis and was treated according to bacterial sensitivity, and the bacteremia resolved after administration of the appropriate antibiotic. An outbreak investigation was done after the second case, BC were isolated from the blood cultures of four patients (total of 5 patients, mean age: 67,6 years). Four subsequent cases had both fever and other infection symptoms, and we decided that we were facing an outbreak with these findings.
Burkholderia is a waterborne and soilborne organism that can survive for a prolonged period in a moist environment. Samples were taken from the potential reservoirs like water reservoir of incubator humidifiers, heated humidifier water, respiratory devices, tap water, incubator surfaces, antiseptic products, intravenous solutions, and hygiene products (povidone, chlorhexidine and etc.). The samples were inoculated into Brain Heart Infusion broth and incubated at 37 °C for 3 days and then subcultured onto blood agar, chocolate agar and EMB agar. Although other bacteria are rarely isolated, BCC was not isolated. We performed a case-control analysis to identify risk factors, but failed to find any source. All isolates from patients and environment were identified by standard microbiological techniques and the VITEK system (VITEK 2 compact, BioMérieux, Marcy l’Etoile, France). Antibiotic susceptibility testing was done by Kirby Bauer’s disk diffusion method on Muller Hinton agar, VITEK system and interpreted based on Clinical Laboratory Standard Institute (CLSI) guideline (M100, 27th edition).
The study was approved by the Ethics Committee of XXX University Medical Faculty, Turkey (40465587-154 ) before the study period. The research was conducted in accordance with the Declaration of Helsinki.
All isolates exhibited identical patterns of antibiotic susceptibility, and all isolates were sensitive to trimethoprim-sulfamethoxazole, ceftazidime and meropenem. Although this finding suggests that all strains are similar, the isolates were typed using pulsed-field gel electrophoresis (PFGE) using the restriction enzymes XbaI and SpeI. As seen in the PFGE result, while 4 strains were similar, one was different. The distribution of molecular types based on PFGE can be seen in Figure 1. In Figure 1, the first line on the left is E. Coli ATCC 25922 strain, the second line is Burkholderia cepacia isolated from the first patient and the others patients.
In our study, it was determined that the outbreak due to BCC should be detected at first, they all show the same sequence except for one strain, the necessary precautions should be taken, the intensive care unit should be closed, and patients should be treated successfully. Although BCC is well described as a cause of respiratory infections in immunosuppressed patients (cystic fibrosis, chronic granulomatous disease such as.,), BCC bacteremia, urinary infections and nosocomial pneumonia have also been reported in intensive care units as sporadic cases or during outbreaks . The non-fermentative group, in which BCC is included, ranks first in hospital infections and outbreaks , BCC has been linked to nosocomial outbreaks caused by contamination of medical devices, parenteral and nebulized medications, antiseptic solutions, and other environmental sources [11,12]. All ICU patients in our study underwent intubation and mechanical ventilation during their ICU stay. In order to determine the source of the BCC outbreak, samples were taken from all equipment and fluid sources, antiseptics in the intensive care unit. Unfortunately, since the outbreak is considered, cultures from the environment and potential reservoirs did not help us to find the source. The only source of happiness for us is the successful treatment of patients and the absence of new cases after the measures were taken.
While Wong et al. identified BCC with three different sequences in an outbreak that occurred in a peritoneal dialysis unit it was determined that the source was a semi-packaging device, and environmental BCC growths should be carefully followed and included in surveillance . Based on these and previous experiences, opportunistic environmental pathogens, such as BCC, Pseudomonas aeruginosa and Bacillus spp, might be used as indicator organisms for environmental contamination and included as part of routine surveillance . B. cepacia is a serious threat for hospitalized patients needing invasive procedures, including the central line placement for chemotherapy, regardless of the need of any intensive care . A review of the literature identified outbreaks caused by a single BCC clone, as well as outbreaks caused by different clones [4, 16, 17]. In another study, the source of BCC that caused the epidemic could not be determined for a long time, and urinary infections continued in patients despite all precautions. As a result of the four-month study, it was determined that the anesthetic gel was the source . In another study, in total, 9 patients were infected with BCC. PFGE confirmed that the isolates were homologous . Abdulfettah et al. isolated BCC from the blood cultures of 14 patients and from the ultrasound gel. Molecular pathogen typing using PFGE showed a 95% similarity between BCC isolates from the blood of these patients and ultrasound gel . Microorganisms that are accepted as environmental contamination should be evaluated together with clinical findings in terms of whether they are a factor or a member of flora or cause contamination according to the characteristics of the region in which they reproduce [21,22]. The salient feature of this outbreak is the presence of multiple clones and unsuccessful efforts to find any source.
Experience from this outbreak reminded us the importance of outbreak investigation in such small outbreaks and continuing to educate health care workers and keep a constant attention on this issue. Perhaps the most important reminder is that we need to maintain our sensitivity to the basic principles of sanitation.
In addition, since the microbiology laboratories of developing countries such as ours do not have the method of detecting microorganism sequences at the molecular level, they can establish regional equipped laboratories and follow up the epidemic more easily.
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Download attachments: 10.4328:ACAM.21136
Ilkay Bahceci, Feray Ferda Senol, Aziz Ramazan Dilek, Ilknur Esen Yildiz, Nuray Arslan, Ömer Faruk Duran. Polyclonal outbreak of bacteremia caused by Burkholderia cepacia in the intensive care unit. Ann Clin Anal Med 2022;13(8):860-862
Agreement between physiotherapists and mothers in the rehabilitation of children with down syndrome
Zeynep Rabia Sahin 1, Süleyman Gürsoy 2, Erdoğan Kavlak 3
1 Department of Therapy and Rehabilitation, Mehmet Akif Ersoy University, Burdur, 2 Department of Physiotherapy and Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, 3 Department of Neurological Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey
DOI: 10.4328/ACAM.21138 Received: 2022-03-12 Accepted: 2022-05-17 Published Online: 2022-05-23 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):863-867
Corresponding Author: Erdoğan Kavlak, Department of Neurological Rehabilitation. School of Physical Therapy and Rehabilitation, Pamukkale University, 20160, Kinikli, Denizli, Turkey. E-mail: firstname.lastname@example.org P: +90 258 296 42 57 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6344-259X
Aim: The aim of this study was to examine the agreement between physiotherapists and mothers about the treatment of children with Down syndrome who received treatment in special education and rehabilitation centers.
Material and Methods: Mothers of 117 children with Down syndrome whose mean age was 26.24±12.94 months, and physiotherapists were included in this study. All participants were treated at special education centers in the province of Aydın. A questionnaire consisting of 6 open-ended questions was used to describe the expectations and views of the physiotherapists and mothers about the physiotherapy and rehabilitation programs for the children.
Results: The mean age of the mothers with a child with Down syndrome was 36.74±4.15 years, and the mean age of the physiotherapists was 34.03±9.32 years and their mean number of working years was 9.91±8.76. Statistically, a moderate agreement was found between the physiotherapists and the mothers in terms of additional treatment (K=0.225 and p=0.000) and the effectiveness of the physiotherapy program applied to DS children (K=0.204 and p=0.000).
When the agreement between the physiotherapists and the mothers about the appropriateness of the treatment applied to DS children was examined, a statistically good agreement was found (K=1.000 and p=0.000).
Discussion: We believe that the views and expectations of the mothers should be taken into account by the physiotherapists when preparing a treatment program for children with Down syndrome.
Keywords: Down Syndrome, Physiotherapist, Mother, Physiotherapy, Kappa
Down syndrome (DS) (or trisomy 21) is the most common genetic cause of intellectual disability, occurring in about 1 in 800 births worldwide .
DS has whole-of-genome and epigenetic effects, affecting the structure and function of the nervous, cardiovascular, musculoskeletal and endocrine systems. The primary clinical feature of DS is intellectual disability, which is usually moderate but can range from mild to severe. Central nervous system structural differences include a smaller cerebrum, cerebellum and brain stem  Common structural differences in the cardiovascular system are congenital heart defects, affecting 40 to 55% of infants with DS . These problems also negatively affect developmental deficiency
Rehabilitation of DS children should be carried out as a team effort involving the family. In order to encourage the family in this regard, physiotherapy and rehabilitation program can be prepared, taking into account their opinions and wishes. For this reason, physiotherapists should talk to the mother to create the most appropriate program for the child before devising a treatment plan .
Families whose expectations are at the maximum level in the treatment of children often ignore the condition of their child, except for the treatments deemed appropriate by the physiotherapist, in order to achieve the best result, and want all treatment methods learned from both local and various publications to be applied to their child, which may or may not be appropriate for that child’s condition. However, physiotherapists, who have assumed the full responsibility for the treatment, support this program with the most appropriate additional treatment recommendations or applications for the child’s condition .
In this sense, this study was planned with the aim of investigating the compatibility of expectations of the physiotherapist and mothers from rehabilitation in relation to the treatment of children with DS who are treated in special education and rehabilitation centers.
Material and Methods
The study included mothers and physiotherapists of children with DS between the ages of 0-6 who were treated at various special education and rehabilitation centers . The study was approved by Pamukkale University Faculty of Medicine Ethics Committee (PAÜ.0.20.05.09/46).
Informed consent forms were obtained from mothers and physiotherapists. The study was completed in accordance with the ethical principles in the Declaration of Helsinki after obtaining written permission for the study from the directors of the rehabilitation center.
The inclusion criteria in the study were as follows:
– All participants agreed to participate in the study,
– Having a child aged 0-6 years with a diagnosis of DS,
– A mother who takes full care of the child
Socio-demographic information was recorded with the participants by face-to-face interview method.
Gross motor function classification system:
The Gross Motor Classification System for cerebral palsy is based on self-initiated and performed movements, focusing on sitting, transfers, and mobility. Differences between levels are based on functional limitations, the need for hand-held walking aids (such as walkers, crutches, or canes) or wheeled mobility devices and, to a lesser extent, quality of movement. The Turkish validity and reliability study of this classification system was carried out in 2007 
Level 1: Walking without limitations.
Level 2: Walking with some limitations.
Level 3: Walking using hand-held ambulation tools.
Level 4: Self-actualization is limited. Can use motorized mobility vehicles.
Level 5: Mobility is severely limited, although assistive technologies are used.
A questionnaire consisting of six open-ended questions was used about the expectations and opinions of the mother and the physiotherapist regarding the rehabilitation programs. The questionnaire form was prepared by specialist physiotherapists working in the field of pediatric rehabilitation in university hospital and special education rehabilitation centers .
For all statistical analyzes, SPSS 21.0 package program was entered into the Windows operating system, continuous variables were given as mean ± standard deviation, and categorical variables were given as numbers and percentages. As a result of the power analysis of this study, when 117 people were included in the study, it was calculated that 90% power would be obtained with 95% confidence. In all statistics, the level of significance was determined as p≤0.05 and interpreted. The kappa coefficient ranged between 0 and 1. The kappa coefficient for two values between 0.0 and 0.20 was considered to indicate statistically insignificant concordance, and one between 0.21 and 0.40 was considered to indicate statistically moderate concordance .
The study involved 117 children with DS and their mothers and physiotherapists. The mean age of the children was 26.24 ± 12.94 months, and the mean age of the mothers was 36.74 ± 4.15 years. It was found that 64.1% of the mothers had 12 years of education or less, 20.5% were over 12 years and 15.4% were illiterate. While the mean age of the physiotherapists was 34.03± 9.32 years, the mean number of working years was 9.91 ± 8.76 years (Table 1).
It is seen that 33.3% (39) of children with DS belong to level 3 and 22.2% (26) to level 4. The distribution of children with DS according to GMFCS is given in Table 1.
According to the results of the survey questioning the views of physiotherapists and mothers about the treatment of children with DS, while 40.2% (47) of physiotherapists and 36.8% (43) of mothers defined the children’s health as “good” in their definitions of the general health of children, agreement between them was found to be 9.4%. While 26.5% (31) of physiotherapists and 22.2% (26) of mothers defined their children’s health as “very good”, the agreement between them was determined as 8.5%. There is no statistically significant agreement between physiotherapists and mothers in terms of the definition of children’s general health (K=0.020 and p=0.673) (Table 2).
When the awareness of mothers and physiotherapists regarding the treatments received by DS children was examined, 100% (117) of the physiotherapists and 28.2% (33) of the mothers stated that the treatment their children received was the Bobath treatment, while the agreement between them was 28.2%; 62.4% (73) of the mothers stated that the treatment they received was special education. When the agreement between the awareness of mothers and physiotherapists about the treatments received by children was examined, there was no statistically significant agreement (K=0.000 and p=1.000) (Table 2).
While 100% (110) of the physiotherapists and 82.1% (96) of the mothers stated that the treatments applied to DS children were appropriate, the agreement between them was 82.1%. When the agreement between the physiotherapists and the mothers about the appropriateness of the treatment applied to the children was examined, a statistically good agreement was found (P=0.000 and K=1.000) (Table 2).
Regarding the application of additional treatments to the DS child, 39.3% (46) of the physiotherapists and 32.5% (38) of the mothers think that they should receive “language and speech therapy” as an additional treatment. The agreement between the physiotherapists and the mothers regarding the application of language and speech therapy to the child was found to be 17.1%; 28.2% (33) of the physiotherapists and 17.1% (20) of the mothers requested “special education, group training, psychosocial support” as additional treatment, and the agreement between them was found to be 8.5%. Statistically significant agreement was found between mothers and physiotherapists in the application of additional treatments to children, around moderate level (K=0.225 and p=0.000) (Table 3).
In terms of the usefulness of the physiotherapy and rehabilitation program applied to children, 41.0% (48) of the physiotherapists and 41.9% (49) of the mothers defined the treatment as “very good” and the agreement between them was found to be 25.6%. When the agreement between physiotherapists and mothers in terms of the usefulness of the physiotherapy program applied to children was examined, a statistically significant agreement was found around the middle level (K=0.204 and p=0.000) (Table 3).
In our study, there was an insignificant agreement between the views of physiotherapists and mothers about the definition of the general health status of children with DS and the treatment methods applied to children.
A significant agreement was found between the opinions of physiotherapists and mothers in terms of the additional treatments that should be applied to the DS child, the suitability and usefulness of the physiotherapy and rehabilitation program applied.
Families face many difficulties in the post-diagnosis process, especially ignorance of medical issues, they also state that they suffer from inadequacy in education and rehabilitation and that they suffer from loneliness in terms of social support . These situations also cause conflicts and a lack of communication within the family. Aksoy and Demirli stated in their study as follows: “It is thought that mothers should be supported and informed by experts after the diagnosis process and they should find support against the difficulties they experience during the process.” .
A high level of education is important for families to adequately care and treat a disabled child. In the study conducted by Kavlak et al, it was found that 83.1% of the mothers had an education level of 12 years or less. In our study, it was found that 64.1 of the mothers had an education level of 12 years or less .
Considering that all rehabilitation processes of the child should be in the natural environment in which they live, it becomes a necessity for the child’s family to participate in the rehabilitation process. The support given to the family on the care and rehabilitation process is as effective as directly focus on the child . In order to increase the participation of the mother in the treatment, to apply the treatments consciously at home, and to better perceive the health status of the children, education should be provided and their communication with physiotherapists should be increased . According to our study, we believe that it is necessary to ensure that the mother is more active during the rehabilitation process, to perceive the appropriateness of the treatments according to the developmental level and health status of the children, and to increase their communication with physiotherapists.
In the study conducted by Kavlak et al., families state that among the treatments applied to their children, the Bobath and special education treatment are the most appropriate and most beneficial treatments . As a result of our study, in parallel with the information above, families state that the most appropriate and most beneficial treatments among the treatments applied to their children is the Bobath treatment.
Likewise, a low level of agreement was found between the views of physiotherapists and mothers about the treatments applied to children and the degree of benefit from the treatments . In our study, there was a significant agreement between the views of physiotherapists and mothers about the treatments applied to children and the degree of benefit from the treatments.
The first expectation of mothers of children with CP is that their children can walk or improve the walking quality. It is observed that the severity of CP does not change the expectation of the mothers. Informing families of children with CP more about CP and rehabilitation goals can increase the efficiency of the rehabilitation program .
There are majority of mothers who think that their disabled children cannot manage their lives on their own. The expectations of mothers with low educational level about their disabled children are more similar to their own future. This similarity concerns who will take care of their children after death and whether the disabled child will be self-sufficient. In addition, among the expectations of mothers from educators in rehabilitation centers is to focus on self-care skills in the education of children .
In the study by Kavlak et al., 38.5% of mothers want their children to be able to walk with or without assistance, and 35.4% want them to be independent in their daily living activities. There is a high degree of agreement between physiotherapists and mothers regarding treatment expectations .
In our study, 58.1% of the mothers wanted their children to be able to walk with or without assistance, and 34.2% wanted them to be independent in their daily living activities. In our study also, a high agreement was found between physiotherapists and mothers regarding expectations from treatment.
As a result of our study, in parallel with the above information, the first expectation of mothers is that their children can walk with or without assistance, and the other expectation is that they can make their daily living activities independent.
In the study conducted by Kavlak et al., 67.72% of mothers and 81.5% of physiotherapists think that alternative treatment methods are necessary . In our study, 60.7% of mothers and 89.7% of physiotherapists think that alternative treatment methods are necessary.
In the study conducted by Kavlak et al., it is seen that there is an insignificant agreement between physiotherapists and mothers regarding the expectations from the treatments received by children with CP . In our study, a statistically significant agreement was found between mothers and physiotherapists within the framework of all expectations. Taaniala et al., emphasize that it is important for the family to have sufficient information about the situation of their disabled children, for the family to adapt to the disabled child, for the care, education and rehabilitation of the child .
In addition, one of the most important factors that positively affect families’ ability to cope with difficulties is education . Singer et al., in their study with the families of disabled children, stated that families with higher education levels are more interested in their children, that is, they have higher awareness of the disease . In the study conducted by Kavlak et al., the agreement between mothers and physiotherapists on the appropriateness of the treatment applied to children is 82.3%, and the agreement between them about treatment awareness (Bobath) is 36.2% . In our study, the agreement between mothers and physiotherapists about the appropriateness of the treatment applied to children was 82.1%, and the agreement between them about treatment awareness (Bobath) was 28.2%. These compliances reveal the importance of informing and educating the family about the treatment given to us.
Our study was carried out in a single province as a region. Therefore, the cases were selected from a narrow population. If a wider region could be reached, the number of data could be increased by accessing cases with different socio-cultural structures. Thus, more precise, reliable and universal results could have been obtained.
As a result, the participation of the family in the treatment program applied to the child with DS and their awareness about the treatment applied are important. Evaluating the results obtained after our research, we think that the mothers’ views on the treatment should be taken into account in determining the most appropriate and most beneficial treatment of the healthcare personnel dealing with the treatment of disabled children. In addition, adequate information is of great importance for mothers in this process.
We think that mothers should cooperate with physiotherapists during rehabilitation and receive informative training about their children’s conditions in order to be aware of the disease of the family with a disabled child, to find the most appropriate treatment option, to apply home treatment effectively and appropriately, and to get more successful results from the applied treatment program.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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Download attachments: 10.4328:ACAM.21138
Zeynep Rabia Sahin, Süleyman Gürsoy, Erdogan Kavlak. Agreement between physiotherapists and mothers in the rehabilitation of children with down syndrome. Ann Clin Anal Med 2022;13(8):863-867
An alternative marker of inflammation in parenteral nutrition: IMA
Mustafa Timurkaan 1, Gulsum Altuntas 2, Mehmet Kalayci 3, Esra Suay Timurkaan 1, Hakan Ayyildiz 4, Semih Dalkilic 5
1 Department of Internal Medicine, Elazig Fethi Sekin City Hospital, Elazig, 2 Department of Intensive Care Unit, Elazig Fethi Sekin City Hospital, Elazig, 3 Department of Biochemistry, Akcakoca State Hospital, Duzce, 4 Department of Biochemistry, Elazig Fethi Sekin City Hospital, Elazig, 5 Department of Biology, Faculty of Science, Firat University, Elazig, Turkey
DOI: 10.4328/ACAM.21141 Received: 2022-03-12 Accepted: 2022-04-13 Published Online: 2022-04-18 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):868-872
Corresponding Author: Mustafa Timurkaan, Department of Internal Medicine, Elazig Fethi Sekin City Hospital, 23300, Elazig, Turkey. E-mail: email@example.com P: +90 505 889 31 50 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1950-0489
Aim: There is an increase in inflammation and metabolic complications in patients receiving PN. Because of inflammation and oxidative stress, an increase in IMA levels can be observed. We aimed to evaluate the effectiveness of detecting IMA and other inflammatory parameters in modulating nutritional therapy of critically ill patients.
Material and Methods: A total of 83 subjects were divided into two groups: 41 receiving PN (F:20, M:21) and 42 receiving EN (F:22, M:20). Patients over the age of 18 whose NRS 2002 score was <3, and who were followed up in the intensive care or palliative care units were included. CBC, glucose, protein, albumin, ferritin, CRP, electrolytes, and IMA levels were compared.
Results: There was a difference in CRP values in the group receiving PN compared to the group receiving EN (p=0.001). NLR and CRP/albumin were found to be higher in the PN group (p <0.05 and p <0.01). IMA levels were also found to be significantly higher in the PN group compared to the enteral group (p <0.01).
Discussion: Compared with EN, inflammation, metabolic and oxidative stress can occur in patients receiving PN. Increased inflammatory parameters and IMA levels are important in terms of additional treatment modalities to nutrition. This oxidant process can be prevented by using antioxidant support such as vitamins and minerals, emulsions containing olive oil, and omega-3 fatty acids. IMA and inflammatory parameters can be guiding as predictors of this process.
Keywords: Nutrition, Enteral, Parenteral, IMA, Hyperinflammation
Nutritional support for critically ill patients in intensive care and palliative care units is an important part of patient treatment and care. These patients are often prone to malnutrition due to decreased caloric intake combined with increased caloric needs because of metabolic stress. Various guidelines and recommendations have been developed by DGEM (German Society for Nutritional Medicine), ESPEN (European Society of Enteral and Parenteral Nutrition), and (ASPEN (American Society of Enteral and Parenteral Nutrition) for enteral (EN) and parenteral (PN) nutrition. Despite this, there is still debate about which is superior. However, the general opinion is that EN is the first choice if there is no contraindication [1-3].
For enteral nutrition, the gastrointestinal tract is used if its integrity is preserved. It is generally administered through a feeding tube inserted nasoenterically. The main reasons for recommending EN in the guidelines are as follows: EN is safer, has lower cost and risk of infection is fewer. In addition, since the continuity of enteral passage is ensured, intestinal atrophy is prevented and thus the continuity of the barrier function of the intestine is ensured .
If it is impossible to provide the patient with oral intake, EN is preferred, and if enteral nutrition is not available, parenteral nutrition is used . PN is often used in patients with gastrointestinal dysfunction. There are studies showing that it supports prognosis and survival rates in this group of patients. Nevertheless, for this patient group, it is recommended to switch to enteral nutrition as soon as possible if there is intestinal integrity. As a result of prolonged PN, unwanted conditions such as atrophy of the intestinal mucosa, increased intestinal permeability and loss of intestinal integrity may be encountered . As a result of disruption of the mucosal barrier, bacterial translocation, endotoxins are likely to enter the circulation, causing inflammation and toxemia. It is important to demonstrate the inflammation and to protect against this.
Albumin is a protein mostly synthesized in the liver and constitutes 25% of the total proteins . It is modified during oxidative stress, ischemic attacks secondary to acidosis, and production of reactive oxygen species, free radical formation alters the ability of the amino-terminal end (N-terminal) of albumin molecule, so this altered albumin cannot bind transitional metals such as cobalt, copper, and nickel, any longer . This altered type of albumin is called ischemic modified albumin (IMA). It is measured by Albumin-Cobalt Binding Test (ACT).
In recent studies, IMA has been suggested as an early biomarker for many diseases associated with oxidative stress (such as myocardial infarction, hyperthyroidism, hypothyroidism, diabetes mellitus, chronic renal failure, cerebrovascular events) . It can be said that IMA is a non-specific marker of tissue ischemia induced after ischemia-reperfusion. Starting from this point of view, we thought that hyperglycemia, ischemia, inflammation, and oxidative stress due to parenteral nutrition may increase serum IMA levels besides other inflammatory markers. This can help us detect the inflammation state of receiving parenteral nutrition. In our literature review, we could not find any study comparing nutritional methods with this biomarker and evaluating parenteral nutrition in terms of inflammation. Therefore, we aimed to evaluate the effectiveness of detecting IMA levels in modulating nutritional therapy of critically ill patients.
Material and Methods
This study was performed in patients who received inpatient treatment in Elazig Fethi Sekin City Hospital intensive care and palliative service clinics and were fed with total parenteral nutrition or enteral nutrition in accordance with ASPEN and ESPEN guidelines. The patients were examined in two groups. A total of 83 subjects, 41 receiving TPN (F:20, M:21) and 42 receiving Enteral Nutrition (F:22, M:20), were included in the study. The study included patients over 18 years of age whose NRS 2002 score was <3 and who were being followed up in the intensive care or palliative care units. The exclusion criteria were as follows: patients with 1-Ischemic heart disease 2-Circulatory disorders such as peripheral artery disease 3-Diagnosis of sepsis 4-Inflammatory bowel disease 5-Rheumatologic/immune system disease 6-Diagnosis of malignancy 7-Chronic liver disease. Demographic data such as age, gender, and comorbidities of the patients were recorded. Informed consent forms were signed by the patients or their relatives.
Our study was approved by the Ethics Committee of Fırat University and complies with the principles of the Declaration of Helsinki.
Blood samples were taken from the groups and 5ml of samples was inserted in tubes containing aprotinin (BD Vacutainer K3EDTA/Aprotinin, Plymouth, UK). Glucose, protein, albumin, and electrolyte measurements were studied in AU-5800. Ferritin levels were studied in DxI 800 (Beckman Coulter, Inc., Miami, FL, USA). CRP levels were determined by nephelometric method on an Immage-800 protein Chemistry Analyzer (Beckman Coulter Inc., Minnesota, USA), complete blood count was analyzed on the DxH 800 device. The blood samples were centrifuged at 4000 rpm for 10 minutes and placed in Eppendorf tubes. These tubes were stored in freezers at -20°C IMA to be studied until the working day.
Plasma IMA levels were studied using the Human IMA ELISA kit (Sunred Biological Technology, catalog no: 201-12-1173, Shanghai, China) in accordance with the operating procedures specified in the kit catalog. The absorbance measurement was made on the Chromate 4300 Microplate Reader (Awareness Technology, Palm City, USA). The minimum detection limit for IMA was 2.26 µg/L. The intra-assay and inter-assay coefficients of variation for plasma IMA were <9% and <11%, respectively.
SPSS program (version 21) was used for statistical analysis. Data were calculated as mean ± standard deviation. The Kolmogorov-Smirnov test was used to find out whether the variables showed a normal distribution. Student’s T-test was used for the analysis of parametric data and the Mann-Whitney U test was used for the analysis of non-parametric data. For evaluation of qualitative data, analysis was performed with the chi-square test. Also, the Spearman correlation analysis was performed to find out any relationship between the investigated parameters. Statistical differences between the means were considered significant if p-values were <0.05.
The laboratory and demographic data of the study are summarized in Table 1. Forty-one of the 83 patients received parenteral nutrition and 42 received enteral nutrition. In the group that received PN, 21 were men and 20 were women. In the group that received EN, 20 were male and 22 were female.
There was a significant difference in CRP values in the group receiving PN compared to the group receiving enteral nutrition (p=0.001). In addition, NLR and CRP/albumin ratios, which have become increasingly popular as an indicator of an inflammatory parameter, were also found to be significantly higher in the PN group (p <0.05 and p <0.01). IMA levels were also found to be significantly higher in the PN group compared to the enteral group (p <0.01).
A positive correlation was found between IMA and CRP (r:0.380, p= 0.014) in the PN group. There was also a positive correlation between CRP and NLR (r: 0.432, p= 0.005) (Figure1). A positive correlation was found between IMA and CRP (r:0.355, p= 0.021) in the enteral group. There was also a positive correlation between CRP and NLR in the enteral group (r:0.317, p= 0.041) (Figure 2).
Nutritional support is a routine requirement for critically ill patients, especially in intensive care and palliative care units. If timely and adequate nutritional support is not provided, energy and protein deficiency occurs . This situation plays an important role in the prognosis of the patient. Problems that will arise in case of insufficient or inappropriate nutrition are as follows: a decrease in fat and muscle mass, hypoalbuminemia/decrease in oncotic pressure, delayed wound healing, inadequate immune response, increased risk of infection, delayed recovery in surgical anastomoses, gastrointestinal, cardiovascular, and respiratory system disorders, metabolic acidosis can be observed .
Enteral nutrition is one of the nutritional methods. EN increases epithelial proliferation and ensures the continuity of the intestinal barrier. It reduces intestinal permeability by preventing intestinal villus atrophy. It stimulates intestinal perfusion and plays a protective role against ischemia-reperfusion injury. It has been shown in previous studies that EN prevents bacterial translocation and improves local and systemic immune response . It has also been found to be more advantageous not causing metabolic problems such as hyperglycemia, water, and electrolyte disorders when compared to parenteral nutrition .
In cases where nutritional support cannot be provided enterally, such as short bowel syndrome, enteric fistulas, severe vomiting and diarrhea, intestinal obstruction, nutritional support is provided by parenteral nutrition. However, there are various complications of parenteral nutrition such as complications related to catheter insertion or catheter infection and metabolic complications such as hypo-hyperglycemia, metabolic acidosis, electrolyte disorders, hypertriglyceridemia, hyperazotemia, fatty liver, and liver dysfunction .
During parenteral nutrition, the gastrointestinal tract is bypassed. Therefore, there is shrinkage and atrophy in the villi [14, 15]. An increase in bowel permeability is observed due to cellular edema. There are studies showing increase in endotoxin and inflammation due to bacterial infiltration . Monitoring of inflammatory parameters is important for the management of this situation. In the literature, CRP, WBC, NLR, Ferritin, IL6, and IL8 are mostly recommended as follow-up parameters of this process .
In this study, we compared enteral and parenteral nutrition in terms of increased inflammation, we found that CRP, NLR, CRP/Albumin ratios were significantly higher in patients with parenteral nutrition. We think that both the increase in inflammation due to atrophy and high permeability of the intestinal villi and metabolic complications caused this situation. As a result, we showed that the inflammatory process, which occurs with increased metabolic stress, became more prominent in the PN group. In a recent study that supports us, Stoll et al. compared newborn pigs given EN or PN. They observed increased myeloperoxidase activity and many inflammatory parameters .
In our study, in addition to these inflammatory parameters, we also evaluated ischemia modified albumin (IMA) level, which has been proven in many studies reflecting the oxidative stress. It has been shown that IMA increased due to high oxidative stress in ischemia conditions affecting many organs, especially the myocardium . Also, IMA values were also found to be high in cases of hypercholesterolemia, hyperglycemia, cirrhosis, metabolic syndrome, oxidative stress, and hyperinflammation [20-22].
We could not find any study in the literature that evaluated the oxidative stress created by parenteral nutrition with IMA levels. The fact that the IMA parameter is not specific to any tissue and is correlated with inflammatory parameters has guided our study in terms of reflecting inflammation in patients receiving different nutritional support. We observed that IMA levels were significantly higher in the PN group. We think that increased inflammatory response caused by PN and released oxygen radicals decrease the cobalt binding capacity of albumin and increase IMA levels. Hypercholesterolemia and hyperglycemia are also common in patients receiving PN. This situation increases oxidative stress together with endothelial damage, causing an increase in inflammatory parameters and IMA value.
We found positive correlations between IMA and CRP, CRP and NLR in patients receiving both parenteral and enteral nutritional support. This showed that the correlation of IMA and inflammatory parameters can be used to indicate oxidative and metabolic stress for both groups. The fact that CRP, CRP/Albumin and NLR levels were significantly higher in the PN group compared to the EN group indicates that inflammation is higher in this group. Therefore, we concluded that the patients in this group were under higher metabolic stress and oxidative load.
Due to this increased inflammation in patients receiving PN, lipid emulsions have gained importance because of their energy source and anti-inflammatory effects . Olive oil-based emulsions and Omega-3 fatty acids have shown beneficial effects on cellular defense and inflammation [23,24]. Besides, various vitamin and mineral supplements are also used in patients with PN due to their antioxidant properties. In our study, increased inflammatory parameters and high IMA values as an indicator of oxidative stress in patients receiving PN are of great importance in terms of additional treatment modalities to nutrition.
Inflammation, metabolic and oxidative stress that occur in patients who receive PN cause negative consequences in the treatment process of these patients. This oxidant process can be prevented by using antioxidant support such as vitamins and minerals, emulsions containing olive oil, and products containing omega3 fatty acids. IMA and inflammatory parameters can be guiding as predictors of this process.
One of the limitations of our study is that it is a single-centered study and the sample size is small. In addition, the patient group in our study was performed in intensive care and palliative care units, and the mortality of the patients is high due to their comorbidities. For this reason, the fact that the patients could not be given antioxidant support and control blood values could not be observed is another limitation.
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Mustafa Timurkaan, Gulsum Altuntas, Mehmet Kalayci, Esra Suay Timurkaan, Hakan Ayyildiz, Semih Dalkilic. An alternative marker of inflammation in parenteral nutrition: IMA. Ann Clin Anal Med 2022;13(8):868-872
Predictive role of SEC in mitral restenosis following successful percutaneous balloon mitral valvuloplasty (PBMV)
Omer Tasbulak 1, Mustafa Duran 2, Ahmet Anıl Şahin 3, Serkan Kahraman 1, Ali Riza Demir 1, Begum Uygur 1, Yalcin Avcı 1, Omer Celik 1, Ahmet Arif Yalcin 1, Mehmet Erturk 1
1 Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 2 Department of Cardiology, Konya Training and Research Hospital, Konya, 3 Department of Cardiology, Istinye University, Faculty of Medicine, Liv Hospital Bahcesehir, Istanbul, Turkey
DOI: 10.4328/ACAM.21143 Received: 2022-03-14 Accepted: 2022-04-14 Published Online: 2022-04-14 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):873-878
Corresponding Author: Omer Tasbulak, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 507 293 61 70 F: +90 212 471 94 94 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6307-5136
Aim: The aim of this study was to investigate the predictive role of spontaneous echo contrast (SEC) in mitral restenosis after percutaneous balloon mitral valvuloplasty (PBMV).
Material and Methods: We retrospectively analyzed 341 consecutive patients who underwent PBMV at our hospital. Subjects who participated in the study were assigned to two groups: patients who had demonstrable SEC in the left atrial cavity and left atrial appendage and patients who did not have SEC in the left atrial cavity and left atrial appendage. For each group, the following variables were analyzed: demographic characteristics, past medical records, laboratory values, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) parameters.
Results: Compared to patients without SEC, patients with SEC were older, had a higher incidence of diabetes mellitus (DM), ischemic stroke and AF (p<0.05). With respect to TTE and TEE measurements, patients with SEC had lower estimated pre-procedural left ventricular ejection fraction (LVEF), a smaller calculated mitral valve area (MVA), a larger left atrial (LA) dimension and higher estimated preprocedural Wilkins score (p<0.05). In addition, the incidence of mitral restenosis following PBMV was significantly higher in patients with SEC compared to patients without SEC ( p <0.05), and this difference was more apparent in patients with grade 3-4 SEC compared to those with grade 1-2 SEC (p<0.05)
Discussion: Our data showed that there is a strong association between SEC formation in the left atrium and left atrial appendage and mitral restenosis following PBMV
Keywords: Percutaneous Balloon Mitral Valvuloplasty, Mitral Restenosis, Spontaneous Echo Contrast
Percutaneous balloon mitral valvuloplasty (PBMV) has become the treatment of choice for patients with rheumatic mitral stenosis (MS) since it was described in 1984 . Although the mechanism of this treatment modality is the same as the previously reported closed mitral commissurotomy, outcomes of PBMV have shown better results regarding immediate and long-term success rates and post-procedural restenosis rates .
One of the major complications following PBMV is symptomatic mitral valve restenosis, which is reported to range between 7% and 23% [3, 4].
Spontaneous echo contrast (SEC) is an echogenic swirling pattern of blood flow mainly associated with blood stasis or low-velocity blood flow . Previous studies demonstrated that the incidence of SEC in rheumatic mitral stenosis ranges from 21% to 67% . Patients with SEC in the left atrium (LA) and left atrial appendage (LAA) were more prone to systemic thromboembolism . Although the relationship between SEC and systemic thromboembolism in patients with rheumatic mitral stenosis is evident, the role of SEC in mitral restenosis is yet not clear.
Therefore, we undertook this study to investigate the predictive role of SEC in mitral restenosis following successful PBMV.
Material and Methods
We enrolled 341 consecutive patients presenting with severe or moderate symptomatic mitral stenosis with favorable valve morphology who underwent Inoue balloon (Toray Inc., Tokyo, Japan) PBMV at our hospital between January 2010 and December 2019. Informed consent was obtained from all patients in accordance with a protocol approved by the Ethics Committee of Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. Patients with mitral regurgitation (MR) more than mild or evidence of LA thrombus by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) were excluded from the study. Patients with concomitant valve disease requiring surgical intervention and patients indicated for coronary artery bypass surgery were also excluded from the study.
According to our study, patients were divided into two groups depending on the presence (group 1) or absence (group 2) of SEC in the LAA or LA. For each group, the following variables were analyzed: demographic characteristics, past medical records, laboratory values, TTE and TEE parameters, including, left ventricular ejection fraction (LVEF), LA dimension, MVA (by planimetric or by pressure half time method), systolic pulmonary artery pressure (sPAP), mean diastolic mitral gradient, Wilkins score and procedural variables. Restenosis was defined as a decrease in mitral valve area >50% from the original gain together with MVA≤ 1.5 cm2 from follow-up TTE.
Transthoracic Echocardiographic Assessment
All patients underwent comprehensive TTE examination using a GE Vingmed Vivid 5 echocardiography device (GE Vingmed Ultrasound, Horten, Norway) before the planned procedure. During the echocardiographic examination, parasternal long-axis, short-axis, and apical 4-chamber and 2-chamber images were obtained and evaluated using M-mode, 2-D, continuous wave Doppler, and pulse wave Doppler, and tissue Doppler methods. MVA was assessed using direct planimetry of the mitral orifice in a 2-dimensional short axis view early in diastole and also by the pressure half-time method. Systolic pulmonary artery pressure (sPAP) was estimated with the help of continuous-wave Doppler studies using the Bernoulli equation. All measurements were performed according to the American Echocardiography Society criteria . Mitral valve apparatus morphology was evaluated using the Wilkins score, which consists of a semi-quantitative assessment of leaflet mobility and thickening, subvalvular changes, and valve calcification . Each abnormality has a possible score of 0-4, corresponding to zero or severe abnormality, and giving a possible total echocardiographic score between 0 and 16. Echocardiographic parameters were evaluated before and immediately after the procedure, at one month, six months, and annually during the follow-up. All patients were followed up at least 24 months after the procedure.
Transesophageal Echocardiographic Assessment
Multiplane TEE was performed in all patients under sedation. All patients underwent TEE examination within 24 hours before the planned procedure using a 5-MHz phased-array transducer (GE Vingmed Ultrasound, Horten, Norway) in order to rule out LA and LAA thrombosis and assess the presence of SEC. Parasternal long-axis and short-axis views and the apical 5-chamber view were evaluated during the TEE examination. With respect to echocardiographic examination, SEC was defined as slowly swirling, smoke-like echoes within the LA. In order to obtain the ideal image and exclude noise artifacts, the gain was recalibrated. The intensity of SEC was graded from 0 (absent) to 4 (severe) as previously described . Mild to moderate echogenicity located in the LAA and in LA was accepted as grade 1-2 and moderate to severe echogenicity located in LAA and LA was accepted as grade 3-4. Echocardiographic studies were recorded and re-analyzed by two experienced echocardiographers who were unaware of the clinical status of subjects, and a third examiner was required in case of discrepancy.
PMBV was performed via a transvenous (antegrade) approach through the femoral vein using a transseptal Brockenbrough needle, as previously described . Initial balloon size was selected according to body surface area. The maximum balloon size was determined by the following formula: (patient height (cm) / 10) + 10) . All procedures were performed under echocardiographic guidance and incremental balloon inflations of increasing volume were implemented. Procedure-related mitral valve regurgitation (MR) was assessed with on-site echocardiographic evaluation. According to our study, technically successful PBMV was defined as MVA ≥1.5 cm2 by Gorlin formula and MR less than moderate by echocardiography immediately after PBMV . The immediate event was defined as events, which occurred during the hospital stay of the patient after PMBV. The early event was defined as an event, which occurred during the first-year follow-up of the patients. Event-free survival was determined as the absence of events such as death, mitral valve replacement (MVR) or redo PMBV, cardiac tamponade, endocarditis and cerebrovascular accident (CVA).
Data were analyzed with the SPSS software version 21.0 for Windows (SPSS Inc., Chicago, IL, USA). Continuous variables with normal distribution were expressed as mean + SD, while continuous variables without normal distribution were expressed as median (25th-75th percentiles) and categorical variables are expressed as percentages. The χ2 test and Fisher’s exact test were used to compare categorical variables. The Kolmogorov- Smirnov test was used to evaluate the distribution of continuous variables. Student’s t-test was used for variables with a normal distribution, and the Mann-Whitney U test was used for variables without normal distribution. Univariate and multivariate logistic regression analyses were done to determine factors that independently predict the presence of future mitral restenosis. The restenosis curve using SEC was analyzed with the Kaplan-Meier method, and the long rank test was used for statistical assessment. P- value <0.05 was considered statistically significant.
The present study retrospectively included totally 341 consecutive patients with symptomatic mitral stenosis who underwent PBMV. The mean age was 40 ± 11 years in SEC (-) and 47 ± 12 years in SEC (+) group. The mean age was significantly lower in the SEC (-) group (p<0.001). The mean history of stroke (p=0.045) and atrial fibrillation (p<0.001) were significantly lower in the SEC (-) group. The mean incidence of DM was significantly lower (5.4%) in the SEC (-) group compared to SEC (+) group (12.7%) (p=0.035). The incidence of antiplatelet usage was significantly higher in the SEC (-) group (p=0.012), while the mean anticoagulant usage was significantly lower in the SEC (-) group (p<0.001).
According to our data, 102 patients had demonstrable SEC in LA cavity or LAA (Group 1) and 239 patients did not have SEC in LA cavity or LAA (Group 2). Compared to patients without SEC, patients with SEC were older (40 ± 11 vs. 47 ± 12, p<0.001), had higher incidence of diabetes mellitus (DM) (13 (5.4%) vs. 13 (12.7%), p=0.035), history of ischemic stroke (7 (2.9%) vs. 8 (7.8%), p=0.045) and AF (36 (15.1%) vs. 46 (45.1%), p<0.001). Although several patients were using antiplatelet and anticoagulant agents for different indications, there was a statistically significant difference with regard to antiplatelet agent usage (122 (51.0%) vs. 37 (36.3%), p<0.012) and anticoagulant agent usage between the groups (44 (18.4%) vs. 46 (45.1%), p<0.001). The most plausible explanation for the lower incidence of antiplatelet usage together with a higher incidence of anticoagulant usage in patients with SEC, is due to the higher rate of ischemic stroke or AF in this patient population.
With respect to TTE and TEE measurements, patients with SEC had lower estimated pre-procedural LVEF (65% (60-65) vs. 60% (60-65), p=0,004), smaller calculated MVA (by planimetry and by pressure half time method) (1.1 cm2 (1.0 – 1.3) vs. 1.1cm2 (1.0 – 1.2) & 1.2 cm2 (1.0 – 1.3) vs. 1.1 cm2 (0.9 – 1.3), respectively, p=0.031 and p=0.014) and increased LA dimension (4.4 cm (4.1 – 4.7) vs. 4.7 cm (4.4 – 5.0), p<0.001). In addition, the estimated Wilkins score was significantly higher in patients with SEC compared to patients without SEC (7.5 (7.0-8.0) vs. 8 (7-9), p=0.036). Baseline TTE and TEE measurements are shown in Table 1.
According to our data, 21 (20.6%) out of 102 patients with SEC later developed mitral restenosis. The average time from hospital discharge to mitral restenosis was 42 (24-84) months. Twenty-one (8.8%) out of 239 patients without SEC later developed mitral restenosis. The average time from hospital discharge to mitral restenosis was 44 (24 – 82) months. Of the whole cohort, the incidence of mitral restenosis was significantly higher in patients with SEC compared to patients without SEC (p=0.004). The successful PBMV (MVA ≥1.5 cm2 and MR ≤ 2) was achieved in 85 (84.3%) patients in the SEC-positive group and 215 (90.0%) patients in the SEC-negative group. Procedural success rate, post-procedural estimated LVEF, MVA (by planimetry and by pressure half time method) and transmitral gradients were similar in both groups (p >0.05). On the other hand, the estimated systolic pulmonary artery pressure (sPAP) and LA diameter were higher in SEC positive group compared to SEC negative group (33.5 (25-37) mmHg vs. 35 (28-42) mmHg and 4.1 (3.8-4.4) vs. 4.4 (4.0-4.7) cm respectively, p=0.035 and p<0.001) (Table 2).
Furthermore, outcomes of subgroup analyses revealed that incidence of mitral restenosis was significantly higher in patients with grade 3-4 SEC compared to those with grade 1-2 SEC [8 (13.6%) vs. 13 (30.2), p=0.040] (Table 3).
Adverse events immediately after intervention were observed in 6 (5.9 %) patients in the SEC-positive group (three developed severe mitral regurgitation and three developed cardiac tamponade) and 7 (2.9 %) patients in the SEC-negative group (two developed severe mitral regurgitation, three developed cardiac tamponade and two developed traumatic aortic injury). Although the incidence of adverse events immediately after intervention was higher in the SEC- positive group compared to the SEC- negative group, it did not reach statistical significance. Additionally, there was no significant difference in terms of early adverse events between groups, except for early restenosis. The SEC-positive group had a significantly higher rate of restenosis in the early period after the procedure (1 (0.4%) vs. 4 (3.9%), p=0.029). Comparison of outcomes of procedures and post-procedural TTE measurements are shown also in Table 2.
Variables with statistical significance in univariate analysis were put into multivariate logistic regression analysis. In multivariate logistic regression analysis, DM (OR: 2.940, 95% CI: 1.098 – 7.873, p=0.032), and SEC (OR: 2.183, 95% CI: 1.049 – 4.542, p=0.037) were found to be independent predictors of restenosis.
In this single-center retrospective study, we investigated the potential relationship between SEC formation in LA and LAA and mitral restenosis in patients who underwent PBMV. The main finding of our study was SEC formation in LA or in LAA was a strong predictor of mitral restenosis following PBMV.
High echocardiographic score (Wilkins score ≥8), older age (aged ≥ 50 years) and post-procedural estimated MVA (MVA ≤1.76 cm2) are well-known risk factors for the development of mitral restenosis following PBMV . On the other hand, there are limited data in the literature regarding the association between SEC formation in LA or LAA and mitral restenosis following PBMV. Besides, the clinical significance of SEC formation in these patient populations is unclear.
SEC formation in cardiac cavities has been noted to be a frequent finding in patients with low flow states including mitral valve disease or severe left ventricular systolic dysfunction . It has been shown that older age, LA enlargement, presence of AF and severity of mitral stenosis are the most prominent factors contributing to SEC formation in patients with mitral stenosis . In addition to those studies, SEC formation is not only associated with blood stasis but also associated with blood components including erythrocytes and platelets . Furthermore, the association between SEC formation in cardiac cavities and the hypercoagulable state has been demonstrated in various studies, and left atrial SEC was considered as a strong predictor of future thromboembolic complications [18, 19].
According to those studies, the presence of endothelial dysfunction and turbulent blood flow due to mitral valve stenosis were underlying mechanisms [20, 21]. It has been confirmed by in vivo studies that endothelial dysfunction and turbulent blood flow resulted in production of thromboxane A2 and beta thromboglobulin, which constituted a hypercoagulable state .
In addition to the above-mentioned potential pathways, patients presenting with severe mitral stenosis and patients who have SEC in LA or LAA also shared similar clinical and echocardiographic variables, including the presence of AF, older age, duration of symptoms, enlarged LA, higher estimated transmitral gradients and smaller MVA [23, 24].
In our study, we confirmed the results of previous studies with respect to predictors of mitral restenosis following PBMV. Also, smaller calculated mitral valve area (MVA) (by planimetry and by pressure half time method) and higher Wilkins score were observed in patients with SEC compared to patients without SEC (p < 0.05).
The relationship between SEC formation in the LA or LAA and mitral restenosis in patients following PBMV was studied for the first time in this study, and we observed significant differences between the two groups. According to our study, the incidence of mitral restenosis was significantly higher in patients with SEC compared to patients without SEC (p < 0.05), and this difference was more apparent in patients with grade 3 – 4 SEC compared to those with grade 1 – 2 SEC (p < 0.05).
The main limitations of the present study were that it was a single-center, retrospective experience with a relatively small sample size. Although we analyzed strong predictive factors for mitral restenosis following PBMV, we did not compare the occurrence of immediate and late mitral restenosis and associated factors. Thus, further prospective studies with larger populations and longer durations are essential to elucidate this question.
In conclusion, older age, prior history of AF, DM, ischemic stroke, estimated pre-procedural higher Wilkins score, smaller MVA and enlarged LA were found to be independent predictors for mitral restenosis in patients who underwent PBMV. Additional to these parameters, which were compatible with outcomes of previous studies, we also demonstrated a strong association between the existence of SEC in LA or LAA and mitral restenosis following PBMV. Thus, we suggest that in patients who have undergone PBMV, taking into account the existence of SEC in LA cavity or LAA could help reduce the incidence of mitral restenosis in the future. In this group of patients, close monitoring and strict medication such as antiplatelet or anticoagulant treatment would be considered for preventing restenosis.
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4. Sharma KH, Jain S, Shukla A, Bohora S, Roy B, Gandhi GD, et al. Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy. Indian Heart J. 2014;66(2):164-8.
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6. Noubiap JJ, Nyaga UF, Ndoadoumgue AL, Nkeck JR, Ngouo A, Bigna JJ. Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob Heart. 2020;15(1):38.
7. Hwang JJ, Kuan P, Lin SC, Chen WJ, Lei MH, Ko YL, et al. Reappraisal by transesophageal echocardiography of the significance of left atrial clot in prediction of systemic embolization in rheumatic mitral valve disease. Am J Cardiol. 1992;70(7):769–73.
8. Quiñones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15(2):167-84.
9. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60(4):299-308.
10. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23(4):961-9.
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Omer Tasbulak, Mustafa Duran, Ahmet Anıl Şahin, Serkan Kahraman, Ali Riza Demir, Begum Uygur, Yalcin Avcı, Omer Celik, Ahmet Arif Yalcin, Mehmet Erturk. Predictive role of SEC in mitral restenosis following successful percutaneous balloon mitral valvuloplasty (PBMV). Ann Clin Anal Med 2022;13(8):873-878
Distribution of cervical epithelial lesions in a conventional Pap smear
Department of Obstetrics and Gynecology, Istanbul IVF-Center, Istanbul, Turkey
DOI: 10.4328/ACAM.21144 Received: 2022-03-15 Accepted: 2022-04-15 Published Online: 2022-04-15 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):879-881
Corresponding Author: Ramazan Ozyurt, Istanbul IVF-Center, Istanbul, Turkey. E-mail: email@example.com P: +90 532 748 34 90 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6822-2222
Aim: In this study, we aimed to examine the distribution of cervical epithelial lesions in conventional pap smear screening.
Material and Methods: The smear results of 4500 patients aged 25-65 years who applied to the Istanbul training and research hospital between 2010 and 2011 for conventional smears were analyzed retrospectively. The smear results of the patients were recorded from their files. Smears taken from all patients using plastic brushes were evaluated according to the Bethesda system. The smears were classified by an experienced pathologist according to the following epithelial abnormalities: ASCUS: Atypical squamous cells of undetermined significance, AGUS: atypical glandular cells of undetermined significance, LGSIL: Low grade squamous intraepithelial lesion, HGSIL=High grade squamous intraepithelial lesion, Squamous cell carcinoma and other rare abnormalities. After the smear was stained with the Papanicolaou method, it was evaluated under light microscopy. ASCUS, AGUS, LGSIL and HGSIL are epithelial anomalies in cervical cells and are diagnosed using light microscopy.
Results: The normal smear rate was found to be 14%. The most common epithelial anomaly was recorded as chronic cervicitis with a rate of 60%. While the rate of smears containing atrophic cells was 9%, the rate of smears containing insufficient cells was 8%. A smear containing squamous cells was detected in 5.2% of the cases. Atypical squamous cells of undetermined significance were detected in 2% of cases, while atypical glandular cells of undetermined significance were found in 0.2%. While low-grade squamous intraepithelial lesion was 0.8%, high grade squamous intraepithelial lesion was found to be 0.3%. Cervical cancer was not detected in 4500 cases. Considering the number of patients who underwent smear screening, it can be considered normal not to detect cervical cancer.
Discussion: A large proportion of cervical epithelial lesions can be accurately detected with conventional pap smear screening.
Keywords: Pap Smear, Cervix, Epithelial Lesion, Screening
Cervical cancer is the fourth most common cause of cancer death in women. Thanks to screening programs, the incidence of cervical cancer has decreased significantly. Conventional Pap smear is the classical method used for cervical cancer screening. The limitations of conventional methods are minimized by liquid-based cytology . Cervico-uterine cancer screening with conventional or liquid-based cytology reduces the incidence of cervical cancer by nearly 50% . Unsatisfactory smears results are higher in conventional pap smears than in liquid-based cytology. However, performing a smear with any method yields significantly better results than no smear at all.
In addition to screening for epithelial abnormalities, the risk of cancer is further reduced if HPV DNA screening is also performed. However, while HPV DNA testing is done in developed countries, it is rarely performed in developing countries. The Pap smear test is an inexpensive, easily applicable and reproducible screening test. It can detect cervical anomalies with high sensitivity and specificity. In doubtful cases, it can be confirmed by repeating the test. It is of critical importance to interpret Pap smear results well and to diagnose and treat accordingly . This study includes the retrospective analysis of 4500 cases of cervical cancer screening with a conventional pap smear. The distribution of cervical epithelial abnormalities obtained according to the smear results was detailed.
Material and Methods
Before the study, permission was obtained from the ethics committee of Istanbul Training and Research Hospital and the patients were informed about the study (2/17-2010). The smear results were obtained from the protocol numbers of the patients who did not have smear results in the file.
The smear results of 4500 patients aged 25-65 years who applied to the Istanbul Training and Research Hospital between 2010 and 2011 for conventional smears were analyzed retrospectively. The smear results of the patients were recorded from their files. Smears taken from all patients using plastic brushes were evaluated according to the Bethesda system. The smears were classified by an experienced pathologist according to the following epithelial abnormalities:
ASCUS: Atypical squamous cells of undetermined significance,
AGUS: atypical glandular cells of undetermined significance,
LGSIL: Low-grade squamous intraepithelial lesion,
HGSIL=High-grade squamous intraepithelial lesion,
Squamous cell carcinoma and other rare abnormalities.
The ages of the patients ranged from 25 to 65. All cases were married couples. While some patients had a smear for the first time, most of the cases consisted of people who had previously had a smear scan. Patients who wanted to have liquid-based cytology were not included in the study. Routine HPV DNA screening was not performed during the initial smear screening. In cases with abnormal epithelial proliferation, smear, tissue sampling and HPV screening were also performed with colposcopy.
The distribution of conventional pap smear results according to the Bethesda system is shown in Table 1. The normal smear rate was found to be 14%. The most common epithelial anomaly was recorded as chronic cervicitis with a rate of 60%. While the rate of smears containing atrophic cells was 9%, the rate of smears containing insufficient cells was 8%. A smear containing squamous cells was detected in 5.2% of the cases. ASCUS was detected in 2% of cases, while AGUS was found in 0.2%. While LGSIL was 0.8%, HGSIL was found to be 0.3%. Cervical cancer was not detected in 4500 cases. Considering the number of patients who underwent smear screening, it can be considered normal not to detect cervical cancer.
The Pap smear is a screening test widely used all over the world to screen for cervical cancer. Although it is easily applicable and inexpensive, its sensitivity is low (approximately 55%). With the help of additional immunohistochemical tests such as Ki-67 and p16, the sensitivity of the pap test can be increased to 90%. By adding HPV DNA, sensitivity rates can be increased even more . Due to low sensitivity, tissue sampling should be performed in the presence of a macroscopically pathological cervix, even if the Pap smear results are normal .
Although early diagnosis of cervical precancerous lesions is important, screening programs do not always give accurate results. Suspicious diagnostic cervical lesions occur with different frequencies depending on the technique of taking the smear or the experience of the cytologist who interprets the smear. Vaccination against HPV is a more effective method than Pap smear screening. However, since it is an expensive method, it must be financed by governments .
The protective effect of the Pap test against cervical cancer varies with age. With advancing age, both the inadequate cytology rate and the risk of epithelial anomalies increase. The sensitivity of screening tests performed in women under the age of 40 is higher than in older ages. For these reasons, it is critical to perform pap smear screenings before the age of 40 . The incidence of cervical cancer is higher in HGSIL cases compared to LGSIL and ASCUS cases. However, a lower grade cervical epithelial lesion or inflammatory change can be detected in the majority of HSIL cases. However, we would like to point out that a smear result will always be considered a low-sensitivity test, unless evaluated by an expert cytologist. The fact that people living in different geographies and cultures have different epithelial anomaly incidence rates is also a feature that should be taken into account during the interpretation of smear results .
Cervical cancer, which is the second most common malignancy in women, is a type of cancer that can be diagnosed in more than 50% by a Pap smear screening. Cervical cancer-related deaths can be significantly reduced if regular pap smear screening becomes routinely available with the joint effort of healthcare organizations and governments. However, women should be willing and conscious to have this test done. The dissemination of Pap test screening, especially in women under 40 years of age, allows for early diagnosis of epithelial abnormalities with higher sensitivity and specificity. In suspicious pap test results, if necessary, repeat testing or colposcopy according to a cervical image and biopsy can be performed . By making HPV DNA test a part of pap smear screening, it will be possible to reach clearer and more precise results . Efforts should be made to inform patients about pap smear and for the routine use of this test. Vaccination of patients in the risk group against HPV is considered a more effective approach. As a result, ensuring the effective use of the pap test is the most important preventive strategy we have in order to prevent fatal cervical cancers.
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Animal and human rights statement
Conflict of interest
1. Pankaj S, Nazneen S, Kumari S, Kumari A, Kumari A, Kumari J, et al. Comparison of conventional Pap smear and liquid-based cytology: A study of cervical cancer screening at a tertiary care center in Bihar. Indian J Cancer. 2018; 55(1): 80-3.
2. Vargas-Hernández VM, Vargas-Aguilar VM, Tovar-Rodríguez JM. Detección primaria del cáncer cervicouterino [Primary cervical cancer screening]. Cir Cir. 2015; 83(5): 448-53.
3. Tsikouras P, Zervoudis S, Manav B, Tomara E, Iatrakis G, Romanidis C, et al. Cervical cancer: screening, diagnosis and staging. J BUON. 2016; 21(2): 320-5.
4. Ghisu GP. Gynäologische Vorsorge [Importance of the Pap smear in the age of HPV testing]. Ther Umsch. 2021; 78(2): 93-8.
5. Nkwabong E, Laure Bessi Badjan I, Sando Z. Pap smear accuracy for the diagnosis of cervical precancerous lesions. Trop Doct. 2019; 49(1): 34-9.
6. Nayar R, Wilbur DC. The Pap test and Bethesda 2014. Cancer Cytopathol. 2015; 123(5): 271-81.
7. Meggiolaro A, Unim B, Semyonov L, Miccoli S, Maffongelli E, La Torre G. The role of Pap test screening against cervical cancer: a systematic review and meta-analysis. Clin Ter. 2016; 167(4) :124-39.
8. Isaoglu U, Yilmaz M, Delibas IB, Bilici AE, Kabalar ME. Evaluation of 37,438 consecutive cervical smear results in the Turkish population. Arch Med Sci. 2015; 11(2): 402-5.
9. Tawfik O, Davis M, Diaz FJ, Fan F. Cell Block Preparation versus Liquid-Based Thin-Layer Cervical Cytology: A Comparative Study Evaluating Human Papillomavirus Testing by Hybrid Capture-2/Cervista, in situ Hybridization and p16 Immunohistochemistry. Acta Cytol. 2016; 60(2): 145-53.
10. Westre B, Giske A, Guttormsen H, Wergeland Sørbye S, Skjeldestad FE. Quality control of cervical cytology using a 3-type HPV mRNA test increases screening program sensitivity of cervical intraepithelial neoplasia grade 2+ in young Norwegian women-A cohort study. PLoS One. 2019; 14(11): e0221546.
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Ramazan Ozyurt. Distribution of cervical epithelial lesions in a conventional Pap smear. Ann Clin Anal Med 2022;13(8):879-881
RT-PCR cycle threshold (Ct) values predicting COVID-19 patients’ outcome
Seyda Ignak 1, Demet Yalcin 2, Olida Cecen 3, Muhammed Mert Sonkaya 3, Isilsu Ezgi Uluisik 3, Ozlem Unay Demirel 4
1 Department of Medical Biology, School of Medicine, Bahcesehir University, 2 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istinye University, 3 5th Year Medical Student, School of Medicine, Bahcesehir University, 4 Department of Biochemistry, School of Medicine, Bahcesehir University, Medical Park Goztepe Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.21145 Received: 2022-05-18 Accepted: 2022-06-28 Published Online: 2022-06-30 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):882-886
Corresponding Author: Seyda Ignak, Department of Medical Biology, School of Medicine, Bahcesehir University, Sahrayıcedid Mah., Batman Sok., No:66, Kadıkoy, 34734, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 216 579 82 26 F: +90 216 468 40 84 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9382-8162
Aim: Clinical presentation of COVID-19 ranges from asymptomatic to fatal cases. Therefore, predictability of prognosis gains importance in managing the disease. The aim of this study is to investigate the relation between RT-PCR cycle threshold (Ct) values and the clinical severity of COVID-19 infection.
Material and Methods: A retrospective study was conducted among 1224 COVID-19 patients. A scoring system, which is designed by the World Health Organization was used to classify patients by means of their clinical status.
Results: The cut-off for Ct value in ROC curves was 21.52 at the point, when the COVID-19 patient clinic is shifting from ambulatory to hospitalized (79.7% sensitivity, 69% specificity). A significant weak positive correlation was found between age and WHO Score (r= .238 p<0.01) and a significant weak negative correlation was found between Ct value and WHO Score (r= -.068 p<0.05) in COVID-19 patients.
Discussion: Patients with lower RT-PCR Ct values were more likely to go through the disease more severely due to higher virulence. Reporting of numerical Ct values may help clinicians in terms of prognosis.
Keywords: PCR, Cycle Threshold, COVID-19, SARS CoV-2
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2), a novel viral agent that belongs to the Coronaviridae family, is an enveloped RNA virus, which is transmitted from person to person via respiratory route [1,2]. Coronavirus Disease 2019 (COVID-19) first emerged in Wuhan, China in December 2019. As of the date of submission of this manuscript, globally more than 414 million cases and over 5.8 million deaths from COVID-19 have been reported to the WHO (available at: https://covid19.who.int). WHO classifies COVID-19 cases as suspected, probable and confirmed. This classification is based on clinical and epidemiological criteria [available at: https://apps.who.int/iris/handle/10665/337834 and https://apps.who.int/iris/handle/10665/332196). The clinical spectrum of COVID-19 changes from ambulatory mild cases to patients in the intensive care unit. Real time polymerase chain reaction (RT-PCR) is used to detect the presence of the virus in nasopharyngeal and oropharyngeal samples, through the identification of one or two gene regions of the virus (one gene for screening, two genes for confirmation) . The cycle threshold is characterized as the number of cycles needed for the fluorescent signal to pass the threshold in order to be detected. Ct levels are conversely related to the quantity of target nucleic acid in the sample . In addition to RT-PCR assays, medical imaging techniques as well as routine clinical chemistry tests are critical for both diagnosis and predict clinical prognosis of COVID-19 patients . In this paper, it was aimed to show the relationship between Ct values and COVID-19 patients’ clinical outcome. Reporting of numerical Ct values may help clinicians regarding the prognosis of COVID-19 patients.
Material and Methods
The study was planned and conducted using a tertiary care hospital. This retrospective cohort study included COVID-19 patients admitted to this hospital from September 15, 2020 to February 12, 2021 with a positive SARS CoV-2 PCR test. For the PCR test nasopharyngeal samples were collected at the time of hospital admission of symptomatic patients. Therefore, sample collection and clinical evaluation were performed simultaneously. Of the 1392 patients with positive SARS-CoV-2 PCR tests, the ones with missing any of baseline characteristics were excluded from the study. Ct values could be obtained from 1224 patients (53.1% males, 46.9% females). Patients included in this study were aged between 18 and 80. The study has been approved by the COVID-19 Scientific Research Evaluation Commission of the Ministery of Health of the Republic of Turkey and by the local institutional ethics committee (Protocol number: E-22481095-020-451).
The Senteligo SARS-CoV-2 (COVID-19) qPCR Detection Kit Protocol, which is optimized for HealForce X960 real-time PCR (qPCR) analyzer (Eryigit, Ankara, Turkey) was followed, the analyzer provides 35 cycles upon the measure of PCR product. A single one-step reverse transcription qPCR test was used for amplification of the targets (N1, N2 and RnaseP) by FAM, HEX and Cy5 labelled probes, respectively. A negative, positive and internal control were used for each run.
Patient information regarding Ct values of PCR tests and hospital admission data were obtained from the electronic health records of the hospital. The data is evaluated and filtered depending on the date, age, clinical status and the relevant test results. The clinical status of the patients was demonstrated with a scoring system, which was designed by WHO for the classification of COVID-19 patients (8). In this scoring system, classification depends on clinical conditions and is scored from uninfected to death between 0 to 8.
All statistical analyses were performed in NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) Software. Descriptive statistics (medians, standard deviation, frequency, minimum and maximum values) and distribution of the data were reported using the Shapiro-Wilk Test. To estimate associations between two independent groups the Mann-Whitney U Test was used. Spearman’s Correlation Analysis was performed to determine the association between two quantitative data groups. The significance level was evaluated as p<0.01 and p<0.05.
From September 15, 2020 to February 12, 2021, 17.531 viral screening PCR tests were done in the hospital among patients with COVID-19 suspicion. The study population flow chart is shown in Figure 1.
The number of the patients grouped by their clinical status using WHO scores were as follows: 1051 patients for a score of 2, 106 patients for a score of 4, 13 patients for a score of 5, 5 patients for a score of 7, 49 patients for a score of 8. The difference between clinical identifications of score 1 and 2 can be interpreted subjectively thus patients in these groups were all scored as 2 in order to unify present data correctly. Since applied additional treatment supports to the patients were not fully detailed in the records, all patients who were hospitalized in COVID-19 ward were scored as 4, and patients who were intubated were scored as 7, regardless of receiving additional organ support.
The mean age of patients was 41.91±16.8 years ranging from 18 to 80; 85.8% (n=1050) of the study population were classified as COVID-19 ambulatory, whereas 14.2% (n=174) of all the patients admitted to the hospital. Among the patients who were admitted to the hospital, 113 of them stayed in the COVID-19 ward, whereas 61 of them were admitted to the ICU. Forty-six (75.4%) of 61 patients who needed intensive care were intubated. During the hospitalization process, 49 (4%) of them died and 125 (10.21%) of them were discharged. The mean age of the survivors (n=1175) was 40.91±15.97 years, when the mean age of the non-survivors (n=49) was 65.86±19.52 years. Ct values changed from 7.5 to 34.18 with a mean of 24.3±3.57. There was no statistically significant difference in Ct values between ambulatory, COVID-19 service admission and ICU admission in comparison to sex and age (Table 1).
A significant weak positive Spearman’s correlation was found between age and WHO Score (r= .238 p<0.01) versus significant weak negative Spearman’s correlation between Ct Value and WHO Score (r= -.068 p<0.05). ROC analysis based on the Ct values regarding hospital admission accounted for 55.7% as area under the curve for evaluating the severity of the disease (Figure 2).
The Ct cut-off value was found as 21.52 in ROC analysis to evaluate COVID-19 patients’ hospitalization needs (ambulatory or hospitalized). This cut-off value had 79.7% sensitivity and 69% specificity.
The uncertainty of the diagnosis and discharge criteria of COVID-19 creates a burden on health systems. In this research, it was aimed to show the relationship between Ct values and COVID-19 patients’ clinical outcomes. Reporting numerical Ct values may help clinicians regarding the prognosis of COVID-19 patients. In Turkey, there is no sufficient research based on this topic.
According to our findings, the cut-off value based on the Ct value for the assessment of the COVID-19 patients’ hospitalization needs was <21.52. Below the cut-off value (<21.52), higher WHO score points were observed. It was aimed to establish the cut-off value by using ROC analysis so that this cut-off value may give an idea of the patients’ clinical outcome either ambulatory or hospitalized on the day of the SARS CoV-2 PCR test result becomes positive. In a prospective cohort study, which was conducted by Tanacan et al., they investigated the relationship between Ct values and obstetric complications in COVID-19, and the cut-off value was found to be 22.9 . In addition, Cerutti et al. categorized values as ≤25, 25–28, 28–30, 30–35, >35 to compare mean Ct values of symptomatic SARS CoV-2 antigen test positive and negative patients. They observed significantly lower Ct values for PCR-positive/antigen positive samples with a mean value of 22.3, and higher Ct values for PCR-positive/antigen negative samples with a mean value of 32.1 . We did not perform antigen testing because of the low sensitivity and specificity in comparison to PCR. Furthermore, Miller et al. claimed that lower Ct values are indicators for more severe progression of the disease, however they did not define a precise cut-off value with acceptable sensitivity and/or specificity for triage with an AUC value of 65.37% .
According to Walker et al., low Ct values are associated with higher viral load in COVID-19 patients . As supported by Lyngse et al., low Ct values indicate higher viral load, which is also associated with an increased rate of SARS CoV-2 transmission . Miranda et al. suggest standardization of Ct values with a formula to improve the interpretation of viral load in the samples . Choudhuri et al. conducted a retrospective study including 1044 SARS CoV-2 positive patients and they demonstrated that Ct values are independent predictors of patient mortality . In a systematic review of eighteen studies, a correlation between Ct values and disease severity was reported by eleven of them, mentioning that the low Ct value would l lead to more serious consequences. There was a significant relationship between Ct value and disease severity among hospitalized COVID-19 patients (73% of the investigations) . In this study, it was observed that ambulatory patients had higher Ct values compared to the patients who were hospitalized in the COVID-19 service (WHO score of 4) and intensive care unit (WHO score of 5 and 7) (P=.001; P<.01). Even though Zhao et al. report that Ct values are significantly associated with viral load among survivors and non-survivors, we did not find any correlation between patient survival and Ct values (P>.05) . The difference of results can be explained by the limitations of RT-PCR testing. Pre-analytical and analytical factors such as sampling procedures, accuracy of the detection kits, specimen obtaining techniques, whether the specimen is taken before or after the symptoms started can affect PCR results . Ct value of men and women who received mechanical ventilation support were 22.98 (4.59) and 23.97 (3.55), respectively, and statistically significant correlation was not found between Ct values and sex of the ICU admitted patients (P=0.422). According to Jin et al. although both sexes were equally susceptible to the coronavirus infection, fatal outcomes were more likely to be seen among male patients . In this present study, the majority of cases were men but we did not show any significant relationship between clinical severity and the sex of the patients (P>.05). In another study, males were more involved in the severe group in the hospitalization period, however no statistically significant difference between Ct values and the sex was found . Moreover, we did not find a significant correlation between Ct values and sex (P>.05). In this retrospective cohort, the data examined did not show any difference in the distribution of Ct values among different age categories, which is in parallel with the study conducted by Ade et al. . The mortality rate in our study was 4% with an increased rate in patients older than 40 years of age. The ages of the patients who died were significantly higher than those who survived (P<.01). Moreover, patients with older age were more likely to have higher WHO scores (P<.01). As supported by Miller et. al, a tendency toward mortality was significantly higher for the elderly and the ones who were hospitalized . It has been shown that comorbidities lead the COVID-19 patient into a vicious infectious cycle and are closely associated with morbidity and mortality . In our study, we did not evaluate patients in terms of comorbidities.
Among patients who required mechanical ventilation, mortality rate was more than 70%. Richardson et al. reported that the mortality rate was 76.4% in the same patient group aged between 18 and 65 likewise our results . According to the COVID-19 Diagnostic Laboratories Quality Management Guide of Turkish Ministry of Health, SARS CoV-2 PCR test results with Ct value of less than 26 are regarded as high positive, 26 to 30 moderate positive and more than 30 low positivite by method with 35 cycles (available at: https://shgmkalitedb.saglik.gov.tr/Eklenti/37841/0/covid-19-kalite-rehber-03072020-sooonnnnpdf.pdf). However, in Turkey SARS CoV-2 RT-PCR test results are reported qualitatively as negative or positive to the clinicians by public health management system. Furthermore in addition to clinical symptoms, numerical Ct values can be used to predict the outcome of COVID-19 patients. Additional research on this topic can help to enhance the understanding of the clinical course. Giving CT results in addition to the qualitative result can guide clinicians about the course of the disease.
This study has several limitations. The data included in the study were restricted to electronic records of the hospital. We took into account only the first PCR test result of patients at the time of admission to the hospital. Serial testing of PCR in patients who were treated in the COVID service and ICU can be evaluated with prospective studies to make a comparison within the groups. A scoring system was used to classify patients for a better understanding of their clinical status. The scores were changing from 1 to 8 as expressed previously. Unfortunately, applied additional treatment supports were not fully detailed in the health records. Hence, the modified version of the scoring did not contain scores 3 and 6. Furthermore, nonhospitalized COVID-19 patients were classified with the WHO score of 2 because the distinction between scores 1 and 2 can be misinterpreted, so a score 1 was not used. In this study, comorbidities of the patients were not taken into consideration while evaluating their clinical status. Underlying diseases should be included in the assessment of patients’ medical conditions for a better understanding of the related case.
The result of the presented data supports that the interpretation of Ct values at the time of admission with SARS CoV-2 RT-PCR positivity, can lead clinicians to make better predictions about the clinical course. Patients with lower Ct values are particularly at higher risk for poor clinical outcomes, whereas patients with higher Ct values usually experience a mild form of the disease. To predict clinical outcome, the cut-off value in ROC curves with the highest sensitivity/specificity was found to be 21.52, which could shed a light on further adjustments of related guidelines and have an impact on precautions taken during the management of COVID-19 cases.
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1. Pal M, Berhanu G, Desalegn C, Kandi V. Severe Acute Respiratory Syndrome Coronavirus-2 (SARSCoV-2): An Update. Cureus. 2020;12(3):e7423.
2. Gorbalenya AE, Baker SC, Baric RS, Groot RJ, Drosten C, Gulyaeva AA, et al. Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020;5(4):536–44.
3. Miller EH, Zucker J, Castor D, Annavajhala MK, Sepulveda, Green DA JL, et al. Pretest Symptom Duration and Cycle Threshold Values for Severe Acute Respiratory Syndrome Coronavirus 2 Reverse-Transcription Polymerase Chain Reaction Predict Coronavirus Disease 2019 Mortality. Open Forum Infect Dis. 2021;8(2):ofab003.
4. Karahasan Yagci A, Sarinoglu RC, Bilgin H, Yanılmaz Ö, Sayın E, Deniz G, et al. Relationship of the cycle threshold values of SARS CoV polymerase chain reaction and total severity score of computerized tomography in patients with COVID 19. Int J Infect Dis. 2020;101:160-6.
5. Mertoglu C, Huyut MT, Arslan Y, Ceylan Y, Coban TA. How do routine laboratory tests change in Coronavirus disease 2019? Scand J Clin Lab Invest. 2021;81(1):24-33.
6. Tanacan A, Anuk AT, Erol SA, Keskin EL, Altinboga O, Yakistiran B, et al. The effect of real-time polymerase chain reaction cycle threshold values on perinatal outcomes of pregnant women with COVID-19. J Matern Fetal Neonatal Med. 2021;34(21):3601-8.
7. Cerutti F, Burdino E, Milia MG, Allice T, Gregori G, Bruzzone B, et al. Urgent need of rapid tests for SARS CoV-2 antigen detection: Evaluation of the SD-Biosensor antigen test for SARS-CoV-2. J Clin Virol. 2020;132:104654.
8. Walker AS, Pritchard E, House T, Robotham JV, Birrell PJ, Bell I, et al. Ct threshold values, a proxy for viral load in community SARS-CoV-2 cases, demonstrate wide variation across populations and over time. Elife. 2021;10:e64683.
9. Rao SN, Manissero D, Steele V.R, Pareja JA Narrative Systematic Review of the Clinical Utility of Cycle Threshold Values in the Context of COVID-19. Infect Dis Ther. 2020;9(3):573–86.
10. Miranda RL, Guterres A, de Azeredo Lima CH, Filho PN, Gadelha MR. Misinterpretation of viral load in COVID 19 clinical outcomes. Virus Res. 2021;296:198340.
11. Choudhuri J, Carter J, Nelson R, Skalina K, Osterbur-Badhey M, Johnston A, et al. SARS-CoV-2 PCR cycle threshold at hospital admission associated with patient mortality. PLoS One. 2020;15(12):e0244777.
12. Zhao Y, Cunningham MH, Mediavilla JR, Park S, Fitzgerald S, Ahn HS, et al. Diagnosis, clinical characteristics, and outcomes of COVID-19 patients from a large healthcare system in northern New Jersey. Scientific reports. 2021;11(1):4389.
13.Younes N, Al-Sadeq DW, Al-Jighefee H, Younes S, Al-Jamal O, Daas HI, et al. Challenges in Laboratory Diagnosis of the Novel Coronavirus SARS-CoV-2. Viruses. 2020;12(6):582.
14. Jin JM, Bai P, He W, Wu F, Liu XF, Han DM, et al. Gender Differences in Patients With COVID-19: Focus on Severity and Mortality. Front Public Health. 2020;8:152.
15. Gaston DC, Malinis M, Osborn R, Peaper DR, Landry M, Juthani-Mehta M, et al. Clinical implications of SARS-CoV-2 cycle threshold values in solid organ transplant recipients. Am J Transplant. 2021;21(3):1304-11.
16. Ade C, Pum J, Abele I, Raggub L, Bockmühl D, Zöllner B. Analysis of cycle threshold values in SARS CoV-2 PCR in a long-term study. J Clin Virol. 2021;138:104791.
17. Magleby R, Westblade LF, Trzebucki A, Simon MS, Rajan M, Park J, et al. Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load on Risk of Intubation and Mortality Among Hospitalized Patients With Coronavirus Disease 2019. Clin Infect Dis. 2020;73(11):4197-205.
18. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020;323(20):2052-9.
Download attachments: 10.4328:ACAM.21145
Seyda Ignak, Demet Yalcin, Olida Cecen, Muhammed Mert Sonkaya, Isilsu Ezgi Uluisik, Ozlem Unay Demirel. RT-PCR cycle threshold (Ct) values predicting COVID-19 patients’ outcome. Ann Clin Anal Med 2022;13(8):882-886
Our experience with hospitalized children with pertussis
Özlem Üzüm 1, Tuba Tınastepe 1, Yavuz Demirçelik 1, Hacer Örsdemir Hortu 1, Gülberat İnce 1, Ali Kanık 2, Kayı Eliaçık 1, Mehmet Helvacı 1
1 Department of Pediatric Diseases, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, 2 Department of Pediatric Diseases, Katip Çelebi University Faculty of Medicine, Izmir, Turkey
DOI: 10.4328/ACAM.21146 Received: 2022-03-16 Accepted: 2022-04-16 Published Online: 2022-04-19 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):887-890
Corresponding Author: Özlem Üzüm, University of Health Sciences, Tepecik Training and Research Hospital, Department of Pediatric Diseases, Izmir, Turkey. E-mail: email@example.com P: +90 507 785 96 37 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3297-7476
Aim: Pertussis is a lower respiratory tract infection caused by Bordetella pertussis, especially seen in children younger than six months, lasting more than fourteen days and developing with paroxysmal cough, inspiratory stridor and vomiting after coughing. In this study, it was aimed to present the demographic data and clinical characteristics of patients whose pertussis diagnosis was confirmed by clinical and Polymerase Chain Reaction tests in the infant service.
Material and Methods: Patients hospitalized with a diagnosis of pertussis between April 2014 and April 2019 were included in the study. Demographic data, symptoms, acute phase reactants, respiratory virus/bacterial sampling results, length of hospital stay and intensive care admissions were recorded.
Results: A total of 65 cases were included. Gender, age younger than or older than one year, low birth weight, and birth before 37 weeks were not associated with follow-up in the intensive care unit, whereas 5 of the 11 cases with other pathogens in addition to Bordetella pertussis were admitted to the intensive care unit. This rate was significantly higher than in cases where no additional pathogen was detected.
Discussion: As a result, it was thought that if there is a clinical suspicion in cases where the probable diagnostic criteria are not met, the diagnosis of pertussis should be confirmed by microbiological tests. In addition, it is thought that predictions can be made regarding the clinical course with the additional pathogen that can be detected using Polymerase Chain Reaction tests.
Keywords: Children, Polymerase Chain Reaction, Pertussis
Pertussis is an acute respiratory tract infection caused by the gram-negative coccobacillus Bordetella pertussis (B. Pertussis), which can cause morbidity and mortality [1,2]. About thirty million cases are seen in the world every year, and one hundred and sixty thousand deaths are reported in children under the age of five [3,4]. B. Pertussis-related morbidity and mortality remain important because vaccination does not provide life-long protection and infants younger than three months of age come into contact with sick cases [1,2].
Pertussis causes recurrent paroxysmal cough, inspiratory stridor, and post-cough vomiting after a clinical course similar to common upper respiratory tract infections . While pertussis causes mild illness in older children and adults, it can cause serious complications and fatal infection in children younger than six months of age, especially in the first three months of life [2,5]. A probable case of pertussis is defined as the presence of at least one of the following conditions: in addition to a cough lasting for at least two weeks, the person has episodes of severe coughing, panting, or vomiting after coughing in the absence of any other problem that could cause vomiting after coughing. In the definitive case, the diagnosis of pertussis is made by the evidence of contact with an infected person or by microbiological testing (Polymerase Chain Reaction-PCR, culture)  (available at: https://asi.saglik.gov.tr/liste/20-bogmaca-hastalığı-nedir-belirtileri-nelerdir.html).
In this study, it was aimed to present the epidemiological data of patients diagnosed with pertussis and to provide information about laboratory tests, treatment and clinical course of pertussis in these patients.
Material and Methods
Inpatients diagnosed with pertussis by PCR testing, between April 2014 and April 2019 were evaluated based on their medical records. Macrolide antibiotics are administered to all pertussis patients hospitalized in accordance with the clinical protocol of our hospital. In addition, in cases with prolonged fever or elevated acute phase reactants suggestive of bacterial pneumonia in the history and physical examination, additional antibiotics to the macrolide group may be started after evaluation of chest X-ray.
Demographic data of the cases, birth weight, week of birth, admission time, symptoms at admission, duration of cough, co-morbidities of chronic lung or congenital heart disease, and family members with pertussis-like symptoms were recorded. White blood cell and lymphocyte count, C-reactive protein (CRP), pathogen results other than B. Pertussis in respiratory tract virus/bacteria samples, oxygen treatment, length of hospital stay, and pediatric intensive care unit (PICU) need were recorded. Patients were grouped as having white blood cell counts above or under 10,000/m³ to compare PICU need and length of hospital stay. The study was performed according to the principles of the Declaration of Helsinki and after obtaining permission from the local ethics committee (26.12.2019, Decision number: 2019/18-37).
The statistical analysis of the available data was performed using the IBM SPSS 24 program (Statistical Package for Social Sciences, Chicago, IL, USA) according to group characteristics. Before the cases were evaluated according to the number of cases in the groups, Skewness and Kurtosis values were checked, and the Shapiro-Wilk and Kolmogorov Smirnov tests were also performed in order to investigate their conformity with the normal distribution. After providing the assumption that the data were normally distributed, Fisher’s Exact test, Chi-Square test and Student’s t-test were used to compare means for two independent groups. The Mann Withney-U test was used for non-normally distributed variables. The significance level was accepted as p<0.05 in all statistical tests.
A total of 65 patients who were diagnosed with pertussis based on clinical features and PCR test results were included in the study. The age range of the cases is shown in Figure 1. The majority of the cases were male. Twenty percent of the cases were premature and 30.8% were small for gestational age (SGA). There was no comorbidities in 73.8% of the patients. Family members with similar clinical symptoms consistent with pertussis were reported in 21 (32.3%) cases (Table 1). The months of admission in most cases were December and January (Figure 2).
While cough was detected as the presenting symptom in all patients, vomiting was detected in only 8 (12.3%) patients (Table 1). The cough duration was 5.9±2.7 days. There were only 2 cases with a history of cough for 14 days or more. In 5 cases with fever, bacterial pneumonia was diagnosed in the follow-up and additional antibiotic treatment was administered.
The white blood cell count was found to be above 10,000/m³ in 42 (33.6%) patients, but there was no difference in terms of length of hospital stay or PICU need between the groups that were above and below this value (respectively p:0.534; p:0.941). All cases were positive for B. Pertussis . Additional pathogens were detected in 11 cases (16.9%) by PCR tests (Table 1). A total of 3 cases developed bacterial pneumonia with Chlamydia pneumoniae (1 patient) and Streptococcus pneumoniae (2 patients). The hospital stay was 6.8±3.1 days. Oxygen therapy was administered to 57 (87.7%) patients (during episodes or continuously). In the following period, 11 (16.9%) of the cases were referred to the PICU. No mortality was observed.
It was determined that gender (0.321), birth weight (p:0.659), week of birth (p:0.869), white blood cell count (0.435), lymphocyte count (0.111), and CRP (p:0.753) were not associated with the need for PICU. Five of the 11 patients with additional pathogens to B. Pertussis were referred to the PICU, and this rate was significantly higher than those with only B. Pertussis (p=0.006).
Gender (p:0.103), birth weight (0.678), week of birth (0.797), and presence of non-B. Pertussis pathogen (p:584) were not associated with length of hospital stay. No significant difference was found in terms of length of hospital stay and PICU need when the cases were grouped as below three months and above, or below one year old and above.
This study was conducted to present the demographic data of the patients hospitalized for pertussis. The siblings were found to be the primary source of infection. The need for PICU in cases with co-infection was significantly higher than in patients with only B. Pertussis.
It was observed that birth weight, week of birth and age were not associated with length of hospital stay and length of stay in the PICU in children under two years of age. Although pertussis can be seen at any age, it has been shown that pertussis is more frequent and severe, especially in children younger than three months, whose vaccination has not yet been completed [3,4,7,8]. It was observed that week of birth and birth weight were not different between pertussis and non-pertussis cases or between severe and non-severe pertussis cases. Reviews also showed that birth weight was not cited as a pertussis risk factor [8,9-11]. Although it is more common under the age of one, we think that clinicians should be careful with every inpatient under the age of two regardless of month and week of birth.
In this study, siblings were reported as the main source of infection. Although siblings are the primary source of infection in many studies, research has shown that the carrier mothers and sick mothers are more frequent sources of infection than siblings. In many of these studies, it was stated that people with similar symptoms at home could be the source of infection without microbiological testing for B. Pertussis [2,12].
In the study, most cases did not have fever, and half of the patients with fever had additional bacterial pneumonia. Studies have reported that high fever may accompany pertussis, but its effect on the clinical course of the disease has not been clarified. In addition, it was thought that the absence of fever may make caregivers think that it was not a serious disease and may result in late admissions [2,12,13]. Therefore, it was thought that the presence of fever should be evaluated to rule out secondary infections.
In only two cases in the study, the cough lasted 14 days or longer. It has been reported in studies that families mostly present with paroxysmal cough symptoms, and cough lasting more than 14 days is seen only in 50% of cases. This suggests that a coughing period of less than 14 days may delay the diagnosis of pertussis [14,15]. In the literature evaluating diagnostic criteria, it has been shown that 9-27% of cases younger than six months will not be diagnosed unless PCR is performed [16,17]. Evaluation with PCR also helps to detect other pathogens that may accompany B. Pertussis . For this reason, although the cough duration was not sufficient, it was thought that PCR test should be performed in the presence of other criteria.
In this study, white blood cell counts or lymphocyte counts were not associated with the need for PICU. Although lymphocytosis is expected in 50-60% of pertussis cases, it is not always specific and causes cases to be diagnosed as acute bronchitis, bronchiolitis, pneumonia, or secondary infections [7,19]. In addition, high white blood cell and lymphocyte counts have been shown to be a risk factor for early-onset pneumonia and death [4,20]. For this reason, laboratory tests should be evaluated as a whole with the patient’s clinic, and high white blood cell or lymphocyte counts should not be used alone for diagnosis or exclusion of the diagnosis.
Additional pathogens to B. Pertussis were detected in a minority of cases, and the need for PICU in these cases was significantly higher than in patients with B. Pertussis alone. In the literature, the length of hospital stay was found to be longer in patients with B. Pertussis and RSV. While many studies have found that co-infection has no effect on the clinical course of severe and non-serious pertussis, some studies have found more frequent pneumonia symptoms in cases with co-infection [10,11,21]. It was thought that if an agent other than B. Pertussis causes pneumonia, it may affect the clinical course
It was observed that most of the cases presented with a cough lasting less than 14 days. It was also determined that cases with additional pathogens needed more PICU. As a result, it was thought that if there is a clinical suspicion in cases where the probable diagnostic criteria are not met, the diagnosis of pertussis should be confirmed by microbiological tests. In addition, it is thought that predictions can be made about the clinical course with the additional pathogen that can be detected by Polymerase Chain Reaction tests.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Saiki-Macedo S, Valverde-Ezeta J, Cornejo-Tapia A, Castillo MR, Petrozzi-Helasvuo V, Aguilar-Luis MA, et al. Identification of viral and bacterial etiologic agents of the pertussis-like syndrome in children under 5 years old hospitalized. BMC Infectious Diseases. 2019;19(1):75.
2. Valle‑Mendoza J, Silva‑Caso W, Aguilar‑Luis MA, Valle-Vargas CD, Cieza-Mora E, Martins-Luna J, et al. Bordetella pertussis in children hospitalized with a respiratory infection: clinical characteristics and pathogen detection in household contacts. BMC Res Notes. 2018;11(1):318.
3. Phadke VK, McCracken JP, Kriss JL, Lopez MR, Lindblade KA, Bryan JP, et al. Clinical Characteristics of Hospitalized Infants with Laboratory-Confirmed Pertussis in Guatemala. J Pediatric Infect Dis Soc. 2017;7(4):310-6.
4. Mahmoudi S, Banar M, Pourakbari B, Alavi HS, Eshaghi H, Ahari AA, et al. Identification of Etiologic Agents of the Pertussis-like Syndrome in Children by Real-time PCR Method. Prague Med Rep. 2018; 119(1):61–9.
5. Riffelmann M, Littmann M, Hülße C, Hellenbrand W, Wirsing von König CH. Pertussis: not only a disease of childhood. Dtsch Arztebl Int. 2008;105(37): 623–8.
6. Otar G, Kılıç A, Yıldız İ, Varkal MA, Devecioğlu E. Boğmaca Enfeksiyonunun Tanı ve Tedavisi (Diagnosis and Treatment of Pertussis Infection). Çocuk Dergisi/Child Journal. 2014; 14(3):100-7.
7. Hançerli Törün S, Budan Çalışkan B, Salman N, Öksüz L, Somer A, Gürler N. Pertussis Cases Hospitalised During the Winter-Fall-Summer Season of 2010. Çocuk Dergisi/Child Journal. 2010; 10(3): 133-8.
8. Gopal DP, Barber J, Toeg D. Pertussis (whooping cough). BMJ. 2019;364:l401
9. Winter K, Harriman K. Risk Markers for Pertussis Among Infants <4 Months of Age: Understanding the Hispanic Disparity. Pediatr Infect Dis J. 2018;37(2):126-31.
10. Liu C, Yang L, Cheng Y, Xu H, Xu F. Risk factors associated with death in infants <120 days old with severe pertussis: a case-control study. BMC Infect Dis. 2020;16;20(1):852.
11. Kang L, Cui X, Fu J, Wang W, Li L, Li T, et al. Clinical characteristics of 967 children with pertussis: a single‑center analysis over an 8‑year period in Beijing, China. Eur J Clin Microbiol Infect Dis. 2022;41(1):9-20.
12. Merdrignac L, El Belghiti FA, Pandolfi E, Jané M, Murphy J, Fabiánová6 K, et al. Incidence and severity of pertussis hospitalisations in infants aged less than 1 year in 37 hospitals of six EU/ EEA countries, results of PERTINENT sentinel pilot surveillance system, December 2015 to December 2018. Euro Surveill. 2021;26(4):1900762.
13. Cherry JD, Wendorf K, Bregman B, Lehman D, Nieves D, Bradley JS, et al. An Observational Study of Severe Pertussis in 100 Infants ≤ 120 Days of Age. Pediatr Infect Dis J. 2018;37(3):202-5.
14. MuloiwaI R, Nicol MP, Hussey GD, Zar HJ. Diagnostic limitations of clinical case definitions of pertussis in infants and children with severe lower respiratory tract infection. PLoS One. 2020;15(7):e0235703.
15. Levene I, Wacogne I. Question 3. Is measurement of the lymphocyte count useful in the investigation of suspected pertussis in infants? Arch Dis Child. 2011;96(12):1203–5.
16. Fry NK, Duncan J, Wagner K, Tzivra O, Doshi N, Litt DJ, et al. Role of PCR in the diagnosis of pertussis infection in infants: 5 years’ experience of provision of a same-day real-time PCR service in England and Wales from 2002 to 2007. J Med Microbiol. 2009; 58(Pt 8):1023–9.
17. Pavic-Espinoza I, Bendezu-Medina S, Herrera-Alzamora A, Weilg P, Pons MJ, Aguilar-Luis MA, et al. High prevalence of Bordetella pertussis in children under 5 years old hospitalized with acute respiratory infections in Lima, Peru. BMC Infect Dis. 2015;2(15):554.
18. Gökçe Ş, Kurugöl Z, Aydemir Ş, Çiçek C, Aslan A, Koturoğlu G. Bordetella Pertussis Infection in Hospitalized Infants with Acute Bronchiolitis. Indian J Pediatr. 2018;85(3):189-93.
19. Winter K, Zipprich J, Harriman K, Murray EL, Gornbein J, Hammer SJ, et al. Risk Factors Associated With Infant Deaths From Pertussis: A Case-Control Study. Clin Infect Dis. 2015;61(7):1099-106.
20. Cherry JD, Paddock CD. Pathogenesis and histopathology of pertussis: implications for immunization. Expert Rev Vaccines. 2014;13(9):1115-23.
21. Jiang W, Wu M, Chen S, Li A, Wang K, Wang Y, et al. Virus Coinfection is a Predictor of Radiologically Confirmed Pneumonia in Children with Bordetella pertussis Infection. Infect Dis Ther. 2021;10(1):335-46.
Download attachments: 10.4328:ACAM.21146
Özlem Üzüm, Tuba Tınastepe, Yavuz Demirçelik, Hacer Örsdemir Hortu, Gülberat İnce, Ali Kanık, Kayı Eliaçık, Mehmet Helvacı. Our experience with hospitalized children with pertussis. Ann Clin Anal Med 2022;13(8):887-890
The relationship of serum copper and zinc levels with oxidative stress markers and other laboratory parameters in COVID-19 patients
Ugur Fahri Yurekli 1, Umran Liste 2
1 Department of Medical Biochemistr, 2 Department of Medical Microbiology, Sanlıurfa Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
DOI: 10.4328/ACAM.21147 Received: 2022-03-16 Accepted: 2022-04-18 Published Online: 2022-05-27 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):891-894
Corresponding Author: Ugur Fahri Yurekli, Department of Medical Biochemistr, Sanliurfa Mehmet Akif Inan Education and Research Hospital, Şanlıurfa, Turkey. E-mail: firstname.lastname@example.org P: +90 532 777 93 99 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7969-5196
Aim: Serum Copper (Cu) and Zinc (Zn) levels can be associated with novel coronavirus disease 2019 (COVID-19). However, the correlation of serum Cu and Zn levels with biochemistry, hormones, and coagulation parameters has not been fully revealed. This study aims to determine serum Cu and Zn levels and their relationships with other laboratory parameters in the acute phase of COVID-19.
Material and Methods: This retrospective observational study was conducted with patients who were diagnosed with COVID-19 in a tertiary hospital. The study was continued with the remaining 116 people: 53 healthy and 63 SARS-CoV-2-positives seriously ill. All laboratory data were retrospectively scanned from patient files at the hospital information system.
Results: It was found that serum Cu, G6PD and TAS levels decreased, Zn TOS and OSI levels increased when COVID-19 patients were compared with healthy individuals. There is a positive correlation between serum Cu level and AST in COVID-19 patients, and a negative correlation between total bilirubin and LDH. There is a negative correlation between serum Zn levels and direct bilirubin, CRP, and procalcitonin.
Discussion: Many studies have been reported showing that both Cu and Zn have antiviral effects against COVID-19. Although our data support these studies, it has been revealed that serum Cu and Zn levels were correlated with AST, direct/total bilirubin, LDH, CRP, and prolactin.
Keywords: COVID-19, Copper, Zinc, G6PD, OSI
The current coronavirus disease-2019 (COVID-19) pandemic is due to the new coronavirus SARS-CoV-2. COVID-19 is a respiratory disease caused by a novel enveloped, positive-sense, single-stranded RNA betacoronavirus, denoted as SARS-CoV-2 . Replication of the viral genome within infected cells is a key stage of the SARS-CoV-2 life cycle. It is a complex process involving the action of several viral and host proteins to perform RNA polymerization, proofreading, and final capping . Once inside the cell, the infected RNA acts as a messenger RNA (mRNA), which is then translated by the host’s ribosomes to produce the viral replicative enzymes, which generate new RNA genomes and mRNAs for the synthesis of the components necessary to assemble the new viral particle .
Data gleaned from animal and clinical studies have highlighted the prominent roles of Zn and Cu in various biological processes as a cofactor, signaling molecule, and structural element. These essential trace elements are a constituent of more than 300 metalloenzymes that participate in several cellular and metabolic processes, such as cell proliferation, differentiation, stabilization of cell membranes, redox signaling, apoptosis, RNA/DNA synthesis, and metabolism of micro-and macronutrients .
Zn is known to exhibit a variety of direct and indirect antiviral properties. Previous literature has demonstrated that Zn homeostasis is interconnected with the emergence of infections related to coronaviridae . Zn displays antiviral properties by several physical processes, including virus attachment, penetration, infection, uncoating, and replication .
Cu exhibits potent virucidal properties and is thus known to neutralize a wide range of infectious viruses, such as bronchitis virus, poliovirus, influenza virus, HIV type 1, and other enveloped or nonenveloped, single- or double-stranded DNA and RNA viruses . An in vivo study showed that Cu ions block the activity of papain-like protease-2, which is essential for the process of SARS-CoV-1 replication .
Studies have shown that Zn and Cu are components of many viral enzymes, proteases and polymerases, and that these elements are important in preventing systemic cell homeostasis and viral infection. In addition, Zn and Cu are involved in the regulation of cellular oxidative stress. The aim of this study is to compare serum zinc and copper levels with parameters that are indicative of prognosis in COVID-19 patients. In addition, it was aimed to determine the relationship of these elements with oxidative stress.
Material and Methods
This study was carried out on adults with COVID-19 admitted to Şanlıurfa Mehmet Akif İnan Research and Education Hospital, Turkey, from January to February 2020. For the diagnosis of SARS CoV-2 infection, the real-time polymerase chain reaction (RT-PCR) test of the nasopharyngeal and oropharyngeal samples was evaluated. The group consisted of SARS-CoV-2 positive severe patients hospitalized in the intensive care unit. All patients have <92 SaO2. The control group consisted of 50 healthy adults. This study has been approved by the Ethics Committee of Mehmet Akif İnan Education and Research Hospital and the Turkish Ministry of Health (E1-20–1009).
The RT-PCR results and biochemistry data of all patients treated in any clinic in our hospital who tested positive for COVID-19 were obtained from the hospital system. Their biochemistry parameters (glucose, urea, creatine, ALT, AST, total bilirubin (T-bil), direct bilirubin (D-bil), GGT, Na, K, and CRP), hormone parameters (procalcitonin, ferritin, CK-MB, and troponin), coagulation parameters (fibrinogen), procalcitonin, and D-dimer levels were studied. Biochemistry-Hormone-D-Dimer analysis, Roche Cobas 8000. Coagulation was measured automatically with Sysmex cs2500 devices (Sysmex Inc., Japan).
Cu and Zn in serum were determined by flame atomic absorption spectrometry (FAAS; Perkin Elmer AAnalyst 400, USA). Cu and Zn were measured at 324.8 nm and 213.9 nm, respectively.
Total oxidant status (TOS) and total antioxidant status (TAS) were measured using Erel’s methods . The ratio of TOS level to TAS level was accepted as the oxidative stress index (OSI). The OSI value was calculated according to the following formula . OSI (Arbitrary Unit)=TOS (µmol H2O2 Equiv/L)/TAC (mmol Trolox Equiv/L).
The evaluation of the data was performed with the SPSS 21.00 program. Descriptive statistics were used. Mean, Standard deviation and percentages are given as descriptive statistics. Conformity of the variables to the normal distribution was examined using the visual Shapiro-Wilk test. Numerical variables, determined according to the state of normal distribution were evaluated using the independent sample T-test between the two groups. Spearman’s Correlation analysis was applied to determine the relationship between numerical variables. Correlation coefficient was accepted as 0.05-0.30 low, 0.30-0.40 low-moderate, 0.40-0.60 moderate, 0.60-0.70 good, 0.70-0.75 very good, 0.75-1.00 excellent correlation. In the statistical analyzes in the study, comparisons with a p-value of less than 0.05 were considered statistically significant.
A total of 116 people, 53 healthy and 63 SARS-CoV-2-positive seriously ill patients, were included in this study. Of these, 58.7% were male and 41.3% were female. The age of the evaluated patients was between 23-92 years, and the mean age was calculated as 67.87±14.38 years. Biochemical parameters are shown in Table 1.
In the COVID-19-positive patient group, t copper level of women was found to be higher than that of men. But the difference between the groups was not significant. There is a positive significant relationship between copper level and AST (r=0.36; p=0.01) and LDH (r=0.32; p=0.02) and a significant negative correlation between copper level and T-Bil (r=-0.28; p=0.03).
In the COVID-19 positive patient group, it was found that the zinc level in COVID-19 positive patients did not differ significantly by gender (p>0.05 and Table 1). There was a negative correlation between zinc level and DBil (r=-0.27; p=0.03), CRP (r=-0.26; p=0.04) and procalcitonin (r=-0.37; p=0.01 and Table 1).
Serum Cu and Zn levels from the patient and control groups were compared. It was found that the serum Cu level was significantly lower (patient 68.59±20.7 μg/dL; control 137.0±17.1 μg/dL p<0.0001) and the Zn level was significantly higher (patient 105.8±32.9; control 87.45±87.45; p=0.001) in COVID-19 patients (Table 1 and Figure 1).
Oxidative stress parameters were studied in COVID-19 patients and control group (Figure 1). TAS and G6PD (glucose-6-phosphate dehydrogenase) values were found to be significantly lower (p=0.0001 and p=0.001, respectively), and TOS and OSI values were found to be significantly higher in patients compared to the control group (p=0.005 and p=0.0005, respectively)
The inflammatory response plays a critical role in COVID-19, and the inflammatory cytokine storm increases the severity of COVID-19 . Elements such as zinc and copper are well known for their regulatory character in controlling oxidative stress and inflammatory cytokine . Our study showed that serum zinc and copper levels have a relation with infection and inflammation status. Zinc is negatively correlated and copper is positively correlated with inflammation in COVID-19 patients. Our findings in this study support these studies. We found that the Cu level was low and the Zn level was higher in COVID-19 patients compared to the control group consisting of healthy people.
As is known, the barrier function of the immune system acts to prevent pathogens from entering the body from the external environment. Many studies have shown that zinc supplementation improves lung integrity. Disturbances in the integrity of the respiratory epithelium facilitate the entry of COVID-19 as well as co-infecting pathogens and can lead to pathogens entering the bloodstream [11 12]. However, during the acute phase of infection, zinc uptake into cells and urinary excretion of zinc increase, which may lead to a decrease in serum zinc levels . Therefore, with these mentioned mechanisms, zinc plays an important role in the inflammatory response and tends to decrease during the acute phase by increasing zinc uptake into cells. It is seen that the mean zinc level in our patients are close to the lower limit of normal and even lower in men with severe COVID-19. On the other hand, serum zinc level was found to be negatively correlated with D-bil, CRP, and procalcitonin, but positively correlated with D-vit. Recent systematic reviews and meta-analyses of trials with zinc report faster healing from common cold, reduced incidence and prevalence of pneumonia, and reduced mortality when given to severe pneumonia [14 15]. Thus, first results and treatment regimens regarding zinc and D-vit supplementation for COVID-19 risk groups and patients can be anticipated soon .
Copper is an essential micronutrient for both pathogens and the patients they infect. There is a progressive increase in serum copper in many cases of infection . When looking at infections in the literature, studies showed that serum copper and urinary copper levels increased in chronic Hepatitis B and HIV patients compared to controls . Our data showed that serum copper level was elevated in severe COVID-19 patients. Serum copper level was found to correlate negatively with total bilirubin and fibrinogen and positively with AST and LDH.
This study showed that serum zinc levels increased, serum copper and G6PD levels increased and decreased in patients diagnosed with COVID-19 compared to controls. In COVID-19 infection, the relationship between zinc, copper, and G6PD changes and oxidative stress index has been demonstrated. These results demonstrated the recently discussed association of zinc with COVID-19 disease. This effect will be better revealed in more comprehensive studies to be planned in the future.
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1. Romano M, Ruggiero A, Squeglia F, Maga G, Berisio R. A Structural View of SARS-CoV-2 RNA Replication Machinery: RNA Synthesis, Proofreading and Final Capping. Cells. 2020;9(5):1267.
2. Rani I, Goyal A, Bhatnagar M, Manhas S, Goel P, Pal A, et al. Potential molecular mechanisms of zinc- and copper-mediated antiviral activity of COVID-19. Nutr Res. 2021;92:109-28.
3. te Velthuis AJ, van den Worm SH, Sims AC, Baric RS, Snijder EJ, van Hemert MJ. Zn(2+) inhibits coronavirus and arterivirus RNA polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture. PLoS Pathog. 2010;6(11):e1001176.
4. Read SA, Obeid S, Ahlenstiel C, Ahlenstiel G. The Role of Zinc in Antiviral Immunity. Adv Nutr. 2019;10(4):696-710.
5. Skalny AV, Timashev PS, Aschner M, Aaseth J, Chernova LN, Belyaev VE, et al. Serum Zinc, Copper, and Other Biometals Are Associated with COVID-19 Severity Markers. Metabolites. 2021;11(4):244.
6. Baez-Santos YM, St John SE, Mesecar AD. The SARS-coronavirus papain-like protease: structure, function and inhibition by designed antiviral compounds. Antiviral Res. 2015;115:21-38.
7. Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem. 2005;38(12):1103-11.
8. Karaagac L, Koruk ST, Koruk I, Aksoy N. Decreasing oxidative stress in response to treatment in patients with brucellosis: could it be used to monitor treatment? Int J Infect Dis. 2011;15(5):e346-9.
9. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
10. Aggarwal J, Singh A, Gupta S, Prasad R. Copper and Zinc Status in Psoriasis: Correlation with Severity. Indian J Clin Biochem. 2021;36(1):120-3.
11. Wessels I, Pupke JT, von Trotha KT, Gombert A, Himmelsbach A, Fischer HJ, et al. Zinc supplementation ameliorates lung injury by reducing neutrophil recruitment and activity. Thorax. 2020;75(3):253-61.
12. Bao S, Knoell DL. Zinc modulates cytokine-induced lung epithelial cell barrier permeability. Am J Physiol Lung Cell Mol Physiol. 2006;291(6):L1132-41.
13. Melichar B, Malir F, Tichy M. Urinary zinc excretion in patients with different disorders: the acute phase response in the kidney. Sb Ved Pr Lek Fak Karlovy Univerzity Hradci Kralove. 1993;36(4-5):325-35.
14. Hemila H. Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage. JRSM Open. 2017;8(5). DOI: 10.1177/2054270417694291.
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Ugur Fahri Yurekli, Umran Liste. The relationship of serum copper and zinc levels with oxidative stress markers and other laboratory parameters in COVID-19 patients. Ann Clin Anal Med 2022;13(8):891-894
Effects of migraine on anxiety, depression symptoms and quality of life: A hospital-based study
Cennet Buyukyoruk 1, Ruhusen Kutlu 1, Emine Genc 2
1 Department of Family Medicine, 2 Department of Neurology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
DOI: 10.4328/ACAM.21155 Received: 2022-03-21 Accepted: 2022-07-25 Published Online: 2022-07-29 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):895-899
Corresponding Author: Ruhusen Kutlu, Department of Family Medicine, Meram Medical Faculty, Konya Necmettin Erbakan University, 42080, Konya, Turkey. E-mail: email@example.com P: +90 332 223 66 01 F: + 90 332 223 61 81 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8502-0232
Aim: Migraine has a great detrimental effect on the daily life of the patient by making negative effects on socioeconomic functioning and quality of life. In this study, it was aimed to evaluate the symptoms of anxiety, depression and quality of life in patients with and without migraine and to determine the factors affecting them.
Material and Methods: This analytical typed case-control study was conducted on 402 people over the age of 18. 201 of whom had migraine and 201 did not have migraine. Hospital Anxiety and Depression Scale (HADS) and World Health Organization Quality of Life Scale Short Form (WHOQOL-BREF TR) were used to collect data about patients.
Results: In the present study, 90.5% (n=182) of patients with migraine were female, 80.1% were married, 58.2% had secondary school education, 21.9% were smokers. Among the factors that triggered the migraine attack, noise ranked first with a frequency of 78.1% (n=157). Anxiety and depression scores were significantly higher in those with migraine than in those without migraine (p<0.001). Quality of life parameters such as physical health, psychological health, social relations and environmental area scores were significantly higher in those without migraine than in those with migraine (p<0.001). General health and life satisfaction of the individuals without migraine were significantly higher (p<0.001).
Discussion: Migraine must be taken seriously since it has a negative impact on patients’ lives. Besides medical treatment, patients should be evaluated carefully for their quality of life and psychiatric conditions. As family physicians, we must approach our patients holistically.
Keywords: Anxiety, Depression, Migraine, Quality of Life
Migraine is a very common neurobiological headache disorder that can affect the daily life of the patient and cause limitations in the activities performed during the day [1-3]. The incidence of migraine in young women is three times higher than in men. It is known that approximately 20% of women and 8% of men suffer from migraine. In addition to headache, symptoms of migraine are hypersensitivity-reactivity, anxiety, depressive mood, decreased attention, stuttering, increased sensitivity to light-sound-smell, abdominal distension, constipation or diarrhea. It affects patients’ quality of life and impairs work, social activities, and family life [4-6].
It is known that anxiety and depression disorders are the most relevant psychiatric comorbidities associated with migraine and have been shown to affect the clinical course of the disease and response to treatment. There is limited information on how specific anxiety and depression symptoms are related to migraine [7-12].
Quality of life (QoL) has a broad structure encompassing many aspects of well-being, including physical, psychological, social and environmental components. QoL is the way people evaluate all aspects of their lives in terms of their cultural structures and set of values. Quality of life is a broad concept that includes personal well-being beyond a person’s health status. Conditions that cause chronic pain, such as migraine, negatively affect the quality of life. This reduces people’s ability to cope with life’s difficulties [13-15]. Migraine should be considered with all its consequences, keeping in mind that it is not only a pain but also causes other problems .
In this study, it was aimed to evaluate the symptoms of anxiety, depression and quality of life in patients with and without migraine and to determine the factors affecting them.
Material and Methods
Study design, setting, and population
This analytical case-control study was conducted on 402 adult subjects with and without migraine between 01.03.2014 and 06.02.2017. The case group consisted of 201 patients with new and/or previous migraine diagnosis who applied to the neurology outpatient clinic. The control group consisted of 201 people who applied to the family medicine outpatient clinic for any reason and had no migraine complaints. Both groups were kept the same in terms of age and gender. According to the literature, the prevalence of headaches in our country has been reported to be approximately 16.4% . Since the number of individuals in the universe was not known in our study, the number of subjects required to be included in the study was calculated using the formula “n=t².p.q/d².” Therefore, 402 people over the age of 18, including with 201 migraine and 201 without migraine, were included in our study.
Before the study started, ethical approval for the study was received from the Ethics Committee of Meram Faculty of Medicine, Konya Necmettin Erbakan University (approval number: 2014/597). Participants were informed about the study and their written and verbal consent was obtained according to the principles of the Helsinki Declaration.
Those with chronic organic disorders, which can affect life quality (chronic kidney and liver disease, hematologic disease, cancer history, uncontrolled hypertension and intracranial space occupying lesion, etc.), those with psychiatric disease, under the age of 18, those who were mentally retarded and pregnant and the individuals who did not give written consent to participate in the study, were not included in the research.
Collection of data
During the study, patients were briefly informed about the aim of the study, verbal and written consent of the patients was obtained. Questioning of the sociodemographic characteristics of the participants (age, marital status, profession, income level, etc.) was conducted using the face-to-face interview technique. To determine anxiety and depression of the participants, Hospital Anxiety and Depression Scale (HADS) was used. World Health Organization Quality of Life Scale Short Form WHOQOL-BREF TR was used to determine quality of life of the patients.
World Health Organization Quality of Life Scale Short Form (WHOQOL- BREF TR)
WHOQOL-BREF is a 26-question self-report questionnaire developed by the World Health Organization to investigate the quality of life (QoL) . The first question asks about overall QoL, rated from “very bad” (1) to “very good” (5). The second question asks about satisfaction with health, rated from “very dissatisfied” (1) to “very satisfied” (5). The remaining 24 specific questions assess four QoL domains: physical (7 items), psychological (6 items), social relationships (3 items), and environmental (8 items). The score for each domain ranges from 4 to 20; high values represent high QoL. The Turkish validity and reliability study of this questionnaire in our country was conducted by Eser et al. .
Hospital Anxiety and Depression Scale
To determine anxiety and depression, the Hospital Anxiety and Depression Scale (HADS) was used. The scale was developed by Zigmoid and Snaith (1983) to determine the risk for the patients in terms of anxiety and depression and to measure the level and intensity . A validity and reliability study of the scale was conducted by Aydemir et al. (1997) in Turkey . For those with physical disease and who apply to primary care health services, it is used not to diagnose but to identify anxiety and depression in a short time and to determine the risk group. The scale contains 14 questions, and odd numbers measure anxiety, even numbers measure depression. The responses are scored in quadruple Likert form and between 0-3. The lowest score that the patients can get from both subscales is 0 and the highest score is 21. The breakpoints of the Turkish form of HADS were determined as 10/11 for the anxiety subscale (HAD-A) and as 7/8 for the depression subscale (HAD-D) .
SPSS for Windows 20.0 software (SPSS Inc, Chicago, IL, USA) was used for the statistical analysis. Descriptive statistics for continuous variables were given in terms of average and standard deviation, and descriptive statistics for categorical data were given in terms of frequency and percentage. The Chi-square test was used to compare categorical data. The Kolmogorov-Smirnov test was used for the distribution of quantitative data. Student t-test was used to compare quantitative data in paired groups, as they showed normal distribution. The results were evaluated at a 95% confidence interval, and the significance was p<0.05. Correlation between parameters was performed by Pearson correlation analysis. The correlation coefficient (r) was evaluated as weak between 0.00–0.249; moderate between 0.250–0.499; strong between 0.500–0.749 and very strong between 0.750–1.000.
The mean age of patients with migraine was 35±9.68 years (ranging from 18 to 65 years), 90.5% (n=182) female, 80.1% married, 58.7% (n=118) overweight, 58.2% (n=117) primary school educated, 71.1% (n=143) non-working and 21.9% (n=44) were smokers. The socio-demographic characteristics of the participants were presented in Table 1.
The first-degree relatives of 46.8% (n=94) of 201 migraine patients had migraine. During the attack, 75.6% (n=152) of the patients with migraine used pain medication, and 41.8% (n=84) preferred to stay in a dark room. During migraine attack, 75.1% (n=151) had nausea-vomiting, 74.6% (n=150) had sensitivity to light and sound, and 71.1% (n=143) had insomnia accompanied by headache, respectively. There was a factor that triggered the attacks in 194 (96.5%) of the migraine patients. Among these factors, noise ranked first with a frequency of 78.1% (n = 157). In descending order, 70.1% (n=141) insomnia, 68.7% (n=138) light, 62.7% (n=126) hunger, 45.8% (n=92) stress triggered migraine attacks.
When HADS scores of migraineurs with attack frequency less than 5 per month (low- frequency group; LFG) were compared to those with attack frequency of more than 5 per month (high- frequency group; HFG), we observed that depression scores were higher in patients with higher attack frequency. Anxiety scores were not significantly different between groups regarding attack frequency.
While the number of migraine attacks was higher in those with a low education level, it was less common in those with a high level of education. This difference was statistically significantly higher (χ2=11.061; p=0.001). When the number of attacks per month and age, BMI, marital status, occupation, economic status and smoking were compared, no statistically significant difference was found (p>0.05).
When patients with and without migraine were compared in terms of general health and quality of life, it was found that the control group was better. This relationship was statistically significant (χ2 = 36.99; p<0.001). When we compared the two groups in terms of general health and life satisfaction, we found that life satisfaction of the individuals without migraine was significantly higher (χ2= 126.097; p<0.001) (Table 2). QoL parameters such as physical health, psychological health, social relations and environmental area scores were significantly higher in those without migraine than in those with migraine (p<0.001). The comparison of domain scores of WHOQOL-BREF in the migraine and not migraine is shown in Table 2. Anxiety and depression scores were significantly higher in those with migraine than in those without migraine (p<0.001) (Table 2).
Correlation of depression, anxiety and QoL parameters such as physical health, psychological health, social relations and environmental in migraine patients is shown in Table 3.
It was discovered in clinical and population-based studies that people with migraine have higher levels of psychiatric disturbances such as depression, anxiety and post-traumatic stress disorder . In a study by Senaratne et al., migraine prevalence and its characteristics were investigated on 206 patients who applied to an anxiety disorder clinic and migraine prevalence was found to be 67%. In this study, it was shown that migraine frequency in anxiety disorder patients increased compared to the general population . In a study performed by Sharma et al. in India on 71 migraine patients using HADS scale, depression and anxiety were more common in migraine patients . In this study conducted on migraine patients using the HADS anxiety depression scale, more depression and anxiety were found in migraine patients than in the control group. Similarly, our results showed that migraine patients had significantly higher depression and anxiety symptoms than healthy controls. Also, depression frequency was significantly higher in married and non-working women with low educational level compared to working women, suggesting that well educated and working women might have developed better skills to cope with anxiety or depression.
In clinical trials, not only headache severity but also headache frequency increases depression and anxiety disorders. In a study performed by Smitherman et al. (2013), it was stated that migraine causes an increase in other physical psychiatric comorbidities depending on headache frequency . Similarly, in our study, depression was seen more often in migraineurs with frequent attacks. However, no difference was observed between migraineurs with high and low frequency attacks in terms of anxiety. In alignment with our results, Irimia et al found that even low frequency headache sufferers showed increased risk of anxiety .
Different studies suggest that the risk of depression is increased in patients with frequent migraine attacks. However, the cut-off point for an increased risk of depression might differ between studies. Contrary to our results, Irimia et al. (2021) found a high headache day threshold for depression, far exceeding the threshold for headache chronicity. We observed that our patients’ threshold of attack frequency for developing depression is much lower than this, even below the frequency threshold per month for chronic migraine. This result is in accordance with several studies suggesting that migraine patients are at risk of depression when the cut-off point for attack frequency is below 15 attacks per month .
Like all chronic diseases, migraine negatively affects the quality of life and reduces the individual’s taste of life, negatively affecting social and physical functions. In our study, the mean score in migraine patients in all domains of WHQOL was significantly lower than in those without migraine. In a study by Sharma et al. (2013) on 71 migraine patients who had just been diagnosed, it was found that life quality was worse than in the control group in all subscales of SF 36 . In another study conducted in Malaysia, females with migraines had significantly lower total, physical and psychological WHOQOL-BREF scores than healthy controls. Contrary to our results, which demonstrated significantly lower scores on social relationship and environmental domains, they reported still lower but not statistically significant scores on both of these domains . The lower WHOQOL scores in our study could be ascribed not only to poor management of migraine attacks, but also to higher anxiety and depression scores in migraineurs.
In conclusion, migraine is not a simple complaint of a headache but it is an important health problem affecting the quality of life with frequent psychiatric diseases. For this reason, psychiatric complaints in patients with migraine diagnosis should be questioned and both diseases should be taken into account during treatment plan if a psychiatric disease has occurred. Psychiatry, neurology and family practice branches should work together in the development of overcoming stress. The goal in the treatment of migraine should not be only to relieve of headache but also to increase the life quality of the patients.
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Animal and human rights statement
Conflict of interest
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Download attachments: 10.4328:ACAM.21155
Cennet Buyukyoruk, Ruhusen Kutlu, Emine Genc. Effects of migraine on anxiety, depression symptoms and quality of life: A hospital-based study. Ann Clin Anal Med 2022;13(8):895-899
Characteristics and management of consultations requested from the emergency department and other outpatient clinics in a surgical oncology clinic
Şeref Dokcu 1, Mehmet Ali Çaparlar 2, Özhan Çetindağ 2, Musluh Hakseven 2, Salim Demirci 2
1 Department of Surgical Oncology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, 2 Department of Oncological Surgery, Faculty of Medicine, Ankara University, Ankara,Turkey
DOI: 10.4328/ACAM.21157 Received: 2022-03-22 Accepted: 2022-04-22 Published Online: 2022-05-16 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):900-904
Corresponding Author: Şeref Dokcu, Department of Surgical Oncology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Üçkuyu Mh., 21010, Kayapınar, Diyarbakır, Turkey. E-mail: firstname.lastname@example.org P: +90 533 443 43 33 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1807-8108
Aim: Interdepartmental collaboration is sought through consultations, which represent a common and important aspect of medical practice. Despite its importance, we have very little information due to the limited number of studies. In this study, we aimed to examine the differences between departments, as well as the characteristics and functioning of consultations requested from a surgical oncology clinic.
Material and Methods: Two hundred eighty-seven consecutive consultations requested by the emergency department and other departments were included in the study. The patients were categorized according to the characteristics of the consultations. The relationship between categorical variables was analyzed with the chi-square (χ2 test) test or Fisher’s exact test.
Results: Most consultations were requested during working hours (85%) and on weekdays (90%). Only 65% of the request forms contained sufficient information. The most common consultation request was from the emergency department (42%), the most common diagnosis was gastric cancer (24%), and the most common reasons for the request were surgical evaluation (30%) and bowel obstruction (29%). Only one interview was conducted with 56% of patients to end the consultation. Patients with a high Charlson comorbidity index were more likely to undergo major surgery (p = .004). Emergency department consultations were associated with early admission (p=0.00). Inadequate request forms were also associated with emergency department consultations (p=0.00).
Discussion: It should be noted that the inadequacy of the consultation text, which can be considered a communication failure during the consultation process, is not uncommon.
Keywords: Consultation, Emergency Medicine, Emergency Service, Medical Interconsultation, Patient Management
Consultation represents a common and important aspect of medical practice that requires a multidisciplinary approach. Hospital departments request the cooperation of other departments through medical consultations in the diagnosis and treatment stages of patients. When specialist assistance is required, prompt consultations are vital to provide patients with good medical care. This activity entails a significant workload in hospitals. However, it has also been shown that inpatient palliative care consultation programs save money in hospitals and provide better care for patients with serious illnesses . Despite its importance, we know very little about this cooperation system between departments, as there are limited studies. COVID-19 has had a disastrous impact on health systems, jeopardizing the treatment of cancer patients. It has an increasing disease burden in the cancer population. As a result, tele-oncology services have become necessary to reduce cancer patients’ risk of exposure to the deadly pathogen. Many government agencies have approved the use of tele-oncology during the COVID-19 era. Experience during the epidemic has shown that providing online treatment via videoconferencing is effective and well accepted by patients as it simulates a face-to-face meeting . Video consultation is a special type of telemedicine that uses technology to provide remote real-time audio-visual patient assessment. There was evidence showing that it was both feasible and effective for use in the clinical care of oncology patients in the pre-epidemic period . In fact, voice recording follow-up consultations are used by most clinics as an inexpensive procedure appreciated by the majority of patients .
Physicians may request a consultation in cases where they deem necessary. At the end of this process, the department consulted should provide one of the following recommendations: admission, discharge with or without physician follow-up, or consultation with another department. . Mutual consultations have many issues, including the enforcement mechanism, limitation/transfer of liability, and flaws in communication. It is essential to have knowledge about these issues, to plan the work to be done in mutual consultation and to correct the issues that prevent their correct implementation [6,7].
There is very little information about the functioning of the consultation mechanism in Turkey, as in the rest of the world. Most of the existing studies, on the other hand, are mostly related to the emergency service consultation process reported by emergency physicians [8,9]. Surgical oncology clinics operate differently from other internal branch departments . The positive impact of a well-functioning consultation mechanism on the quality of health delivery is obvious.
In this study, we aimed to evaluate the characteristics and management of consultations requested from our surgical oncology clinic, the causes of poor functioning, if any, and possible differences between departments. Our study is the first report that, to the best of our knowledge, evaluates consultations requested from the surgical oncology department.
Material and Methods
The study design was retrospective. The study was approved by the Medical Ethics Review Committee of Ankara University (Decision no: İ5-349-21, Date: 02-07-2021). The study was conducted in accordance with the Declaration of Helsinki. Between January 2018 and May 2021, medical records of 336 patients who were consulted in our Surgical Oncology clinic, primarily in the emergency department and other external clinics, were collected retrospectively in a single center through the electronic data system.
Forty-nine patients were excluded and 287 patients were included in the study due to deficiencies in their data or the inability to reach the consultation request note. Patients were documented according to their demographic and clinical characteristics, and clinicopathological variables were recorded. The adequacy of the request text was evaluated by examining the consultation texts by two specialist physicians. Consultations were categorized according to the time of the request, the department making the request, and the reasons for the request. The patients were categorized according to the type of the first operation as major surgeries with resection and reconstruction, palliative minor interventions, and non-operated ones. In addition, medical treatment was classified as minor interventions (Paracentesis, PEG, Jejunostomy, Celiac and hypogastric nerve blocks, etc.), major interventions (bridectomy, organ resections and anastomosis) according to the treatment applied before and after hospitalization. Charlson comorbidity indexes were calculated from the files of all patients and included in the analysis.
All data analyses were performed using SPSS version 24.0 and data are presented as mean ± standard deviation (SD), median (min-max) for nonnormally distributed variables, and many cases and percentages (%) for nominal variables. The relationship between categorical variables was analyzed with the chi-square (χ2 test) test or Fisher’s exact test. Since no normal distribution was observed in the correlation analysis between the variables, the analysis was performed with the Spearman correlation test. Statistical analyses were performed with a confidence interval of 95 % and a p-value less than 0.05 was considered statistically significant.
The number of patients who were asked for consultation from our clinic within the specified period and included in the study was 287. The mean age of the patients was 58.87±15.2 (18-92) years; 141 (69%) of them were female and 146 (51%) were male. Patients who planned to be hospitalized could be admitted to our clinic after an average of 2.4±2(1-14) days. However, most patients (56.1%) were hospitalized within the first day. The mean Charlson comorbidity index was 5.9 ± 3.7 in total, 4.5±2.3 in those who had medical treatment and minor interventions, and 7.8± 4.2 in those who had major surgery. In the correlation analysis, patients with a high Charlson comorbidity index were found to be more likely to undergo major surgery (p = .004).
Characteristics of consultations
Departments requesting a consultation
The distribution of consultation requests by departments is shown in Table 1. The relationship between the departments that requested termination of the consultation and frequency of requests differed significantly in the chi-square analysis (p=0.00). Accordingly, the frequency of visits to the emergency department was associated with the excess. Likewise, this relationship with hospitalization time was also significant (p=0.00). Emergency service consultations were associated with early admission.
Reason for a consultation request
Of the requested consultations, 85 (29.6%) underwent surgical indication evaluation, 82 (28.6%) ileus-subileus, 22 (7.7%) peritonitis carcinomatosis and ascites, 22 (7.7%) distant metastases, 18 (6.3%) ) were requested for anastomotic leakage and abscess, and 14 (4.9%) for diagnosis biopsy, 10 (3.5%) patients for GIS bleeding, local recurrence and nutritional evaluation, 14 (4.9%) for minor surgical interventions. Minor surgical procedures requested were port insertion, paracentesis, and core biopsy. A correlation was found between the reasons for consultation and the duration of admission to the clinic (p=0.00). Patients with pathology requiring emergency surgery (bleeding, ileus, anastomotic leakage, etc.) were hospitalized earlier (1 day), while patients who could be considered elective (biopsy, surgical indication, nutritional status assessment, etc.) were hospitalized for a longer time (≥2 days). Of the consultations, 171 (59.6%) were requested for elective reasons and 116 (40.4%) for urgent reasons.
In 196 (68.3%) patients whose consultation request forms were examined, the forms were sufficient, while the request forms of 91 (31.7%) patients were considered insufficient. In the correlation analysis, the admission time to our clinic was longer in patients whose request form contents were not sufficient (p=0.012). In addition, in the analysis performed with the clinics that made the request, we found that insufficient requests were associated with the emergency department (p=0.00).
The distribution according to the consultation request time and frequency is shown in Table 1.
The distribution of the patients according to their diagnosis is shown in Table 2. The majority of the rare malignancies group consisted of melanomas, skin tumors, and soft tissue sarcomas.
The treatment characteristics of the patients are shown in Table 2. After the consultation, major operations such as bridectomy, resection, and reconstruction were performed in 144 (50.2%) patients, and noninvasive and minor interventions (such as paracentesis, PEG, nerve blockade) were performed in 57 (19.9%) patients, but only 86 (30%) patients. He was given medical treatment without intervention. However, 86 (30%) of them were given medical treatment without any intervention.
Consultations have an important place as a widely used consultation and support request mechanism among different disciplines of medicine. Despite its importance, we know very little about this mechanism of collaboration between departments, particularly about identifying shortcomings from both perspectives. The ineffectiveness of mutual consultations also brings an economic cost .
For the effectiveness of these consultations, the centers record the consultation request and response texts, providing a preliminary preparation for other physicians who will evaluate the patient, and providing a basis for solving possible medico-legal legal problems. For this reason, the consultation texts must be filled in clearly and precisely. We determined that one-third (32%) of the consultation forms we examined in our study were problematic and inadequate. In our analysis, we found that this situation prolonged patient admission times. In particular, we encountered this problem in half of the consultations requested from the emergency department. In fact, in the analysis, the relationship between problematic requests and emergency services was significant. This explains the frequency of multiple visits to the emergency department, which has reached statistical significance. In a study conducted by scoring the adequacy of consultation forms requested from an internal medicine department, only 38.3% of emergency service consultations and 43.4% of inpatient consultations were determined to be good or very good. Consultation request texts are generally insufficient and do not inform the relevant physicians sufficiently .
One of the reasons for the high frequency of visits to the emergency department was probably the missing tests requested. This attitude is generally adopted by all professionals. In a study conducted by the Department of General Surgery, it was observed that although 92% of the consultations requested were from the emergency department, no examination was requested from 21% of the patients before the consultation .
These conditions are probably due to the frequent seizure circulations of emergency room physicians. It is especially important to draw attention to problematic patients who are not terminated during the seizure phase. Such problems were less common in consultations requested by other inpatient clinics. Because of the perceived difficulty with consultations, strategies to improve the emergency physician consultation process in the emergency department seem necessary .
The department that requested consultation most frequently was the emergency service (42%). Most emergency department consultations at academic centers result in acceptance . Despite the uncertainty in the emergency service consultation forms, 65% of the patients hospitalized on the first day consisted of emergency service admissions. We found that the request for consultation from the emergency department was associated with early hospitalization.
Another aspect of the requested consultations was their distribution over the weekly time frame. Although the weekday consultations corresponded to 90% of all consultations, half of them took place on the start and end days of the weekend holiday (Friday, Monday). The increase in requests on Fridays is not justified by the increased number of patients, as on Mondays, but is probably due to the uncertainty of the weekend causes for the physicians responsible for patients. One of the reported reasons for requesting an interim consultation is assumed to reduce the physician’s anxiety in the sensitive clinical setting .
Gastric cancer was the most common diagnosis, which was observed in a quarter of the consulted patients. Digestive system tumors are the most common reason for admission to surgical oncology outpatient clinics after breast cancer . Sixty-five percent of the patients were oncological patients who had previously undergone major resection and reconstruction. After consultation, major surgeries requiring resection and reconstruction were performed in half of the patients. This justifies the requested emergency consultations. The most common reason for requesting consultation was evaluated in terms of surgical indication in elective patients, and applications due to ileus-subileus in emergency patients. One-third of the patients consisted of patients who were hospitalized for palliative care and received medical treatment. These patients who are terminal cancer patients or who are not considered to benefit from hospitalization are stretching the hospitalization criteria of physicians due to social indications and medico-legal reasons. Since our clinic has a separate intensive care unit, admissions to our clinic are mostly accepted rather than palliative care units. Indeed, this patient group, which is seen as a problem in Turkey and even all over the world, is waiting for an urgent solution .
Finally, consultation is a two-way process, and data on views on the process were obtained only from the perspective of emergency room physicians. In future work, consultants should be involved to hear their views on consultation processes. High-quality patient-centered care relies on effective patient- physician communication .
Differences are especially great in the mortality rates of cancer patients who apply to the emergency department for surgical consultation . Vandyk et al. investigated range, prevalence, and outcome of treatment-related or disease-related symptoms for cancer patients presenting to the emergency department; they found variation and inconsistency in reporting symptoms and mortality .
Therefore, the emergency service consultation system is of great importance.
As a result, it should be noted that the inadequacy of the consultation text, which can be considered a communication failure during the consultation process, is not uncommon and may adversely affect patient care, cost-effectiveness, and even education in academic centers. This behavior is similar in both medical and surgical fields. Correction of these problems is important for hospital activity. Possible measures that can be taken to address these problems would be the initiation of joint care (comanagement) and, as far as possible, the standardization and protocolization of conversations.
Our study has limitations due to its retrospective nature. There is also a need for studies on the initiation of joint care (co-management) and, as far as possible, the standardization and protocolization of mutual talks.
Scientiﬁc Responsibility Statement
The authors declare that they are responsible for the article’s scientiﬁc content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientiﬁc review of the contents and approval of the ﬁnal version of the article.
Animal and human rights statement
Conflict of interest
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Download attachments: 10.4328:ACAM.21157
Şeref Dokcu, Mehmet Ali Çaparlar, Özhan Çetindağ, Musluh Hakseven, Salim Demirci. Characteristics and management of consultations requested from the emergency department and other outpatient clinics in a surgical oncology clinic. Ann Clin Anal Med 2022;13(8):900-904
Is really posterior approach better than anterior in recurrent inguinal hernia?
Ersin Turan 1, Kemal Arslan 1, Barış Ayhan 2, Serap Melek Doğan 3, Osman Doğru 1
1 Department of General Surgery, Konya City Hospital, Konya, 2 Department of General Surgery, Karapınar State Hospital , Konya, 3 Department of General Surgery, Kepez State Hospital, Antalya, Turkey
DOI: 10.4328/ACAM.21158 Received: 2022-04-06 Accepted: 2022-06-11 Published Online: 2022-06-20 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):905-909
Corresponding Author: Ersin Turan, Department of General Surgery, Konya City Hospital, Konya, Turkey. E-mail: email@example.com P: +90 530 326 85 75 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6413-6949
Aim: In inguinal hernia operations, patient comfort is as important as postoperative recurrence in the success of surgery. The aim of this study is to compare the effects of minimally invasive preperitoneal single-layer mesh (MIP) and Lichtenstein repair (LR) on patient comfort in patients with recurrent inguinal hernia (RIH).
Material and Methods: The files of 107 patients with RIH were retrospectively reviewed. 48(%44.8)patients had MIP and 59(%55.2) patients had LR. Sheffield Pain Scale(SPS) and Verbal Pain Scale (VPS) were used for the evaluation of pain scores. Patients were questioned during preoperative period, postoperative 1st month and 1st, 3rd, 6th, 9th years regarding SPS, VPS and ability to perform daily activities.
Results: The mean time to return to work was 10 days shorter in the MIP group. There was no significant difference between the groups in terms of preoperative SPS scores, ability to perform daily activities and VPS scores. Both early postoperative pain scores as the SPS (1.24 vs 1.68, respectively, p = 0.01) and VPS scores (3.67 vs 4.68, respectively, p = 0.02) and late postoperative SPS scores (1.10 vs 1.30, respectively, p = 0.02) and VPS scores (2.46 vs 3.61, respectively, p = 0.04) were lower in the MIP group when compared with the LR group. The patient comfort parameters were significantly improved in the MIP group.
Discussion:The number of studies investigating patient comfort in recurrent hernias is very low in the literature. According to our study, MIP seems to be a better technic for recurrent inguinal hernias.
Keywords: Recurrent Inguinal Hernia, Lichtenstein Repair, Minimally Invasive Preperitoneal Repair, Patient Comfort
Despite advances in inguinal hernia surgery, recurrent inguinal hernia (RIH) repair remains an important problem . The recurrence rate after primary inguinal hernias is around 16-18%, while more than 30% recurrence is reported after RIH surgery [1,2]. Recurrence rates after hernia surgeries have been decreased with developing technologies, so the focus is now on clinically improving patient comfort. In particular, early return to daily activities and chronic inguinal pain sufficient to impair quality of life are factors determining patient comfort after inguinal hernia surgery. Nienhuijcs et al. reported that open preperitoneal repair caused less postoperative pain than the Lichtenstein procedure in primary inguinal hernias . However, there are only few studies investigating the effect of anterior and posterior approach on patient comfort in RIH surgery. Therefore, there is no consensus on the ideal surgical method to preferred for RIH .
The aim of this study is to compare the effects of minimally invasive preperitoneal single layer patch (MIP) and Lichtenstein repair (LR) on postoperative pain and patient comfort in patients with RIH.
Material and Methods
Patients who applied to Konya Education and Research Hospital General Surgery Clinic for RIH between February 2009 and February 2018 and aged 18 years or older were included in this retrospective study. Female patients, patients presenting with femoral hernia, obstructive or incarcerated inguinal hernia, or bilateral inguinal hernia, patients with chronic comorbitic disease such as diabetes, congestive heart failure, cirrhosis, and patients with malignancy or immune system defect were excluded from the study. Informed consent was obtained from each patient before enrolment in the study.
The surgical method was determined according to the preferences of the surgeon in all patients. Spinal or general anesthesia was used according to the patient’s preference and medical condition.
Minimally invasive preperitoneal single-layer mesh
This procedure is basically similar to the Kugel repair , but the only difference is that the mesh we used is a single-layer, 14×9 cm oval shaped polypropylene mesh (Prolene ©, Ethicon, San Loreno, Puerto Rico) that is prepared preoperatively in order to prevent the mesh from folding, we created lines with no:1 PDS (Pedesente ©, Doğsan, Trabzon, Turkey) in 4 rows in an oval shape (Figure 1). Then we used 2×2 cm polypropylene mesh to create a pocket on the main mesh to allow the entrance of the index finger and fixed it again with no:1 PDS. This pocket allowed the mesh to be placed properly in the preperitoneal area without folding.
On the operation side, the skin and subcutaneous tissues were passed through a 4 cm transverse incision, 1/3 lateral and 2/3 medial from the midpoint of the distance between the tuberculum pubicum and the anterior superior of the iliac spine. After muscle dissection, preperitoneal area was reached. Spermatic cord structures were found and hernia sac was dissected. The inferior preperitoneal distance was opened by blunt and sharp dissection up to the Cooper ligament. In this way, enough space was created to cover the anulus inguinalis profundus and to ensure full spread of the mesh. Mesh is wrapped on the finger by entering the pocket on the mesh with the index finger and was laid to completely cover the anulus inguinalis profundus at the level of the Cooper ligament. Thus, the medial edge of the mesh was located at symphysis pubis, lateral edge was located 3 cm lateral to the annulus inginalis profundus, and the lower edge was located 3 cm below the inginal ligament . While closing, one suture was passed from fascia transversalis and the mesh.. The other anatomical structures were closed one by one and the operation was completed.
The classic LR was performed as described by Amid et al .
Evaluation of patient characteristics and comfort
Patients were divided into two groups according to the type of the surgical procedure. Age, body mass index, operative findings (direct, indirect hernia), duration of surgery, length of hospital stay, and early postoperative complications were reviewed from the patient files.
In our clinic, we routinely apply questionnaires preoperatively and in the postoperative first month to all patients who underwent RIH surgery to evaluate chronic pain and ability to perform daily activities, and to assess pain severity during activity. The time to return to work after surgery, the presence and severity of postoperative chronic pain, and the ability to perform daily activities were evaluated with a face-to-face questionnaire preoperatively and in the postoperative 1st month. These data were reviewed retrospectively. In addition, all patients were questioned via phone calls, by a third specialist who was blinded to the surgical procedure, at 1st, 3rd, 6th and 9th years regarding the development of recurrence, pain state using the Sheffield Pain Scale (SPS) and Verbal pain Score (VPS), the ability to perform daily activities, and the severity of pain during daily activity. The presence and severity of chronic pain were performed according to the SPS, which was rated at 4 points . The Sheffield Pain Scale was as follows: 0, no pain; 1, no pain at rest, but pain on movement; 2, relieving pain at rest but moderate pain on movement; 3, continuous pain at rest and severe pain during movement. The ability to perform daily activities was assessed using a questionnaire system consisting of 9 questions that evaluated the presence of pain during simple movements in daily life to challenging sports activities. It was accepted that the daily activities were restricted in patients who answered yes to 5 or more questions. In addition, the severity of pain during the daily activities of the patients was evaluated with VPS. In VPS, we classified 0 as no pain, and 10 as irresistible pain and asked patients to score the pain they felt during daily activities between these numbers.
Mean, standard deviation, median, lowest, highest, frequency and ratio values were used in descriptive statistics of the data. The distribution of variables was measured using the Kolmogorov-Simirnov test. The Mann-Whitney U test was used for the analysis of quantitative independent data. The chi-square test was used for the analysis of qualitative independent data and the Fischer test was used when the chi-square test conditions were not met. SPSS 22.0 program was used in the analysis.
A total of 124 patients were included in the study. However, 17 patients who could not be reached at the last call were excluded from the study, and 107 patients were finally included in the study. There were 48 (%44.8) patients who had MIP and 59 (%55.2) patients in the LR group. All patients included in the study were male. The mean age of the patients was 38.26 ± 12.04 (20-60 years), and the mean BMI was 28.1 ± 6.01 (24.1-35.6) kg/m2. The primary surgery of all patients was LR. Seven (12.2%) patients had undergone LR surgery twice. The time between primary surgery and recurrence ranged from 6 weeks to 10 years. Both groups were statistically similar in terms of age, BMI, operation time and hospital stay.
Twenty-eight (%26.1) patients had direct, 71(%66.3) patients had indirect and 8 (%7.6) patients had a combined hernia. The mean operative time was 40.2 ± 22.45 minutes. Fifty patients were operated under spinal anesthesia, and 7 patients required general anesthesia. No major complication was observed in any of the operations. Postoperative complications are listed in Table 1. The mean hospital stay was 1.09 ± 0.31 days. Most patients were discharged on the first postoperative day. However, 8 (%7.4) patients who developed hematoma were followed up conservatively for 2 days and no additional treatment was required. Antibiotic treatment was started in 3 (%2.8) patients who developed superficial surgical site infection; wounds were cleansed and dressed, and the patients were discharged on the 3rd day without mesh excision. There was no statistically significant difference between the groups in terms of early complications.
The mean follow-up period was 63.12 ± 12.14 (24-105) months. One recurrence was observed in both groups. Pseudohernia was detected in 2 (%4.1) patients in the MIP group in the early postoperative period. However, the pseudohernia disappeared in the first month of the follow-up of these patients. The mean time to return to work was 17.1 ± 9.14 (10-31) days in the MIP group and 26 ± 12.24 (11-44) days in the LR group, and the time to return to work was significantly lower in the MIP group (p = 0, 02).
Chronic pain was evaluated according to the SPS during the preoperative period, postoperative 1st month and 1st, 3rd, 6th, 9th years. There was no significant difference between the groups in terms of preoperative pain scores. In the postoperative follow-up, pain scores were significantly lower in the MIP group compared to the LR group both in the 1st month and in the third year or late period (Table 2).
In the preoperative period, there was no significant difference between the groups in terms of the number of patients whose daily activities were restricted and VPS scores. However, both the number of patients whose daily activities were restricted and VPS scores decreased significantly in the MIP group in the first postoperative month, and this decrease was also significant in the long term (Table 3). Seven patients in the MIP group, and 13 patients in the LR group reported using analgesic drugs for 1 month. Although no patients in the MIP group had a long-term history of analgesic drug use, 6 patients in the LO group needed analgesic drugs until the 6th month.
The popularity of preperitoneal approaches is increasing along with the recent advances in surgery, especially in RIH repair, reducing the risk of damage to testicular blood vessels, lymphatics and ilioinguinal nerves by providing untouched space. Indeed, Bin Yang et al. reported that there was no chronic inguinal pain and scrotal complication in inguinal hernia repair by preperitoneal approach . Also, the re-recurrence of preperitoneal interventions after RIH is reported to be between 10% . Despite the superiority of the results of preperitoneal repair, LR still continues to be performed in the majority of the surgeries for RIH [11,12]. There is still no consensus about the best surgical method, especially in RIHs developed after hernia repair with anterior approach .
In this retrospective study, we compared the effects of MIP and LR on patient comfort in recurrent inguinal hernia repair and observed some important findings. Although there are studies comparing the effects of hernia repair techniques on chronic pain and quality of life, to the best of our knowledge, there are only few studies in the literature evaluating the effects of repair techniques on patient comfort [6,14,15]. In the study by Arslan et al., which compared the results of preperitoneal repair and LR in primary inguinal hernias, it was reported that preperitoneal repair caused less chronic pain during the 2-year follow-up period . In this study, a single-layer polypropylene mesh was used instead of the double-layer mesh, which Kugel described in the classical preperitoneal repair method . In the study of Yang et al., which compared the effects of different surgical techniques in patients with recurrent inguinal hernia, it was reported that 10.3% of the patients had chronic inguinal pain, and 6% had a restriction in daily activities . In our study, unlike the Kugel technique, we used a single-layer mesh in MIP repair. In this way, we think that the mesh load is reduced. There was no significant increase in recurrence rates after single layer mesh usage.
It is known that laparoscopic surgery provides less incidence of chronic pain, less wound related problems, and return to daily activities in a shorter period of time in primary hernias compared to open surgery , but there are long learning curves and cost increases in laparoscopic procedures. In their study comparing laparoscopic and open preperitoneal approaches in RIHs, Feliu et al. reported that both methods are very effective, but the length of hospital stay was shortened in the laparoscopic group . Our study is consistent with the study of Feliu et al.
In our study, operative times and postoperative recurrence rates were also similar with LR. Therefore, we believe that MIP method can be safely preferred in RIHs both in terms of ease of learning and cost.
One of the rare studies investigating the effect of surgical methods on patient comfort and chronic pain in recurrent inguinal hernias is a meta-analysis reported by Sevonius et al. . In this study, it was reported that endoscopic preperitoneal interventions caused less chronic pain, discomfort, and insufficiency in physical activities compared to LR repair. In the literature, there are rare clinical studies examining the effect of anterior and posterior interventions on patient comfort and chronic pain after recurrent surgery. We hope that we will contribute to the literature with this study. In our study, we observed significantly less chronic pain rates in MIP group at 1st, 3rd, 6th and 9th years. In addition, while the postoperative complications were similar, the time to return to work was shorter in the MIP group.
There was one recurrence in both groups. Therefore, we could not evaluate the effect of the method used in RIH repair on recurrence. According to the algorithm specified by Schwab, it is recommended that posterior approach should be preferred for recurrences after LR . In our study, there was no difference between the two groups in terms of complication rates. However, we can say that MIP is superior in the treatment of recurrences after LR due to the decrease in chronic pain and increase in physical activity ability in the long term.
Sevonius et al. reported that 29% of the patients had pain that limits their physical activities and 6% had pain that affects daily activities after the surgery performed for RIH . Although chronic pain seems to have decreased to some degree in the first years after hernia repair, it may still limit the patient’s ability to perform daily activities and affect health-related quality of life [21,22]. In our study, 77.1% of the patients stated that there was pain that limited daily activities during the preoperative period.
However, limitation in daily activities was significantly less in the MIP group both in the short term and long term after surgery (MIP vs LR; 39.13% vs 52.9%, and 13.4% vs 29.4%, respectively).
This study had some limitations. As it was a retrospective study and some demographic features could not be standardized.
MIP repair can be preferred as a surgical method in RIHs because it leads to less chronic pain and an İncrease in patient comfort both in the short term and long term, and it is an effective, less costly and safer method.
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1. Kohno S , HasegawaT, Aoki H, Ogawa M, Yoshida K, Yanaga K, et al. Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults. Asian J Surg . 2022; 45(4):1001-6.
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3. Nienhuijs S, Staal E, Keemers-Gels M, Rosman C, Strobbe L. Pain after open preperitoneal repair versus Lichtenstein repair: a randomized trial. World J Surg . 2007; 31(9): 1751-7.
4. Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg. 2010; 97(1):4-11 .
5. Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg. 1999; 178(4):298–302.
6. Arslan K, Erenoglu B, Turan E, Koksal H, Dogru O. Minimally invasive preperitoneal single-layer mesh repair versus standard Lichtenstein hernia repair for inguinal hernia: a prospective randomized trial. Hernia. 2015; 19(3):373-81 .
7. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia. 2004; 8(1):1–7.
8. Franneby U, Sandblom G, Nordin P, Nyren O, Gunnarsson U. Risk factors for long-term pain after hernia surgery. Ann Surg. 2006; 244(2): 212– 19.
9. Yang B, Jiang Z-P, Li Y-R, Zong Z, Chen S. Long-term outcome for open preperitoneal mesh repair of recurrent inguinal hernia .International Journal of Surgery. 2015; 19:134-136.
10. Lydeking L, Johansen N, Oehlenschläger J, Bay-Nielsen M, Bisgaard T. Re-recurrence and pain 12 years after laparoscopic transabdominal preperitoneal (TAPP) or Lichtenstein’s repair for a recurrent inguinal hernia: a multi-centre single-blinded randomised clinical trial. Hernia. 2020; 24(4):787-92 .
11. Eker HH, Langeveld HR, Klitsie PJ, Van’t Riet M, Stassen LP, Weidema WF et al. Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a long-term follow-up study. Arch. Surg. 2012; 147(3): 256-60.
12. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343- 403.
13. Karatepe O, Acet E, Altiok M, Adas G, Cak RA, Karahan S. Preperitoneal repair (open posterior approach) for recurrent inguinal hernias previously treated with Lichtenstein tension-free hernioplasty. Hippokratia.2010; 14(2): 119-21.
14. Berrevoet F, Sommeling C, De Gendt S, Breusegem C, de Hemptinne B. The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study. Hernia. 2009;13(3):243-249.
15. Tanrikulu Y, Cagsar M, Yalcin B, Kokturk F, Yilmaz G, Temi V. Effect of peritoneal incision on immediate pain after inguinal hernia repair: A Prospective Cohort Study. Int Surg. 2019; 104 (11-12): 556–62.
16. Yang J, da Tong N, Yao J, Chen W. Laparoscopic or Lichtenstein repair for recurrent inguinal hernia: a meta-analysis of randomized controlled trials. ANZ J Surg. 2013; 83(5):312–18.
17. Köckerling F, Bittner R, Kuthe A, Stechemesser B, Lorenz R, Kochet A, al. Laparo-endoscopic versus open recurrent inguinal hernia repair: should we follow the guidelines? Surg Endosc. 2017; 31(8):3168–85.
18. Feliu X, Torres G, Viñas X, Martνnez-Ródenas F, Fernández-Sallent E, Pie J. Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach. Hernia. 2004; 8:113-16.
19. Sevonius D, Montgomery A, Smedberg S, Sandblom G. Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact of anterior and posterior mesh repair. Hernia. 2016; 20(1):43-53.
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22. Singh AN, Bansal VK, Misra MC, Kumar S, Rajeshwari S, Kumar A, et al. Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: a prospective randomized controlled trial. Surg Endosc. 2012; 26(5):1304–17.
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Ersin Turan, Kemal Arslan, Barış Ayhan, Serap Melek Doğan, Osman Doğru. Is really posterior approach better than anterior in recurrent inguinal hernia? Ann Clin Anal Med 2022;13(8):905-909
Treatment of ganglion cysts on the wrist: Why and how?
Numan Duman 1, Numan Atilgan 2, Tahsin Sami Colak 3, Mehmet Demiryurek 3
1 Department of Orthopedics and Traumatology, Faculty of Medicine, Uskudar University, Istanbul, 2 Department of Orthopedics and Traumatology, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Sanliurfa, 3 Department of Orthopedics and Traumatology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
DOI: 10.4328/ACAM.21160 Received: 2022-03-23 Accepted: 2022-05-24 Published Online: 2022-05-27 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):910-913
Corresponding Author: Numan Atilgan, Department of Orthopedics and Traumatology, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Sanliurfa, Turkey. E-mail: firstname.lastname@example.org P: +90 507 221 19 45 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7184-978X
Aim: Our study aimed at comparing the results of surgical treatment and additional cortisone application to ganglion cysts aspiration formed on the wrist, and to evaluate the reasons that lead patients to treatment.
Material and Methods: Patients who applied to our clinic between 2012 and 2019 were diagnosed with ganglion cysts were divided into two groups. Group A consisted of 91 patients who underwent surgical excision, and Group B consisted of 33 patients who underwent cyst aspiration with 1 ml of betamethasone administration. A total of 124 patients were evaluated regarding the cyst side, age, gender, complications after treatment modalities, preoperative and postoperative pain, and function scores.
Discussion: Pain was the leading complaint in 63 (50.8%) patients in our study. Considering the current literature, the most common complaint among symptomatic patients is pain. Also, the cyst size of the group that chose surgical treatment was larger than in the group that underwent aspiration with injection.
Results: In our study, it was observed that wrist ganglion cysts were more common in women than in men, they were more common on the dorsal side than on the volar side, and the first reason for choosing surgical treatment was cosmetic concerns and suspicion of the tumoral lesion after pain occurrence. The incidence of recurrence was 11.5 times higher in the patient group treated with aspiration and betamethasone injection compared to the patient group treated with surgical treatment.
Keywords: Cyst, Ganglion, Wrist, Aspiration
Ganglion cysts are synovial cysts filled with gelatinous mucoid material, of unknown etiology, believed to be formed due to mucinous degeneration of the connective tissue as a result of repetitive microtraumas . Ganglion cysts are the most common benign soft-tissue tumors of the hand and wrist . Among the treatment options, the best known and most frequently applied method is open surgical excision. In addition, observation/reassurance, aspiration alone, aspiration with steroid, hyaluronidase, or ethanol injection and arthroscopic surgical excision are the other treatment options . Although most ganglion cysts are asymptomatic, some of the patients present with complaints such as localized pain, tenderness, cosmetic dissatisfaction, and tumor suspicion. In addition, although rarely, clinical entities such as ulnar neuropathy, central canal stenosis, cubital tunnel syndrome, trigger thumb can be seen due to the compression of the cyst on the surrounding tissues [4-7].
Material and Methods
The patients who were diagnosed with ganglion cysts at our clinic between 2012 and 2019 were examined retrospectively. The diagnosis was performed by clinical examination and magnetic resonance imaging (MRI) technique (Figure 1). Cyst sizes were measured in cm2 using MRI images. Patients with ganglion cysts 1 cm in diameter or larger were treated with two different methods: open surgical excision and aspiration with betamethasone injection (Figure 2). Open surgical excision was performed in 91 (73.4%) patients, and aspiration with betamethasone injections was performed in 33 (26.6%) patients. Surgery involved excision of the ganglion traced back to the carpal joints, along with its stalk, under local anesthesia and tourniquet control. Both senior and junior orthopedists and hand surgeons performed the surgeries. All patients were followed up for 22 months regarding pain and functional scores, complications, and recurrence assessment.
The study was approved by the Ethics Committee of University of Necmettin Erbakan Faculty of Medicine (protocol no 2021/3551).
The data obtained from the research were transferred to the SPSS (Statistical Package for Social Sciences) v.18.0 package program for statistical analysis.
deviation and median (minimum, maximum) were used to summarize numerical data, and numbers and percentages were used to summarize categorical data.
The compliance of numerical variables to the normal distribution was analyzed with the Kolmogorov-Smirnov test. The relationship between the categorical data was analyzed with the Chi-square (χ2) test.
Since it was determined that the patients’ q DASH, VAS, and MAYO scores were not normally distributed, comparisons made for two separate times as preoperative and postoperative were compared with the Wilcoxon paired-sample test. The model, which was created with the parameters that could affect recurrence, was analyzed using regression analysis.
A p-value of <0.05 was considered statistically significant.
Among the patients, 76.6% (n=95) were females and 23.4% (n=29) were males. The mean age of the patients was 32.94 ± 14.11 years (min:11, max:72).
Ganglion cysts were located on the right wrist in 51.6% of the patients and on the left wrist in 48.4%, while anatomically they were located dorsally in 75.8% and on the volar side in 24.2% of the patients. While the surgery was performed in 75.5% of patients with dorsal location, n steroid injection was performed in 24.5% of them; surgery was performed in 66.7% of the patients with volar location, and steroid injection was performed in 33.7% of them.
The reasons leading patients to treatment were as follows: 50.8% were due to severe pain, 24.2% were due to cosmetic reasons, 12.9% were due to suspected malignancy, and 12.1% were due to environmental effects (Table 1). The mean preoperative cyst size in the surgical group was 1.74±1.37 (min:1, max:12) cm2. The mean cyst size of the patient group who underwent aspiration with betamethasone injection was 1.16±0.23 cm2 (min:1, max:1.80).
Recurrence was observed in 15.3% (n=19) of all the patients. While the recurrence rate was 5.5% (n=5) in the surgical excision group, it was 42.4% (n=14) for the patients who had aspiration with betamethasone injection. Patients who underwent surgery had a significantly lower recurrence rate than patients who received aspiration with betamethasone injection. (χ2=25.45, p<0.001).
Age, gender, side, location, preoperative cyst size, and the type of treatment, which were thought to affect recurrence, were examined with regression analysis, and only the treatment type was found to affect the recurrence.
There was no statistically significant relationship between the recurrence rate and gender, side, and anatomical location. (χ2=0.84, p=0.35; χ2=0.35, p=0.55; χ2=1.95, p=0.66).
Postoperative complications were seen in 8 (6.5%) patients, all of whom were in the surgical intervention group (Table 2). Four patients had keloid development, two had adhesions, and two had radial artery damage. Triamcinolone treatment was applied to four patients who developed keloids. Two patients with adhesions underwent tenolysis, and radial artery damage was repaired intraoperatively.
Detailed information and measurements of the surgical excision group and aspiration with the betamethasone injection group are given in Table 2.
Preoperative q DASH scores of patients were significantly higher compared to postoperative q DASH scores (Z=-7.61; p<0.001), preoperative VAS scores were significantly higher compared to postoperative VAS scores (Z=-7.21; p<0.001). In addition, postoperative MAYO scores were higher compared to preoperative MAYO scores. (Z=-7.42; p<0.001).
Ganglion cysts are the most common soft tissue tumors seen in the hand and wrist . Although many treatment methods have been tried in their treatment from the past to the present, open surgical excision is the most common treatment method . In accordance with the general literature, we performed open surgical excision in 91 (73.4%) of our 124 patients.
Pain was the leading complaint in 63 (50.8%) patients in our study. Considering the current literature, the most common complaint among symptomatic patients is pain . On the contrary, in the study by Westbrook et al. with 50 patients, cosmetic problems were reported as the most common symptom . Similarly, in the study by Tomlinson et al., cosmetic problems were reported as the most common reason for referral .
In our study, the most common reason for patients to choose surgical treatment was pain, while cosmetic problems and tumor suspicion were the second and third most common reasons for surgery. It is seen that the preoperative VAS scores of the patients who underwent surgery were higher than the VAS scores of the patients who underwent aspiration. Our study showed that the preoperative visual analog score of the patients who underwent open surgical excision was 3.12, while it decreased to 1.68 postoperatively. As a result of different clinical studies, it was observed that the VAS score regressed significantly after surgery [12,13]. Similarly, we observed a significant improvement in q DASH and MAYO scores after surgery. However, we observed an improvement in all these three scores in the aspiration and injection group, and after both treatment options, the pain decreased significantly in the patients, and there was an improvement in functional scales.
Also, the cyst size of the group that chose surgical treatment was larger than in the group that underwent aspiration with injection. It is also known that asymptomatic wrist ganglion cysts improve by 50% during follow-up . Tumoral lesion anxiety has directed some patients to surgical treatment despite this information. In our study, 14 of 16 patients with suspected tumoral lesions chose surgical treatment, while only two patients preferred aspiration and injection treatment. Limitation of wrist movement, decreased grip strength, and cosmetic reasons determine the choice of surgery in the treatment .
When we consider the recurrence results, Nasab et al. reported recurrence rates in patients who underwent aspiration alone (62.5%), aspiration and cortisol injection (45%), aspiration and ethanol injection in ganglion cysts (36.5), respectively . Limpaphayom et al. examined patients with a dorsal ganglion cyst and observed recurrence in two (18.2%) out of 11 patients who underwent surgery and in eight (61.5%) out of 13 patients who had cyst aspiration and methylprednisolone injection . Paramhans et al. administered 2 ml of 10% triamcinolone injection in one group and surgical treatment for the other group for adult ganglion cysts. They reported that there were 14 recurrences (12.2%) among 114 surgeries and eight (8.4%) recurrences out of 105 patients who had aspirations and triamcinolone administration . As a result of a systematic review and meta-analysis conducted in 2015, the recurrence rate was found as 21% on average in open surgical excision and 59% in aspiration . Our findings were consistent with the literature. At the end of the 22-month follow-up period in patients who underwent aspiration and betamethasone, the recurrence rate was 11.5 times higher than in patients who underwent surgery. Different studies have tried to apply various chemicals into the cyst after aspiration. In particular, intracystic injection of steroids was performed, emphasizing the idea that ganglion cysts occur after an inflammatory process.
Contrary to what had been predicted, it was observed that there were few fibroblasts and mesenchymal cells in the wall of the ganglion cyst and that it did not contain inflammatory cells [14,20]. Based on this information, there is no medical reason to support the steroid injection with high anti-inflammatory properties into the cyst. Although aspirating the cyst and applying chemicals into the cyst cavity seems to be a simple procedure, complications such as neuropathy may occur due to the adjacency to the nerves. In addition, since cysts located in the volar part of the wrist are primarily associated with the ulnar and radial arteries, ischemia, an undesirable complication, may occur in the distal extremity. In our study, no complications occurred in the aspiration and injection groups.
In our study, patients were followed up for an average of 22 months. It can be thought that complications and recurrence rates may change in a longer follow-up period.
In our study, we observed that the most common reason for choosing surgical treatment in wrist ganglion cyst was pain, and in addition to these complaints, cosmetic appearance and suspicion of a tumoral lesion were among the decision-making concerns in the choice of surgical treatment. We found that the recurrence rate was significantly lower in surgical treatment compared to aspiration and betamethasone application. The search for treatment for ganglion cysts continues. Our study will contribute to the literature by investigating the causes and consequences of the two most commonly applied treatment options.
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1. Gregush RE, Habusta SF. Ganglion Cyst. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
2. Cavit A, Özcanli H, Sançmiş M, Ocak GA, Gürer Eİ. Tumorous conditions of the hand: a retrospective review of 402 cases. Turk Patoloji Derg. 2018; 34(1): 66-72.
3. Head L, Gencarelli JR, Allen M, Boyd KU. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015; 40(3): 546-53.
4. Nico B, Waclawik AJ. Ganglion cysts as a cause of ulnar neuropathy at the wrist. WMJ. 2021; 120(4): 325-9.
5. Allison CM, Bonanos G, Varma A. Bilateral ganglion cysts at L4/5 causing central canal stenosis and producing sciatica and neurogenic claudication: a case report. Ann R Coll Surg Engl. 2022; 104(2): 41-3.
6. Tong J, Xu B, Dong Z, Liu J, Zhang C, Gu Y. Cubital tunnel syndrome caused by ganglion cysts: a review of 59 cases. Acta Neurochir (Wien). 2017; 159(7): 1265-71.
7. Altaf W, Attarde D, Sancheti P, Shyam A. Triggering of thumb by a ganglion cyst of the flexor tendon sheath at A1 pulley: a case report. J Orthop Case Rep. 2021; 11(3): 10-2.
8. Strike SA, Puhaindran ME. Tumors of the hand and the wrist. JBJS Rev. 2020; 8(6): e0141.
9. Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007; 32(5): 502-8.
10. Westbrook AP, Stephen AB, Oni J, Davis TR. Ganglia: the patient’s perception. J Hand Surg Br. 2000; 25(6): 566-7.
11. Tomlinson PJ, Field J. Morbidity of hand and wrist ganglia. Hand Surg. 2006; 11(1-2): 5-8.
12. Kim JY, Lee J. Considerations in performing open surgical excision of dorsal wrist ganglion cysts. Int Orthop. 2016; 40(9): 1935-40.
13. Uludağ A, Tosun HB, Yasar MM, Gunay A, Turk BA, Uludağ Ö. The Effect of tourniquet usage and anesthesia method on prognosis in the treatment of dorsal wrist ganglion cysts by open surgery. Cureus. 2019; 11(10): e5981.
14. Gude W, Morelli V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008; 1(3-4): 205–11.
15. Singhal R, Angmo N, Gupta S, Kumar V, Mehtani A. Ganglion cysts of the wrist: a prospective study of a simple outpatient management. Acta Orthop Belg. 2005; 71(5): 528-34.
16. Nasab SAM, Mashhadizadeh E, Sarrafan N. Comparative study between three methods of aspiration alone, aspiration plus steroid injection and aspiration plus ethanol injection for treatment of dorsal wrist ganglions. Pak J Med Sci. 2012; 28(3): 404-7.
17. Limpaphayom N, Wilairatana V. Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion. J Med Assoc Thai. 2004; 87(12): 1513-7.
18. Paramhans D, Nayak D, Mathur RK, Kushwah K. Double dart technique of instillation of triamcinolone in ganglion over the wrist. J Cutan Aesthet Surg. 2010; 3(1): 29-31.
19. Head L, Gencarelli JR, Allen M, Boyd KU. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015; 40(3): 546-53.
20. Shoaib A, Clay NR. Ganglions. Curr Orthop. 2002; 16(6): 451-61.
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Numan Duman, Numan Atilgan, Tahsin Sami Colak, Mehmet Demiryurek.Treatment of ganglion cysts on the wrist: Why and how? Ann Clin Anal Med 2022;13(8):910-913
The effect of light and noise reduction on the sleep state of preterm infants
Müjde Çalıkuşu İncekar 1, Duygu Gözen 2, Ayhan Taştekin 3
1 Department of Pediatric Nursing, Faculty of Health Sciences, Yuksek Ihtisas University, Ankara, 2 Department of Pediatric Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpaşa, Istanbul, 3 Department of Neonatology, Medical Faculty, Medipol University, Istanbul, Turkey
DOI: 10.4328/ACAM.21162 Received: 2022-03-26 Accepted: 2022-06-03 Published Online: 2022-06-09 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):914-918
Corresponding Author: Müjde Çalıkuşu İncekar, Department of Pediatric Nursing, Faculty of Health Sciences, Yuksek Ihtisas University, Ankara, Turkey. E-mail: email@example.com Corresponding Author ORCID ID: https://orcid.org/0000-0002-4472-2406
Aim: The aim of this study was to determine the effect of reducing light and noise on the sleep of preterm infants.
Material and Methods: This randomized controlled trial study was conducted on 80 preterm infants. Infants in the study group were observed under a coated oxygen hood to reduce light and noise, and the infants in the control group were observed under a standard oxygen hood, for two hours.
Results: The gestational age of preterm infants in the study group was 32.92±1.17 and in the control group- 33.31±0.90 weeks. There was a significant difference between the study and control groups in terms of the sleep state and activity count (p< 0.05).
Discussion: It was concluded that the preterm infants slept longer and the activity count was lower by reducing the light and noise.
Keywords: Infant, Light, Neonatal Intensive Care Unit, Noise, Premature
Nearly 4% of newborns with normal birth weight and 85% of newborns with low birth weight are hospitalized in high-tech Neonatal Intensive Care Units (NICUs) every year . While NICUs can potentially offer remarkably life-saving precautions to such vulnerable infants after birth, they pose a traumatic process for these infants suffering from critical illness due to separation from their mother, pain, social isolation, sleeplessness, and environmental features (stressors), which activate the hypothalamic-hypophysis-adrenal (HPA) axis . The presence of complex, multidimensional (physical, psychosocial, clinical practice), painful and negative stimuli and the lack of developmentally supportive stimuli in the NICUs cause critical and destructive stressors, primarily in these vulnerable infants’ brain development as well as in their other systems . Infants respond to stress with bradycardia or tachycardia, changes in oxygen saturation, and abnormal sleep patterns .
Due to stressors, preterm infants spend more energy; their healing process, growth, and ability to organize themselves are all negatively affected . The healing environment, which one of the most important components of developmental care, constitutes the most emphasized steps of developmental care present in developmental care models [5,6]. The goal of the healing environment is to support healing by minimizing the negative effect of the extrauterine NICU setting on the developing preterm infant’s neurodevelopment . It has been reported that high light levels impair the health of the newborn, therefore the newborn light environment should be individualized . Noise and loud light are recognized as sources of stress that can alter the well-being and development of sensitive preterm infants . Reduction of light and noise in the healing environment is important, especially when it comes to providing preterm infants with supportive developmental care [5,6,9].
By taking these features into consideration, an oxygen hood coated with a transparent film was developed to protect preterm infants from light and noise. The aim of this study was to determine the effect of reducing light and noise on sleep, oxygen saturation and heart rate of preterm infants in NICU.
Material and Methods
The study was conducted as a randomized controlled trial in the NICU of a university hospital between April 2017 and October 2018. The rooms contained incubators, one sensor door, as well as devices such as ventilator, monitor, and pump based on the patient’s condition. Three nurses were working in each ward where the study was conducted. Five physicians, sixteen nurses, four staff members, and four secretaries were on duty between 8:00 am and 4:00 pm every day in the NICU. The physicians, staff members, and secretaries went in and out of the wards.
The NICU, where care was given to high-risk newborns, provides level III and advanced level III intensive care service in terms of its equipment and medical staff. A central bright light was used in the rooms where the study was conducted. The incubators were routinely closed with a cover that just covered the top of the incubators in order to allow the infants to be viewed. In order to determine whether the groups were homogeneous in terms of noise, the researchers took noise measurements outside the incubators of all preterm infants in the study and control groups.
According to one study , it was assumed that the sleep duration of the infants in the study group was longer than those in the control group at the rate of 20%, and the sample size was determined as a total of 74 cases, including minimum 37 cases in each group at the power of 80% at the level of α=0.05. A total of 80 preterm infants were included in the study by considering the possible case losses. The inclusion criteria were determined as follows: 1) Being born at ≤ 34 GW and being within the first 48 hours after delivery , 2) Able to receive treatment with an oxygen hood, 3) Having passed ABR (BERA) test.
The exclusion criteria were determined as follows: 1) Suffering from either a congenital anomaly and/or sepsis, 2) Being sedated and being diagnosed with neurological problems, 3) Be intubated, and 4) Receiving CPAP therapy.
The study was conducted using randomization URN method . The colors of the balls used for the study group and the control group were red and white, respectively. When there was an infant who met the inclusion criteria, the balls previously prepared by the researcher were put into a black bag. Any nurse working in the unit at that time was asked to select one of the balls from the bag upon closing her eyes. The infant was assigned to the study group or control group according to the color of the selected ball. In the CONSORT diagram , while 39 preterm infants were included in the study group, 41 preterm infants were included in the control group (Figure 1).
The information form consists of information about the preterm infants’ gestational age, inclusion time, birth weight, birth height, sex, and delivery type.
A standard oxygen hood (Natus Medical Inc., San Carlos, CA, USA) was used in the control group. In the study group, the researchers used a standard oxygen hood coated with a transparent, single-layered, and polyester film having a high tensile and breaking strength and low light and ultraviolet transmittance (3MTM, Denmark). A metallurgical and materials engineer covered the outer part of the oxygen hood. The outer part of the oxygen hood was coated with 0.75 mm film. After the oxygen hood was coated, it was left to dry for one month.
The light penetrating standard oxygen hood was determined as 370.2 lx and the light penetrating coated oxygen hood was determined as 214.8 lx in the same environment using a calibrated light meter/photometer (Apollo 1.0, Labino, Sweden). The noise was measured using two calibrated sound level meters (Geratech Sound Level Meter DT-8852/data logger). The noise level in the incubator was 58.1 dBA with the standard oxygen hood and 55.7 dBA with the coated oxygen hood. The coated oxygen hood is registered by the Turkish Patent Institute (Registration no: 2016 19181).
Continuous data monitoring of the oxygen saturation and heart rate was performed using Draeger infinity vista xl medical monitor (Dragerwerk AG & Co.KGaA, Dubai, UAE) and probe (Amydi-med, Nellcor Spo2 Neonate/adult). The data were recorded on the monitor for each one minute between 10:00 am and 12:00 pm.
A sleep-wake activity monitor (Actiwatch 2, Phillips Respironics, USA) was used to measure the sleep-wake status of an infant. In a study conducted in Australia with thirteen term and nine preterm infants, the sleep state of the infants was examined using an Actiwatch and polysomnography devices. It was reported as a result of the study that there was a coherence rate of 89-94% between the Actiwatch and polysomnography device. It was recommended to use the Actiwatch device in infants under six months of age [13,14]. Another study examined the validity of the Actiwatch upon assessing the sleep-wake state of preterm infants in a NICU in Taiwan. In the study, the device was compared with the Anderson Behavioral State Scale (ABSS) and attached to the infants’ wrists. The Actiwatch device was assessed as follows: “0” if the infant was asleep and “1” point if the infant was awake. The scale was assessed as follows: the infant was considered asleep for “1 – 4” point(s) and awake for “5 – 12” points. It was found that there was a coherence rate of 68.23 – 81.30% between the Actiwatch device and the ABSS . It was noninvasively attached to the wrist of each preterm infant in the study and control groups. The sleep-wake status of the infant was recorded.
The approval from the ethics committee (No: 10840098-604.01.01-E.24329; Date: 16/11/2016), written institutional permission, and necessary ethics committee approval from the national Medicine and Medical Devices Agency (No: 71146310-511.06-E .49431; Date: 2/3/2017) were obtained. Written consent was obtained from the families of the infants to be included in the study.
All of the infants were given clustered care at the clinic. The infants were fed either every two hours (≤ 1250 g) or every three hours (≥ 1250 g) based on their weight and clinical condition. In the literature regarding sleep reports a follow-up duration of 2 – 4 hours in order to assess sleep . The follow-up duration in the present study was determined as two hours, as some of the infants were fed every two hours and some others were fed every three hours in the present study. It was reported that the prone position decreased stress behaviors against environmental stressors (noise, light, and touching), therefore meaning that infants slept for a longer time . In the present study, the infants in the study and control groups were not touched for two hours and were laid down in the prone position only. Permission was obtained from the doctor and nurse of the baby in each group included in the study. The nurse responsible for the infants performed the care, feed, and treatment times of the infants in the study group and control group. It was ensured that in the study and control groups, preterm infants took a rest and were not touched for two hours between 10:00 am and 12:00 pm. Both groups were followed up with a sleep-wake activity device and monitor device between these hours and the measurements were recorded. Ambient noise was measured from outside the incubator of each baby.
The NCSS 2007 program was used for statistical analyses. Descriptive statistical methods (mean, standard deviation, median, frequency, percentage, minimum, maximum) were used to evaluate the data of the study. Compatibility of the quantitative data to the normal distribution was tested using the Shapiro-Wilk test and graphical examinations. Independent samples t-test and repeated measures test were used in the comparison of normally distributed quantitative variables between two groups; whereas, the Mann-Whitney U test and Friedman Test were used in the comparison of quantitative variables, which did not show normal distribution, between two groups. Pearson chi-square test and Fisher’s exact test were used to compare the qualitative data. The p<0.05 was accepted as statistical significance.
It was determined that the mean gestational age of the preterm infants in the study and control groups was 32.92±1.17 and 33.31±0.90 weeks, respectively. There was no significant difference between the groups in terms of descriptive characteristics and environmental variables (p> 0.05) (Table 1).
The ambient noise level was 62,36±1,58 dBA (min: 59,16 dBA; max: 65,73 dBA) and 62,23±1,78 dBA (min: 58,44 dBA; max: 65,32 dBA) in the study and control group, respectively for two hours (p> 0.05).
The sleep state of the infants was longer in the study group than in the contol group for a total of two hours and was statistically significant (p< 0.05). The total activity count of the preterm infants in the study group for a total of two hours was found to be significantly lower than the control group (p< 0.05). There was no significant difference between the groups in terms of oxygen saturation and heart rate of the infants for a total of two hours (p> 0.05) (Table 2).
Clinical studies that reduce light and noise as components of the healing environment are limited in the literature. In the present study, we used a coated oxygen hood that reduced light and noise and evaluated the sleep state of preterm infants in the NICU. We showed that the preterm infants slept longer and the activity count was lower by reducing the light and noise. There was no difference in terms of oxygen saturation and heart rate values between the groups for total of two hours.
In a similar study, earmuffs were used on preterm infants to decrease the noise and their sleep state, oxygen saturation and heart rate were measured. Thirty-minute records were taken from the infants every two hours within 8 hours during the day for 2 days. It was found that infants’ ABSS scores were 1.34±0.3 for with earmuffs and 3.07±1.1 for without earmuffs, which means that those with earmuffs slept significantly longer than the ones without (p< 0.01) . Oxygen saturation and heart rate of the infants were comparable (p> 0.05) between the groups, similar to our study. In another study using earmuff, the physiological and behavioral findings of the infant were recorded every 2 hours between 8:00 am-4:00 pm. Similarly, ABSS scores were found lower in babies with earmuffs compared to ones without earmuffs, but differently, oxygen saturation values were significantly higher and heart rate values were significantly lower in babies with earmuffs. In that study, the fact that the noise level experienced by the infants with and without earmuffs during the procedure was not measured was emphasized as a limitation .
Aita et al.  conducted a study using earmuff and eye patch to decrease the light and noise, and they determined that oxygen saturation was the minimum and mean heart rates were the same between groups, except for the higher maximum heart rate. They said that this finding that preterm infants had higher maximum heart rate while they were wearing the earmuff and eye patch should not be an indication that light and noise should not be controlled in the NICU .
In a recent study examining the effect of light and noise, no intervention was made to the infants on the first day. It was found that the noise level was 59.4±3.0 dB and the light level was 204±29 lx. On the second day, the infants were given ear plugs and were exposed to a light level of 202±26 lx. The incubator cover was applied on the third day. The noise level was 57±10.6 dB, and the light level was 1.45±0.35 lx. The sleep states of the infants were measured using an electroencephalography (Amplitude-Integrated Electroencephalogram (aEEG)) device for three days. Their NREM sleep scores were higher on the 3rd day (1447±180) compared to the scores determined on the first (1215±129) and second days (1356±162), which means that reducing light and noise increased the infants’ NREM sleep states .
According to the results of our study compatible with previous studies, reducing light and noise exposure provides longer sleep with fewer movements in preterm infants. It may be suggested to carry out studies that examine other components of the healing environment for future research.
The researchers would like to thank Erkan İncekar, a metallurgical and materials engineer, for his support to produce coated oxygen hood, which was used for the study. The researchers thank the staff and preterm infants’ families of the neonatal intensive care unit where the study was conducted. This study was presented for oral presentation as an abstract at the 2nd International 7th National Pediatric Nursing Congress between 27-30 November 2019 and received the second oral presentation award. This study has been completed as a Doctorate Thesis at Istanbul University-Cerrahpasa, Institute of Graduate Studies, Pediatric Nursing Department.
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Funding: The research was funded by TUBITAK, the project number was 217S271
Conflict of interest
1. Weber A, Harrison TM. Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes. Nurs Outlook 2019; 67(2): 169-89.
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15. Yang SC, Yang A, Chang YJ. Validation of actiwatch for assessment of sleep-wake states in preterm infants. Asian Nursing Research. 2014; 8: 201-6.
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Müjde Çalıkuşu İncekar, Duygu Gözen, Ayhan Taştekin. The effect of light and noise reduction on the sleep state of preterm infants. Ann Clin Anal Med 2022;13(8):914-918
Evaluation of glycated hemoglobin (HbA1C) as a predictor of dyslipidemia in type 2 diabetic patients
Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Northern Border University, Arar, Kingdom of Saudi Arabia
DOI: 10.4328/ACAM.21166 Received: 2022-03-30 Accepted: 2022-06-03 Published Online: 2022-06-05 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):919-922
Corresponding Author: Nida Suhail, Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Northern Border University, Arar, Kingdom of Saudi Arabia E-mail: firstname.lastname@example.org P: +90 +96 650 922 32 95 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1314-5041
Aim: Patients with type 2 diabetes mellitus have an increased prevalence of dyslipidemia and are easy targets for cardiovascular diseases. This retrospective study investigated the serum lipid profile of patients with type 2 diabetes mellitus and assessed the relationship between HbA1c levels, lipid profile, and BMI to evaluate the importance of HbA1c as a predictor of dyslipidemia.
Material and Methods: The study was conducted at the Diabetes Center of the Tertiary Care Hospital in Arar, Saudi Arabia. Demographic and biochemical data of 100 patients with type 2 diabetes were collected from electronic records of the hospital. Correlation analysis was performed to analyze the association between HbA1c, lipid profile and BMI.
Results: The results revealed an increase in the levels of fasting blood glucose, blood urea nitrogen, total protein and HbA1C levels, accompanied by a decrease in albumin levels among both male and female patients with no significant difference among the genders. The study also demonstrated an alteration in the lipid profile of the patients with elevated levels of total cholesterol, TAGs and LDL-C with a concomitant reduction in HDL-C levels. Correlation analysis demonstrated a significant (p<0.05) positive correlation between HbA1C and different lipids (total cholesterol, Triglyceride and LDL-C) and BMI. A significant (p<0.05) negative correlation was found between HbA1C and HDL-C levels.
Discussion: The results indicate that in addition to as a biomarker for glycemic control, HbA1c can also be used in predicting dyslipidemia associated with type 2 diabetes to prevent the development of cardiovascular diseases.
Keywords: Type 2 Diabetes Mellitus, Dyslipidemia, Glycated Hemoglobin, Cardiovascular Diseases
Diabetes Mellitus (DM) is the most common endocrine disease characterized by metabolic abnormalities and long-term complications involving the eyes, kidneys, nerves and blood vessels. The disease is spreading at an alarming rate in both developed and developing countries. More than 451 million people worldwide were reported to be affected in 2017, and it is expected to reach 693 million by 2045 . Such a dramatic increase will have a significant impact on the meager health resources of the developing countries, as diabetes is a chronic disease with devastating complications.
Glycated hemoglobin (HbA1c) is the most reliable marker, which is routinely utilized for monitoring glycemic control. It may be used to assess changes in metabolic control that follow an alteration in treatment . Dyslipidemia is a common complication among DM patients and may be a predictor of diabetes. Patients with insulin resistance often show elevated cholesterol levels, even before they have developed full-blown diabetes. Dyslipidemia is associated with a high body mass index, and this has increased emphasis on other risk factors for cardiovascular disease such as high blood pressure. Coronary artery disease, especially myocardial infarction, is the leading cause of morbidity and mortality worldwide . There is a link between hyperglycemia and atherosclerosis in type-2 diabetes mellitus (T2DM), and therefore, the management of hyperglycemia with a reduced level of HbA1c is likely to decrease the danger of extreme complications .
The prevalence and incidence rates of diabetes are increasing in Saudi Arabia . The trend towards urbanization and lifestyle changes (unhealthy eating habits and declined level of physical activity) over the past four decades are responsible for a dramatic increase in diabetes prevalence . Keeping in perspective the growing incidence of T2DM, this study was undertaken to evaluate the serum lipid profile of patients with T2DM and to find out the possible relationship between HbA1c levels, lipid profile and BMI to evaluate the importance of HbA1c as a predictor of dyslipidemia.
Material and Methods
This retrospective study was conducted at the Diabetes Center of the Tertiary Care Hospital in Arar, Saudi Arabia. Data of 100 patients diagnosed with type 2 diabetes mellitus was collected from the electronic records of the hospital. Files of patients suffering from any other metabolic disease or disorder other than Type-2 Diabetes Mellitus were excluded from the study. Approval was obtained from the Director of the diabetes center before collecting the data. Privacy and confidentiality of the obtained data had been insured.
Plasma glucose values for diagnosing diabetes were identified in accordance with the 2019 criteria of the American Diabetes Association . Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/L or HbA1c ≥ 6.5%. Hyperlipidemia was defined as total cholesterol ≥ 5.2 mmol/L or triglyceride TG ≥ 1.70 mmol/L or low-density lipoprotein cholesterol (LDL-C) ≥ 3.4 mmol/L or High-Density Lipoprotein-Cholesterol (HDL-C) < 0.91 mmol/L.
Anthropometric data were collected. Body mass index (BMI) was calculated as weight/height2 (kg/m2). All blood samples were obtained in the morning (8 a.m.) after a 10- to 12-h overnight fast and then centrifuged (3,000 × g for 5 min) for serum separation when applicable. The level of HbA1c was determined with whole blood, while other parameters were tested with serum. HbA1c levels were determined by high-performance liquid chromatography using Arkray HA-8160 analyzers (Arkray, Japan). Serum levels of fasting glucose were tested using the glucose oxidase/peroxidase method in Abbott C16000 analyzers (Abbott, America). Albumin, total protein, blood urea nitrogen, total cholesterol, triglycerides, LDL-C and HDL-C were measured using Abbott C16000 analyzers (Abbott, America).
Results are expressed as means ± SD. The significance of differences between the means was carried out using Students t-test. P-values <0.05 were considered significant. The correlation/association between various parameters was determined using Pearson’s correlation coefficient (r).
Among the 100 participants, 50 were males and 50 were females. The mean age of male participants was 62.52 ± 9.38 years with an age range of 40-77 years and the mean age of female participants was 54.44 ± 10.39 years with an age range of 33-77 years. The mean BMI of males was 31.33 ± 5.56 kg/m2 and females 29.75 ± 4.14 kg/m2.
Biochemical characteristics of the study population are shown in Table 1. There was an increase in the levels of fasting blood glucose, blood urea nitrogen, total protein and HbA1C levels accompanied by a decrease in albumin levels from normal value among both male and female patients with no significant difference among the genders. The main finding of the study was an alteration in the lipid profile of the patients demonstrating elevated levels of total cholesterol, TAGs and LDL-C from the normal values with a concomitant reduction in HDL-C levels.
Correlation analysis was performed to analyze the association between HbA1c and lipid profile (Table 2). A significant (p<0.05) positive correlation was observed between HbA1C and different lipids (total cholesterol, Triglyceride and LDL-C). A significant (p<0.05) negative correlation was found between HbA1C and HDL-C levels. Correlation analysis also demonstrated a significant (p<0.05) positive correlation between HbA1c and the BMI of the study population (Figure 1).
The burden of cardiovascular disease (CVD), the major cause of morbidity and mortality around the world, is particularly high among patients with type 2 diabetes mellitus (T2DM). This may be partially explained by the lipoprotein abnormalities associated with diabetes mellitus. The management of diabetic dyslipidemia, may be helpful in the multifactorial approach to prevent CVD in individuals with type 2 diabetes.
Glycosylated hemoglobin (HbA1c) is the most widely used and reliable marker for the assessment of chronic glycemia . The HbA1c reflects the overall blood glucose levels over a period of 2-3 months and may be used to assess changes in metabolic control that follow an alteration in treatment. In the present investigation, all the patients showed significantly elevated levels of HbA1c in blood. This was in agreement with Murugan  who reported that there was a strong relationship between fasting blood sugar level, postprandial blood sugar level and HbA1c level in diabetic patients.
The result of the present study showed that all diabetic subjects had higher fasting blood glucose and total protein level, while albumin level was slightly below normal in the diabetic patients. Patients were also found to have higher blood urea than normal. All these biochemical changes may be attributed to the decreased renal function in these patients.
Abnormal lipid profile is very frequently observed in T2DM patients and this may be due to insulin resistance leading to increased release of free fatty acids from fatty tissue, impaired insulin-dependent muscle uptake of free fatty acids and increased fatty acid release to the hepatic tissue . All these events have been closely associated with diabetic dyslipidemia, hypertension and a high risk for cardiovascular diseases . High blood glucose levels cause glycation of apolipoproteins and obstruct the normal pathway of lipoprotein metabolism . In the present study, the results showed that all diabetic subjects had elevated total cholesterol, TAG and LDL-C levels and reduced levels of HDL-C. Lipoprotein lipase is an insulin-dependent enzyme, which together with insulin resistance leads to an increase in TAG levels, resulting in type-2 diabetes having high levels of TAG, HDL levels may be further reduced in DM due to elevated hepatic lipase activity that catalyzes HDL . In the present study, a highly positive significant correlation was observed between HbA1c and Lipid profiles (total cholesterol, Triglycerides and LDL-C) and a significant negative correlation was observed between HbA1c and HDL-C, which was in agreement with Khan et al.  who stated that HbA1c exhibited direct correlations with cholesterol, TAG and LDL and reverse correlation with HDL. It has been shown that HbA1c value of <7.0% minimizes the risk of cardiovascular diseases and a value >7.0% leads to dyslipidemia in patients . The present study also demonstrated a significant affirmative correlation between HbA1c and BMI, which is in concordance with another study carried out on the Western Indian population, showing that the dyslipidemic obese subjects had a significant linear association with HbA1c in T2DM subjects .
The study concludes that HbA1c can be used not only as a biomarker for glycemic control, but also to predict dyslipidemia associated with type 2 diabetes to prevent the development of CVD. Furthermore, no significant differences were observed between sex and HbA1c with respect to lipid profile suggesting the reliability of HbA1c for predicting dyslipidemia irrespective of patient’s gender.
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1. Cho N, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018; 138:271-81.
2. Ketema EB, Kibret KT. Correlation of fasting and postprandial plasma glucose with HbA1c in assessing glycemic control; systematic review and meta-analysis. Arch Public Health. 2015; 73:43.
3. Sushritha K, Sharma A, Suman K, Goud PH, Akari S. Epidemiological Study of Risk Factors in Myocardial Infarction Patients. J Young Pharm. 2020;12(2): S108-12.
4. Giri B, Dey S, Das T, Sarkar M, Banerjee J, Dash SK. Chronic hyperglycemia mediated physiological alteration and metabolic distortion leads to organ dysfunction, infection, cancer progression and other pathophysiological consequences: An update on glucose toxicity. Biomed Pharmacother. 2018; 107:306-28.
5. Alotaibi A, Perry L, Gholizadeh L, Al-Ganmi A. Incidence and prevalence rates of diabetes mellitus in Saudi Arabia: An overview. J Epidemiol Glob Health. 2017;7(4):211-8.
6. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl. 1): S13-28.
7. Saudek CD, Derr RL, Kalyani RR. Assessing glycemia in diabetes using self-monitoring blood glucose and hemoglobin A1c. JAMA. 2006;295(14):1688-97.
8. Murugan K. Biochemical Investigation of Glycosylated Haemoglobin in Diabetes Associated Nephropathy in Chhattisgarh Population. Adv Appl Sci Res. 2010;1(2):106-13.
9. Sears B, Perry M. The role of fatty acids in insulin resistance. Lipids Health Dis. 2015; 14:121.
10. Ormazabal V, Nair S, Elfeky O, Aguayo C, Salomon C, Zuñiga FA. Association between insulin resistance and the development of cardiovascular disease. Cardiovasc Diabetol. 2018;17(1):122.
11. Toma L, Stancu CS, Sima AV. Endothelial Dysfunction in Diabetes Is Aggravated by Glycated Lipoproteins; Novel Molecular Therapies. Biomedicines. 2021; 9(1):18.
12. Harno KE, Nikkila EA, Kuusi T. Plasma HDL cholesterol and post hepatic plasma hepatic endothelial lipase activity. Relationship to Obesity and NIDDM. Diabetologia. 2008; 19:281-5.
13. Khan HA, Sobki SH, Khan SA. Association between glycaemic control and serum lipids profile in type 2 diabetic patients: HbA1c predicts dyslipidaemia. Clin Exper Med. 2007;7(1): 24–9.
14. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE. Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care. 2002;25(2):275-8.
15. Sheth J, Shah A, Sheth F, Trivedi S, Nabar N, Shah N, et al. The association of dyslipidemia and obesity with glycated haemoglobin. Clin Diabetes Endocrinol. 2015; 1: 6.
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Nida Suhail. Evaluation of glycated hemoglobin (HbA1C) as a predictor of dyslipidemia in type 2 diabetic patients. Ann Clin Anal Med 2022;13(8):919-922
Analysis of the nervus vagus effect on gastric adenocarcinoma development
Salih Kara 1, Esra Dişçi 1, Mehmet Dumlu Aydın 2, Betul Gündoğdu 3, Mehmet İlhan Yıldırgan 1, Nurhak Aksungur 1, Rıfat Peksöz 1
1 Department of General Surgery, 2 Department of Neurosurgery, 3 Department of Pathology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
DOI: 10.4328/ACAM.21167 Received: 2022-03-31 Accepted: 2022-06-17 Published Online: 2022-06-21 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):923-926
Corresponding Author: Salih Kara, Department of General Surgery, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey. E-mail: email@example.com P: +90 442 344 79 46 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7877-9064
Aim: In this study, we aimed to investigate whether there was an association between a change in the histological composition of the neuroelectrical activity of the vagal nerves and the gastric tumor.
Material and Methods: The pathological materials of patients who were operated on in our hospital with the diagnosis of gastric adenocarcinoma were analyzed retrospectively. Tumor cells, vagal nerve and tumor-invading nerve cells were photographed in successive sections at 4x, 10x, 20x and 40x magnifications for stereotypic counts. During the course of the vagal nerve, axon density per square millimeter and neuronal densities were counted. Statistical analysis was performed between the number of degenerated axons, VSI, axon thickness, and tumor stage by scoring according to the tumor size stage (Tumor 1-2-3-4:10).
Results: Twelve (44.4%) patients were female and 15 (55.6%) were male, with a mean age of 62.9 ± 7.7 years. As the tumor grade increased, the difference between the normal axon numbers was found to be significant. Likewise, as the tumor stage increased, there were significant differences between the number of degenerated axons and tumor stage, also there were significant differences between VSI and tumor stage, similarly. Tumor size and axon thickness differences were found to be significant.
Discussion: Increased electrical potentials lead to a decrease in apoptosis and an increase in tumorogenesis. In this context, vagal hyperactivity may cause gastric adenocarcinoma. Vagal nerves may become more degenerate in high-grade malignant tumors. Thus, it is concluded that vagal nerve weakness may contribute to the progression of tumors.
Keywords: Gastric Adenocarcinoma, Tumorogenesis, Vagal Nerve, Axon Density, Vasospasm Index
Gastric carcinoma is an insidious disease. It usually gives quite late symptoms and the symptoms are not specific to the disease. When it is caught in the early gastric cancer stage, the 5-year survival of this disease reaches 90% rates. For this reason, screening programs are being applied in some countries, such as Japan, where gastric carcinoma is common and early diagnosis success is achieved .
Multiple reasons play a role in the etiology of gastric cancer. While the majority of Helicobacter pylori infection contributes to cancer development, dietary features, lifestyle, obesity, smoking, genetics and other environmental features also play a role in the development of gastric cancer.
There is no primary tumor of the motor cortex and motor nerves of the brain. Tumors develop from the sensory cortex and sensory nerves. The failure of the autonomic nerves of the organs invites the inflammatory and tumoral process. Increasing electrical potentials causes a decrease in apoptosis and the development of tumogenesis. In this context, vagal hyperactivity can cause gastric adenocarcinoma. The nervous system regulates epithelial homeostasis in different ways, and this regulation by the nervous system partially involves the modulation (exchange) of stem cells and progenitor cells [2,3]. There is also a bilateral relationship between tumor cells and nerve cells such that tumors cause an activation of neurogenesis resulting in increased neuronal cell density in preneoplastic and neoplastic tissues. Also, activation of muscarinic receptors has been shown to promote cell transformation and cancer progression . Recent studies have shown that surgical or pharmacological denervation suppresses gastric tumorigenesis. Denervation therapy has been effective in both early preneoplasia and late neoplasia/dysplasia. In the analysis of patients with gastric cancer, it has been shown that the risk of tumor in the vagotomized stomach is reduced and there is a correlation between more advanced tumors and increased innervation. It has been reported that no cancer is observed in the vagotomized part of the stomach in patients with unilateral vagotomy [5,6]. Our aim in this study is to investigate whether there is a relationship between gastric tumors and a change in histological composition that creates neuroelectric activity of vagal nerves in the development of gastric tumors.
Material and Methods
This study was approved by the Ethics Committee of Erzurum Atatürk University Faculty of Medicine (No: 2017/2-1-27). All procedures in this study involving human participants were performed in accordance with the 1964 Declaration of Helsinki and its later amendments.
All patients who underwent total gastrectomy with the diagnosis of gastric cancer between January 2010 and January 2017 at Atatürk University Faculty of Medicine General Surgery Service were retrospectively analyzed. While patients with pathological diagnosis of gastric adenocarcinoma were included in the study, tumors other than pathological adenocarcinoma were not included in the study. Patients with paraffin blocks of the vagal nerve, which were prepared and evaluated simultaneously with the examined tumor tissue, were included in the study. Thus, a total of 27 patients were included in the study group. All data were obtained from the hospital electronic archive system, patient files and preparations in the pathology department archive.
Changes in the nerve vagus that were taken in the simultaneous operation from patients who had undergone total gastrectomy for gastric adenocarcinoma were histopathologically compared with tumor cells. Tumor cells stained with hematoxylin–eosin dye and nerve cells located close to the tumor or with tumor invasion were photographed in sequential sections for stereotypic counting at 4x, 10x, 20x and 40x magnifications. Throughout the course of the vagal nerve, axon density per millimeter, number and neuron density of gastric ganglia were counted. The vasospasm index (VSI) was calculated in the gastric artery branch. The ratio of the radius of the vascular ring of the gastric artery end branch to the radius of the lumen area was accepted as the VSI. Similarly, for axon count in a normal vagal nerve, the total number of axons was found by completing the count of axons in an area of 45 degrees at a magnification of 10 in the light microscope, completing 360 degrees or multiplying by 8. In a case with a tumor, the number of axons in the damaged vagal nerve bundle was calculated in the same way.
Statistical analysis was performed between the number of degenerated axons, VSI, axon thickness, and tumor stage by scoring according to the tumor size stage (Tumor 1-2-3-4:10).
Twenty-seven patients were included in the study, 12 (44.4%) were women and 15 (55.6%) were men. The average age was 62.9 ± 7.7 years, and the age of the patients ranged between 46 and 79. None of our patients have a family history; 11 of our patients (40.7%) had a history of smoking.
In 17 (62.9%) of our patients, no radiological findings were observed with radiological examinations. Wall thickening was detected in 4 (14.8%) gastric cardia, 2 (7.4%) small curvature, 3 (11.1%), gastroesophageal junction (GOJ), 1 (3.7%) large curvature, using computed tomogrophy. In addition, liver metastasis was detected in 2 (7.4%) of the cases, and total gastrectomy was performed because of the presence of obstruction in these patients. In the preoperative endoscopy, 66.6% of the cases were detected in cardia, 25.9% in small curvature, 7.4% in large curvature
In our analysis according to the pathology result, all cases were adenocarcinoma, and 4 (14.8%) had sub-type mucinous adenocarcinoma, 1 (3.84%) of our patients had early gastric carcinoma and 1 (3.7%) of our patients had neuroendocrine differentiation in adenocarcinoma. In 22.2% of our cases, there were various rates of mucinous components. In addition, perineural invasion was present in 48.1% of cases (Table 1).
Statistical data were compared using the Mann-Witney U test by counting the number of normal and degenerated axons per mm² of the vagal nerves, measuring the vagal axon thickness, calculating the vasospasm index values (VSI) of the gastric artery branches and tumor scale scores in preparations containing the vagal nerve and gastric artery branches that were photographed stereotypically in gastric adenocancer cases (Figures 1, 2 and 3).
The normal number of axons in the vagal nerve in low-stage tumors was 34,234±4.320 per square millimeter, while it was 21,543±3.943 per square millimeter in high-stage tumors. A statistically significant difference was found between tumor size and normal axon numbers (p<0.001). Therefore, a higher number of healthy axons in the vagal nerve may result in smaller tumor size and lower stage. In addition, the number of degenerated axons per square millimeter in the vagal nerve was 245±34 in low-stage tumors, and 11.876±1.234 n/mm² in patients with high tumor size. The difference in numbers was found to be statistically significant (p<0.001) (Table 2).
Vagal axon thickness was >2.3±0.95µm in T1-2 tumors and <1.8±0.07 µm in T3-4 tumors. Here, too, a significant difference was found, indicating that the tumor size will increase as the axon thickness increases (p <0.001). The VSI in the gastric artery branches was 0.432±0.034 in low-stage T 1-2 tumors and 3.850±0.76 in T 3-4 tumors. This was also found to be statistically significant (p<0.005) (Table 2).
Gastric cancer is the most common type of cancer after lung prostate, vesical and colorectal cancer in men and after breast, thyroid, colorectal, uterus and lung cancer in women . Gastric carcinoma is an insidious disease. It usually gives quite late symptoms and the symptoms are not specific to the disease. When it is caught in the early gastric cancer stage, the 5-year survival of this disease reaches 90% rates. For this reason, screening programs are applied in some countries, such as Japan, where gastric carcinoma is common and early diagnosis success is achieved . Although multiple causes play a role in the etiology of gastric cancer, the number of studies in the literature about the effect of nervus vagus, which is important in gastric innervation, on cancer development, is insufficient. Our aim in this study was to observe the relationship between the stage of the tumor and nerve damage. Thus, it was necessary to reveal whether nerve damage was involved in the tumor development process and tumor progression process. It is thought that vagal weakness may play a role in gastric cancers . In lung cancers, it is claimed that nicotine leads to cancer development by blocking nicotinic receptors and reducing the electrical resistance of the vagal nerves in the lung [8,9]. Therefore, it is thought that the same mechanism may also induce gastric cancer.
There are publications that congenital weakness of the vagal nerve or tumoral invasion may cause cancer formation by weakening gastric immunity or may cause further progression of existing cancer . In addition, it was thought that vagal nerves may affect mood . Therefore, in people with pessimistic personality, the vagal nerve may be weaker, and gastrointestinal immunity may be weak. Thus, this situation may induce gastrointestinal tumorogenesis. In the study on the effect of bilateral or unilateral vagotomy on gastric carcinogenesis published by Tatsuta et al. in 1988, vagotomy has been reported to have a promoting effect on gastric carcinogenesis . In a study published in 2014 by Zhao et al., it was stated that vagal innervation contributes to gastric tumorigenesis, and denervation is a viable strategy for stomach cancer control . In our study, when we investigated the relationship between axon numbers and tumor, we found that the number of degenerated axons was high in cases where the tumor size stage was advanced. In addition, when we compared axon thickness and tumor size, we concluded that lower grade tumors had greater axon thickness. Accordingly, it was concluded that vagal nerve conduction would be better in lower grade tumors, and vagal nerve conduction would be worse as axon thickness decreased in higher-grade tumors. We conclude that vagal nerve damage may cause tumor progression or the vagal nerves may become more degenerated in high-grade malignant tumors.
In a study published by Mozsik et al., the possible mechanisms of the vagal nerve were examined in the development of gastric mucosal defense, and after vagotomy, it has been identified that protective factors on the gastric mucosa decreased and mucosal damage increased . Based on this, gastrointestinal bleeding may be higher in vagal nerve injuries. In our study, when VSI differences were compared according to tumor size, they were found statistically significant. Thus, it was thought that vagal nerve damage in malignant tumors with a higher grade according to tumor size causes more vasoconstriction in the gastric arteries, which can lead to tumor necrosis by disrupting tumor nutrition. While the invasion of the vagal nerves is in favor of the tumor, it can be interpreted as an advantage considering that the tumor may shrink to the necrosis as a result of denervation and vasospasm of the arteries feeding the tumor. In addition, it was thought that the arteries that had advanced spasms due to increased VSI with vagal nerve damage could be ruptured.
We could not perform a statistical study because we could not access enough parasympathetic ganglion data for statistics, but it may be considered responsible for gastric carcinomas with mucinous and hypersecretion. We have collected data on the presence of more parasympathetic ganglia in some mucinous cancers. Studies on this subject can be done in the coming years. Although there are not enough studies in the literature about the effect of the vagal nerve on gastric carcinogenesis, we anticipate that the effect of the vagal nerve on gastric adenocarcinoma can be revealed with future studies.
To the best of our knowledge, this is the first study in the literature in terms of histopathological examination of the effect of vagal nerve on gastric adenocarcinoma. The small number of patients and the retrospective nature of our study are limitations. Nevertheless, although there is not enough study in the literature on the effect of the vagal nerve on gastric carcinogenesis, we predict that this study may guide for studies to be carried out in the coming years.
Vagal nerves may become more degenerate in high-grade malignant tumors. Consequently, vagal nerve weakness may contribute to the progression of tumors. Thus, we think that vagal nerve degeneration may be a poor prognostic marker in the coming years.
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Conflict of interest
1. Hamashima C; Systematic Review Group and Guideline Development Group for Gastric Cancer Screening Guidelines. Update version of the Japanese Guidelines for Gastric Cancer Screening. Jpn J Clin Oncol. 2018;48(7):673-83.
2. Lundgren O, Jodal M, Jansson M, Ryberg AT, Svensson L. Intestinal epithelial stem/progenitor cells are controlled by mucosal afferent nerves. PLoS One. 2011 9;6(2):e16295.
3. Katayama Y, Battista M, Kao WM, Hidalgo A, Peired AJ, Thomas SA, et al. Signals from the sympathetic nervous system regulate hematopoietic stem cell egress from bone marrow. Cell. 2006 27;124(2):407-21.
4. Raufman JP, Shant J, Xie G, Cheng K, Gao XM, Shiu B, et al. Muscarinic receptor subtype-3 gene ablation and scopolamine butylbromide treatment attenuate small intestinal neoplasia in Apcmin/+ mice. Carcinogenesis. 2011;32(9):1396-402.
5. Zhao CM, Hayakawa Y, Kodama Y, Muthupalani S, Westphalen CB, Andersen GT, et al. Denervation suppresses gastric tumorigenesis. Sci Transl Med. 2014;6(250):250ra115.
6. Rabben HL, Zhao CM, Hayakawa Y, Wang TC, Chen D. Vagotomy and gastric tumorigenesis. Curr Neuropharmacol/ 2016; 14(8): 967-72.
7. Horn CC. Brain Fos expression induced by the chemotherapy agent cisplatin in the rat is partially dependent on an intact abdominal vagus. Auton Neurosci. 2009; 148(1-2):76-82.
8. Li HF, Yu J. Airway chemosensitive receptors in vagus nerve perform neuro-immune interaction for lung-brain communication. Adv Exp Med Biol. 2009;648:421-6.
9. Chernyavsky AI, Shchepotin IB, Galitovkiy V, Grando SA. Mechanisms of tumor-promoting activities of nicotine in lung cancer: synergistic effects of cell membrane and mitochondrial nicotinic acetylcholine receptors. BMC Cancer. 2015 19;15:152.
10. Atalay C, Gundogdu B, Aydin MD. Vagal Ischemia Induced Lung Immune Component Infarct Following Subarachnoid Hemorrhage: An Experimental Study. Turk Neurosurg. 2017;27(4):509-15.
11. Balzarotti S, Biassoni F, Colombo B, Ciceri MR. Cardiac vagal control as a marker of emotion regulation in healthy adults: A review. Biol Psychol. 2017;130:54-66.
12. Tatsuta M, Iishi H, Yamamura H, Baba M, Taniguchi H. Effects of bilateral and unilateral vagotomy on gastric carcinogenesis induced by N-methyl-N’-nitro-N-nitrosoguanidine in Wistar rats. Int J Cancer. 1988;42(3):414-18.
13. Mózsik G, Karádi O, Király A, Matus Z, Sütö G, Tóth G, et al. Vagal nerve and the gastric mucosal defense. Journal of Physiology-Paris. 1993;87(5):329-34.
Download attachments: 10.4328:ACAM.21167
Salih Kara, Esra Dişçi, Mehmet Dumlu Aydın, Betul Gündoğdu, Mehmet İlhan Yıldırgan, Nurhak Aksungur, Rıfat Peksöz. Analysis of the nervus vagus effect on gastric adenocarcinoma development. Ann Clin Anal Med 2022;13(8):923-926
Wells score and prediction of pulmonary embolism in patients with coronavirus disease 2019 in Morocco
Mohamed Amine Baba 1, 2, 4, Ahmed Kharbach 4, 5, Bouchra El Mourchid 4, Khadija Sabiri 4, Yassmine Maatoubi 4, Soukaina Wakrim 2, 3
1 Department of Health Sciences, Laboratory of Health Sciences Research, Ibn Zohr University, Agadir, 2 Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, 3 Department of Radiology, University Hospital of Souss Massa, Ibn Zohr Agadir University, Agadir, 4 High Institute of Nursing Professions and Health Technics of Agadir, Agadir, 5 Department of Public Health, Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohamed V University, Rabat, Morocco
DOI: 10.4328/ACAM.21173 Received: 2022-04-04 Accepted: 2022-06-18 Published Online: 2022-06-28 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):927-931
Corresponding Author: Mohamed Amine Baba, Department of Public Health, Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohamed V University, 10100, Rabat, Morocco. E-mail: firstname.lastname@example.org P: +21 263 344 25 54 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6660-9527
Aim: This study aimed to evaluate the performance of the WELLS score for the diagnosis of pulmonary embolism in patients with COVID-19 in Souss-Massa Regional Hospital Center. This article reviewed the diagnostic accuracy of the WELLS score associated with the dosage of D-dimer biomarkers.
Material and Methods: This retrospective observational descriptive and transversal study was conducted at Souss-Massa Regional Hospital Center, from March 15, 2021 to June 26, 2021.
Results: The study included 77 patients who underwent chest CT angiography due to oxygen desaturation associated with the values of the biological marker D – dimers. The most responsive antecedents were type II diabetes (41.00%), hypertension (17.9%), and heart disease (15.4%). The mean age of 47 patients with pulmonary embolism had an average age of 62.09 years (±13.31), including 40 men (85.1%) and 7 women (14.9%); 9 patients died, with no medical history available. Comorbidity factors presented in 80.85% (38/47 cases) of patients, the most frequent being type II diabetes 44.73% (17/38 cases), arterial hypertension 28.94% (11/38), heart disease 5.26% (2/38), chronic respiratory failure 2.63% (1/38), smoking history 10.52% (4/38), asthma patients were 5.26% (2/38), and tuberculosis patients were 2.63% (1 /38). Among these patients 38.29% died. The combination of the Wells score with the value of D-dimers can be useful to guide the appropriate care for his patients.
Discussion: The combination of the Wells score with the value of D-dimers can be useful to guide the appropriate care for his patients.
Keywords: WELLS Score, Pulmonary Embolism, Patients, COVID-19
Since the emergence of coronavirus disease-2019 (COVID-19) following infection with respiratory syndrome coronavirus 2 severe acute (SARS-CoV-2) , when the first cases of COVID-19 appeared, the clinical picture was constructed as a viral respiratory infection, the severity of which depended on the degree of parenchymal damage, damage thought to be responsible for the hypoxemia . Then several reports described significant procoagulant events, including a life-threatening pulmonary embolism (PE), in these patients [3-7]. These thrombotic complications may be due to excessive inflammation, platelet activation, endotheliitis and stasis . Studies reporting both arterial and venous thrombotic events in patients with COVID-19 have emerged in the literature, and emerging evidence suggests a high prevalence of pulmonary embolism cases in hospitalized patients with COVID-19 in care intensive [8, 9].
The detection of PE is established by a “diagnostic strategy”, which has evolved over time, but computerized tomography (CT) angiography of the pulmonary arteries remains the gold standard for the detection of this disease thanks to its rapidity and the availability of highly sensitive scanning. To improve throughput and reduce the number of unnecessary CT scans, the routine use of PE prediction scores is recommended as a clinical decision aid . Studies have demonstrated a reduction in imaging demands when pre-test use of clinical prediction rules is combined with rapid plasma D-dimer assays of cross-linked fibrin degradation products [11, 12]. This study aimed to evaluate the performance of the WELLS score for the diagnosis of pulmonary embolism in patients with COVID-19 in Souss-Massa Regional Hospital Center. as Also, the diagnostic accuracy of the WELLS score associated with the dosage of D-dimer biomarkers has been addressed in this article.
Material and Methods
This retrospective observational descriptive and transversal study was conducted at the Souss-Massa Regional Hospital Center (SMRHC), from March 15, 2021 until June 26, 2021, we selected consecutive hospitalized adult patients with confirmed SARS-coV2 infection and who underwent CT angiography due to suspicion of PE, and D-dimer biological examination. While the sample excluded from the study was any patient with an incomplete and unusable hospital file.
The original Wells score, published in 2000, includes clinical parameters: history of PE or deep vein thrombosis (DVT), heart rate greater than 100/min, recent surgery or immobilization, clinical signs of DVT, hemoptysis and presence of cancer. It also includes a criterion titled “an alternative diagnosis is less likely than PE” . For this last criterion, the formulation of which is not very intuitive, the reasoning can be carried out as follows: if it is estimated that PE is the most probable diagnosis, three points are added to the score. If, however, an alternative diagnosis is deemed as likely or more likely than PE, no points are added to the total score. Although this score item is predictive of the presence of PE .
Data collection is based on a survey form consisting of 3 parts: sociodemographic and biological, the Wells score and the results of the chest CT angiography. The survey sheet form was completed after reviewing all hospital records of the COVID-19 patient and it was completed by ourselves.
Statistical analysis of the data was performed using SPSS (statistical package for social science) version 13 statistical software. Quantitative variables were expressed as mean ± the standard deviation, and the qualitative variables were presented as tables, numbers and frequencies. The sensitivity and specificity of the D-dimer biomarkers were assessed by a receiver operating characteristic (ROC) curve.
The area under the curve (AUC) and 95% confidence intervals (CI) were calculated to assess the strength of any association. This study complied with ethical and regulatory considerations of the institutional agreement of the Souss-Massa Regional Hospital Center (SMRHC) for the realization of this research. We also wanted to respect the anonymity and the confidentiality through the codification of the identification data, and not to have conflicts of related interests.
During the study period, 85 of the patients were referred to the COVID-19 services and underwent a chest CT angiography at the level of the medical radiology service, of which 8 patients were excluded due to the predefined exclusion criteria, the demographic and clinical characteristics of people with and without PE are shown in Table 1.
The 77 patients included underwent chest CT angiography due to oxygen desaturation associated with the values of the biological marker D – dimers, 47/77 (61.00%) were positive for pulmonary embolism and 30/77 (39.00%) were negative (Figure 1).
The incidence of patients hospitalized in the medical department was 49.4%, while 50.6% in the intensive care resuscitation unit COVID-19, of which 32 (82.1%) were males and 7 (17.9%) were females.
The most responsive antecedents were type II diabetes (41.00%), hypertension (17.9%), and heart disease (15.4%). The mean age of 47 patients with pulmonary embolism was 62.09 years (±13.31), including 40 men (85.1%) and 7 women (14.9%); 9 patients died with no medical history available. Comorbidity factors in patients are represented by 80.85% (38/47 cases), the most frequent being type II diabetes 44.73% (17/38 cases), arterial hypertension 28.94% (11/38), heart disease 5.26% (2/38), chronic respiratory failure 2.63% (1/38), smoking history 10.52% (4/38), asthma patients accounted for 5.26% (2/38), and tuberculosis patients accounted for 2.63% (1 /38). Among these patients, 38.29% died.
The numbers and proportions with a low Wells score < 2 were 47/77 (41%), intermediate 2-6 were 28/77 (36.4%), with a high > 6 were 2/77 (2.6%). The most frequently present Wells score items were immobilization ≥ 3 days or recent surgery (n = 53), heart rate > 100/min (n = 25) and “less likely alternative diagnosis” (n = 11).
Only one patient had a history of deep vein thrombosis or pulmonary embolism, DVT symptoms were confirmed in (n=6) patients. The frequency of all Wells score components is shown in Tables 1 and 2.
A total of 71 patients had positive D-dimer results and 6 had negative. D-dimer values were significantly higher in people with confirmed PE. The prevalence of PE increased with higher D-dimer levels. Figure 2 shows the performance of different combinations of D-dimer values and Wells score in predicting pulmonary embolism at hospitalization, with higher values seen in people with PE in the probability groups weak and intermediate pre-test.
The performance of the D-dimer assay to determine EP is represented by a receiver operating characteristic (ROC) curve (Figure 3). The area under the curve (AUC) was 0.761 (95% confidence interval (CI) 0.655-0.866). Above 4849 ng/ml, D-dimer has a positive predictive value for PE; this threshold had a sensitivity of 0.532 and a specificity of 1.
The D-dimer values are homogeneous in patients who do not present with PE and have a low or intermediate probability, while they are heterogeneous in those who present with PE and have a low or intermediate probability, therefore do not share the same D-dimers because the values are more scattered.
CT angiography result
In the 77 patients, the overall involvement of the lung parenchyma was less than 25% in 5 patients (6.5%), between 25% and 50% in 11 (14.3%) patients, between 50 and 75% in 22 (32.5%) patients and more than 75% in 30 (39%) patients. Among patients with confirmed PE, the majority presented with distal PE 93.62% (n=43), of which 28/44 were bilateral, and 16/44 were unilateral. Whereas only 6.4% (n= 3) presented with a proximal PE (Table 3).
Our study provides information on the cumulative incidence of pulmonary embolism in patients hospitalized for COVID-19 pneumonia in the COVID-19 departments of the Souss-Massa Regional Hospital Center. We found 47 patients with proven PE and COVID-19 pneumonia out of 77 chest CT angiograms performed. These data support the hypothesis that COVID-19 patients have an increased thromboembolic risk that tends to manifest as pulmonary arterial thrombosis [12, 15]. Hospitalization in intensive care and especially mechanical ventilation were associated with the occurrence of PE. The high rate in intensive care (53.2%; 25 patients out of 77) is consistent with the current bibliography, but seems higher than most studies, especially compared to a recent meta-analysis showing an overall rate of 30.4% of patients in intensive care [16, 17]. Helms et al reported a higher rate (67.3%) in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 compared to patients with ARDS due to other causes . The importance of these clinical incidence rates is further underlined by a recent series of 12 consecutive autopsy reports showing the presence of PE in 58% of cases, which were not recognized until death .
It should be noted that a large proportion of patients hospitalized in intensive care has a mortality rate of 46%, this can be explained by the high comorbidity rate in these patients, mainly diabetes 80%, hypertension 60%, and heart disease with 50% [20, 21].
According to our data, PE was more likely in case of Wells score <6 points and D-dimer value ≥4849 ng/ml. These results are similar to the study by Kampouri et al, which was conducted at the University Hospital of Lausanne, Switzerland, on a sample of 443 patients who concluded that the combination of the Wells score with the value of D-dimers at the Admission can be a useful tool to guide empiric anticoagulant therapy when diagnostic imaging is not possible or available . Moreover, our data suggest that D-dimer has a positive predictive value for thrombotic events of approximately 90% when values >4849 ng/ml.
In our case series of patients with a low to moderate pre-test probability of pulmonary thromboembolism, 61.7% and 60%, respectively showed signs of PE on chest CT angiography, with 7 out of 10 patients with EP having a score of 0 points. Additionally, considering the true prevalence of pulmonary embolism in our small cohort of COVID-19 patients, we found an increase greater than the prevalence reported by the original study by Wells et al .
However, in the retrospective cohort study by Monfardini et al, they described an increased risk of PE in patients with a moderate to high pre-test probability ; this observation could be explained by the subjective component of the Wells score “Is PE the most probable diagnosis?” was not a good predictor in our series. Three points are added to the final score based on the presence of the differential diagnosis of PE; this question, when positive, has been criticized as subjective and dependent on the accumulation of points from other categories.
Knowledge of the risk factors for PE in COVID-19 patients is crucial to establish the indication for pulmonary CT angiography because of the logistical difficulty involved in the practice of this technique: mobilization of patients, acute respiratory failure, iatrogenic contrast, risk of transmission of the virus and optimization of resources, in a situation of saturation of care . There is some debate as to whether the PE observed in COVID-19 represents a true “thrombosis embolization” or whether it may be localized “immunothrombosis”; in our series, PE was mostly (59.6%) distal bilateral, so PE probably did not have an impact on prognosis.
Several limitations of our work are worth mentioning. First, this is a single-center retrospective study; thus, the results may not be generalized safely due to our small sample size, as well as to fully exclude a selection bias related to the possibility that some patients meeting our inclusion criteria are not referred for chest CT angiography because they had contraindications to the administration of iodinated contrast agents or because CT examinations were temporarily unavailable due to the number of patients requiring chest CT without injection for triage purposes.
The present research showed that pulmonary embolism appears to be a common complication of SARS-CoV-2 infection, especially in intensive care. The combination of the Wells score with the value of D-dimers can be useful to guide the appropriate care for his patients. Our data discourage the use of a stepwise increase in D-dimer threshold alone.
These data reinforce the need to combine it with PE risk stratification scores, in particular the WELLS score. Therefore, the use of chest CT angiography should be encouraged in patients who present with a low and intermediate WELLS score associated with a threshold D-dimer value >4849 ng/ml, this feature may represent the severity of the disease.
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Conflict of interest
1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020; 382(8):727-33
2. Bertoletti L. COVID-19: pulmonary embolism or pulmonary endothelitis? Journal of Vascular Medicine. 2021; 46(5): 28.
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5. Foch E, Allou N, Vitry T, Masse L, Allyn J, Andre M, et al. Pulmonary embolism in a returning traveller with COVID-19 pneumonia. J Travel Med. 2020; 27(5):taaa063. DOI: 10.1093/jtm/taaa063.
6. Rotzinger D.C, Beigelman-Aubry C, Von Garnier C, Qanadli S.D. Pulmonary embolism in patients with COVID-19: time to change the paradigm of computed tomography. Thromb Res. 2020; 190: 58-9.
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11. Goekoop RJ, Steeghs N, Niessen RW, Jonkers GJ, Dik H, Castel A, et al. Simple and safe exclusion of pulmonary embolism in outpatients using quantitative D-dimer and Wells’ simplified decision rule. Thromb Haemost. 2007; 97(1): 146-50.
12. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014; 311(11): 1117-24.
13. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000; 83(03): 416-20.
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23. Kampouri E, Filippidis P, Viala B, Méan M, Pantet O, Desgranges F, et al. Predicting venous thromboembolic events in patients with coronavirus disease 2019 requiring hospitalization: an observational retrospective study by the COVIDIC Initiative in a Swiss University Hospital. BioMed research international. 2020;34.
24. Wells PS, Anderson D R, Rodger M, Stiell I, Dreyer J F, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001; 135(2): 98-107.
Download attachments: 10.4328:ACAM.21173
Ahmed Kharbach, Bouchra El Mourchid, Khadija Sabiri, Yassmine Maatoubi, Soukaina Wakrim, Mohamed Amine Baba. Wells score and prediction of pulmonary embolism in patients with coronavirus disease 2019 in Morocco. Ann Clin Anal Med 2022;13(8):927-931
Ultrasound-guided erector spinae plane block versus rhomboid intercostal block for postoperative analgesia following thoracotomy
Tahsin Şimek 1, Fatih Doğu Geyik 1, Aynur Kaynar Şimşek 2, Yücel Yüce 1, Kemal Tolga Saraçoğlu 1, Recep Demirhan 3
1 Department of Anesthesiology and Reanimation, Health Sciences University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, 2 Department of Nursing, Faculty of Health Sciences, Marmara University, 3 Department of Thoracic Surgery, Health Sciences University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.21189 Received: 2022-04-14 Accepted: 2022-06-11 Published Online: 2022-06-21 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):932-936
Corresponding Author: Tahsin Şimşek, Health Sciences University, Kartal Dr. Lütfi Kirdar Training and Research Hospital, Cevizli Mh., Semsi Denizer Cd., E-5 Karayolu Cevizli Mevkii, 34890, Kartal, Istanbul, Turkey. E-mail: email@example.com P: +90 216 441 39 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3068-4998
Aim: For the thoracotomy pain relief, opioids, thoracic paravertebral and epidural interventions are frequently used practices. In recent years, interfascial blocks such as the erector spinae plan block (ESPB) and rhomboid intercostal block (RIB) have started to be used for analgesia. We aimed to compare the postoperative analgesic effect of ESPB, RIB, and a control (C) group in pain management after open thoracotomy.
Material and Methods: This is a single-centered randomized controlled trial. A total of 75 patients were included in the study in three groups as the ESPB, RIB and control (C) groups. Under general anesthesia, in block groups, blockage was performed with 20 ml 0.25% bupivacaine. In Group C, no procedures other than the standard postoperative analgesia protocol were performed. The amount of postoperative analgesic consumption by the patients, and visual analogue scale (VAS) values were recorded.
Results: In group ESPB and RIB, the mean 24-hour tramadol consumption was 124±29.08 mg and 116±28.65 mg, respectively (p>0.05). In Group C, the consumption was 204±44.06 mg, significantly higher than in group ESPB and group RIB (p=0.004). The VAS values (p<0.05) and the numbers of patients needing rescue analgesic (p=0.048) were lower in groups ESPB and RIB than in group C. There was no significant difference between group ESPB and group RIB in any of these parameters
Discussion: ESPB and RIB were similar and they are more effective than the control group, whereas the former did not have superiority over each other.
Keywords: Analgesia, Block, Thoracotomy
Thoracotomy is one of the most painful surgical procedures. Providing effective analgesia is highly important especially for preventing respiratory and thromboembolic complications . Multimodal analgesia is frequently used to treat pain after thoracotomy and includes neuraxial, paravertebral, and fascial plane blocks, as well as opioids, acetaminophen, and other medications like NSAIDS . However, neuraxial approaches such as thoracic epidural analgesia may lead to side effects such as hypotension, dural puncture, and motor block [3,4]. Opioids may display several negative effects such as nausea-vomiting, constipation, respiratory depression, and itching .
In recent years, interfascial plane blocks such as the erector spinae plane block (ESPB) [2,5] and rhomboid intercostal block (RIB) [6,7] have started to be used. ESPB is a regional block method developed by Forero . With this method, by injecting a local anesthetic between the transverse process and erector spinae muscles, the blockage of the dorsal and ventral branches of the regional spinal nerves is provided, and analgesia is induced. It has a broad usage area in surgeries in the thoracal and abdominal regions such as thoracotomy, hysterectomy, and lumbar surgery . In addition to being an effective analgesic technique, its low complication risk, and high feasibility are among its main advantages . In RIB, by making a local anesthetic agent injection between the intercostal muscles and the rhomboid muscle, with the blockage of the intercostal and thoracal spinal nerves, analgesia is provided in the anterior and posterior hemithorax . It was reported that this method provided an effective and safe analgesic . It has been used in thoracic surgery [6,7], breast surgery , rib fractures , and myofascial pain . Determining the most effective and feasible method in post-thoracotomy pain management is crucially important to increase patient comfort, reduce analgesic consumption and avoid complications. The literature review revealed studies on the effectiveness of RIB and ESPB in thoracotomy analgesia. However, most of these studies have consisted of case series, and the number of randomized controlled studies is very low. Moreover, a study comparing RIB and ESPB was not encountered.
This study aimed to compare the effects of ESPB, RIB, and a control group in terms of pain management after open thoracotomy. The primary out¬come was to compare the postopera¬tive 24-h consumption of tramadol as a rescue analgesia. The secondary out¬come was to compare VAS, number of patients requiring rescue analgesics, nausea, and vomiting.
Material and Methods
This prospective randomized controlled trial was conducted between 1 February 2020 and 1 January 2021 at a Research and Training Hospital. The protocol of the study was approved by the Local Ethics Committee (protocol no: 2019/514/150/21- date: 27.03.2019) and registered on the ClinicalTrials.gov (NCT04294394). All patients provided written informed consent for their inclusion in this study. The Consolidated Standards of Reporting Trials (CONSORT) flow diagram was used for patient enrollment and allocation (Figure 1).
Patients aged between 18 and 75 years with the American Society of Anesthesiologists (ASA) physical statuses I-III, who were scheduled for the elective resection of non-metastatic lung malignancies, were included in the study. Patients who did not agree to participate, as well as those who had coagulopathy, liver and kidney dysfunctions, or local anesthetic allergies, were excluded.
All patients were monitored in the operating room with temperature monitoring, electrocardiogram (ECG), pulse oximetry (SpO2), and non-invasive blood pressure measurement. For general anesthesia, the patients were given 1-1.5 mcg/kg fentanyl, 1-2 mg/kg propofol and 0.6 mg/kg rocuronium bromide in IV induction. Following tracheal intubation, for the maintenance of anesthesia, sevoflurane 1-2% in a mixture of oxygen and air and remifentanil at the dose of 0.1-0.3 mcg/kg/min were administered. After ending of surgical procedure and before reversing the muscle relaxant, patients were randomly divided using a computer-generated table into 3 equal groups as the control group (Group C), erector spinae plane block group (Group ESPB), and rhomboid intercostal block group (Group RIB). The blocks were applied by the same anesthesiologist who was not involved in the data collection or analysis process. ESPB or RIB was applied under general anesthesia on the patients except for those in the control group.
Thirty minutes before the end of the surgery, all patients including the control group were given 100 mg of tramadol and 1 g of paracetamol. For nausea-vomiting, 10 mg metoclopramide was administered. Following the end of the operation, after administering 2-4 mg/kg sugammadex for decurarization and observing sufficient respiratory effort, the patient was extubated and transferred to the post-anesthetic care unit.
Erector spinae plane block
The patient was placed in a lateral position. Regional sterile conditions were achieved by 10% povidone-iodine solution. An experienced anesthesia doctor placed a 6-13 MHz linear ultrasonography (USG) probe (Esaote, Via E. Melen, 77 16152 Genova, Italy) at 3 cm lateral of the T5 spinous process. The trapezius, rhomboid major, and erector spinae muscles were imaged. With a 20 G and 100 mm block needle (Stimuplex® Ultra 360® B-Braun medical, Melsungen, Germany), the fascial plane between the transverse process and erector spinae muscle was entered. After conducting hydro dissection with 3 ml normal saline (NS) for confirmation, 20 ml of the local anesthetic solution consisting of 0.25% bupivacaine was given.
Rhomboid intercostal block
The patient was placed in a lateral position. Regional sterile conditions were achieved by 10% povidone-iodine solution. A 6-13 MHz linear USG probe was placed at the medial of the scapula on the level of the thoracal 6th-7th vertebrae in the sagittal position. The trapezius, rhomboid major, intercostal muscles, and costae were imaged. With a 20 G and 100 mm block needle, the fascial plane between the rhomboid muscle and intercostal muscle was entered in the craniocaudal direction. After conducting hydro dissection with 3 ml NS for confirming the area, 20 ml of the local anesthetic solution consisting of 0.25% bupivacaine was given.
Standard postoperative analgesia protocol
During the 24-hour postoperative period, all patients (group ESPB, group RIB, control group) were administered 1 g paracetamol every 8 hours. In the case that values of 4 or higher were observed in the 24-hour visual analog scale (VAS) follow-ups of the patients, tramadol was administered in the form of infusion in 30 minutes as a rescue analgesic at the dose of 1mg/kg (at a maximum of 100 mg per use)
The pain levels were assessed on a 10-point VAS at 1, 2, 3, 6, 9, 12, and 24 hours by pain nurses blinded to the study. Zero points were recorded as no pain, while 10 points were recorded as unbearable pain. For the first 24 hours, VAS, total tramadol consumption, number of patients, requiring rescue analgesics, and incidents of nausea and vomiting were recorded.
A previous study  reported a large effect size for Tramadol consumption (d=1.424). We planned our study for three groups, and a power analysis was performed before the study for a three-group comparison and a large effect size value (f=0.4). Accordingly, when at least 66 people (at least 22 for each group) would be included in the study, this would result in 80% power within a 95% confidence interval. Considering the possibility of a loss of subjects, 15% more subjects were included in each group. We included 75 patients (25 for each group) in this study. Regarding the ‘tramadol consumption quantity’ results, we had a large effect size (f=0.397), and we reached 86.4% (post-analysis power) power within a 95% confidence interval.
All statistical analyses were performed using SPSS 25.0 (IBM SPSS Statistics 25 software (Armonk, NY: IBM Corp.)). Continuous variables were defined as mean ± standard deviation (for parametric tests); median (for non parametric tests) and categorical variables as numbers and percentages. The Kolmogorov-Smirnov test was used for the determination of the normal distribution. For independent groups comparisons, we used One Way Analysis of Variance (post hoc: Tukey test) when parametric test assumptions were provided, and the Kruskal-Wallis Variance Analysis (post hoc: Mann-Whitney U test with Bonferroni Correction) when parametric test assumptions were not provided. Categorical variables were analyzed using a Chi-square test. Statistical significance was determined as p<0,05.
Eighty patients were screened for the study. Two patients were excluded due to having coagulopathies, and 3 patients were excluded as they did not agree to participate. The remaining 75 patients were analyzed in three groups as group ESPB, group RIB, and group C (Figure 1).
There was no significant difference among the groups in terms of the patients’ distributions of age, sex, body mass index, ASA class, and operation duration. No complications developed in the patients in any group (Table 1).
There was also no significant difference between the groups in terms of their nausea-vomiting scores (Table 2).
Mean 24-hour tramadol consumption was 124 ± 29.08 mg in group ESPB, 116 ± 28.65 mg in group RIB and 204 ± 44.06 mg in group C (p = 0.004). In the post hoc analysis that was conducted, while there was no significant difference between groups the ESPB and RIB, there were significant differences
between the ESPB and C groups and between the RIB and C groups (Table 2).
There was a significant difference among the groups based on their VAS scores (VAS 1=0.003, VAS 3<0.001, VAS 6=0.027, VAS 9<0.001, VAS 12=0.023, VAS 18<0.001, VAS 24<0.001) (Table 2) and numbers of patients requiring rescue analgesic use (p=0.048) (Table 2). In the post-hoc analysis that was conducted to see the source of the difference, in terms of both the VAS scores and numbers of patients requiring analgesic use, while there was no significant difference between the ESPB and RIB groups, there were significant differences between the ESPB and C groups and between the RIB and C groups (Table 2).
In this study, the outcomes of the non-metastatic lung malignancy patients undergoing open thoracotomy were evaluated among the ESPB, RIB, and control groups. The comparison of the ESPB and RIB groups did not result in a significant difference in terms of the postoperative 24-h tramadol consumption, VAS scores, number of patients requiring rescue analgesic. However, postoperative 24-h tramadol consumption was found to be lower in the block groups compared to the control group. The number of patients requiring rescue analgesic and the mean VAS scores was lower in the ESPB and RIB groups than in the control group.
Forero et al.  in their cadaver study containing case series, showed that after the dye injection in ESPB, staining was observed at the T2-T8 levels in regions containing both the ventral and dorsal rami of the spinal nerves. As a result, they concluded that ESPB created a sensory block on the posterior and anterolateral thorax. In a similar way with the help of pin-prick test we found out in our study that sensorial block occurs at the level of T3-T9 in ESPB.
A recent study found the postoperative VAS scores and analgesic consumption quantities after thoracotomy in the ESPB group were lower than those of the control group . Our study also found lower VAS scores and rescue analgesic consumption quantities after ESPB compared to the control group.
Çiftçi et al.  observed that post-thoracotomy analgesic consumption quantities, VAS scores, and postoperative nausea-vomiting levels were lower in the ESPB group than in the control group. In our study, similar to Çiftçi et al., analgesic consumption quantities and VAS scores were also found to be lower in the ESPB group than in the control group. However, we found no significant difference between the groups in terms of their nausea-vomiting levels. The reason for this difference may be considered as the fact that Çiftçi et al. used fentanyl and meperidine as two opioid agents in their postoperative analgesia protocol.
In their cadaver study, Elsharkawy et al.  reported that a dye applied with RIB showed a cranial and caudal spread between the rhomboid major and intercostal muscles between the T2 and T8 levels, and there was staining in the lateral cutaneous branch of the intercostal nerves between the levels of T2 and T8 and the posterior rami of the thoracic spinal nerves on the levels of T2-T9. Additionally, they observed that in a patient with multiple costal fractures, with 25 ml 0.25% bupivacaine, there was a symptomatic improvement in the posterior, lateral, and mid-anterior hemithorax between the levels of T2 and T9. In a similar way, in our study, we saw that analgesia could be achieved by a RIB with 20 ml 0.25% bupivacaine. Studies are suggesting that the RIB practice is an effective analgesia method following breast surgery [13,17] and thoracotomy . In their case series including 5 patients on RIB after thoracotomy, Ökmen K.  reported that the VAS scores of all patients were lower than 3, 3 patients needed low-dose rescue analgesics (50 mg tramadol in 2 patients and 75 mg tramadol in 1 patient), and 2 patients did not need rescue analgesics. In our study, there was no need for the rescue analgesic in 32% of the patients in the RIB group and 36% of the patients in the ESPB group. However, while there was a need for the rescue analgesic in 92% of the patients in the control group, there was no need only in 8%. In our study, the VAS scores were also lower than 3 in both the RIB and ESPB groups, and they were significantly lower compared to the control group.
Although thoracal epidural analgesia is accepted as the gold standard analgesic approach after thoracotomy, this technique also has some side effects. Dural puncture, epidural hematoma, spinal abscess, and significant hemodynamic sequelae resulting from local anesthesia-related sympathetic blockade are among these side effects [1,2,4].
In our study, effective analgesia levels were achieved in the patients in both groups ESPB and RIB, and no complications occurred in any patient. This is why we believe both ESPB and RIB are reliable methods. The RIB and ESPB procedures that we compared in this study did not have any analgesic superiority over each other. The reason for this was considered to be that both RIB and ESPB spread through the nerves in similar regions, and induce sensory blocks [8,11]. Despite the similar analgesic effectiveness of both interfascial blocks, between the two, we think that transverse process visualization while performing ESPB makes the procedure easier, and it may be successfully applied also by less experienced users.
As a limitation of our study, we can conclude that the dermatomal assessment of block function may be interpreted as not formal since we performed the blocks under general anesthesia. However, we can report that, similar to routine clinical practice, we performed these blocks via ultrasonographic imaging after general anesthesia induction. Thus, this way of block application may decrease the suspicion about the effectiveness of the blocks.
The second limitation of the study may be the small sample size. New studies with larger samples may better clarify the effectiveness of these blocks.
In conclusion, it was observed that ESPB and RIB were techniques with low complications and high success rates. While they had no analgesic superiorities over each other after thoracotomy, as they reduced total anesthetic consumption quantities and VAS scores in comparison to the control group, it was concluded that these methods could be safely used in such operations.
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Tahsin Şimek, Fatih Doğu Geyik, Aynur Kaynar Şimşek, Yücel Yüce, Kemal Tolga Saraçoğlu, Recep Demirhan. Ultrasound-guided erector spinae plane block versus rhomboid intercostal block for postoperative analgesia following thoracotomy. Ann Clin Anal Med 2022;13(8):932-936
Evaluation of vaginal culture results in patients with threatened preterm labor
Fehmi Unal 1, Nursu Kara 2
1 Department of Obstetrics and Gynaecology, 2 Department of Neonatology, Istanbul Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.21278 Received: 2022-06-17 Accepted: 2022-07-25 Published Online: 2022-07-27 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):937-941
Corresponding Author: Fehmi Ünal, Department of Obstetrics and Gynaecology, Istanbul Training and Research Hospital, 34098, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 212 459 60 00 F: +90 212 459 62 30 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8182-2051
Aim: In this study, we aimed to investigate the effects of certain infections on preterm birth by examining cervicovaginal cultures from patients with and without premature rupture of membranes (PROM) who were diagnosed with threatened preterm labor.
Material and Methods: Records of 85 patients diagnosed and treated for threatened preterm labor were retrospectively reviewed. Cervicovaginal cultures and laboratory results were analyzed. Preterm labor was diagnosed based on the Creasy-Herron criteria. Medical and obstetric histories, ultrasound examinations, vaginal examinations, and information on non-stress tests were recorded for all patients. The latency period was determined by subtracting the week of gestation at hospital admission from that at birth.
Results: A total of 74 patients who met the inclusion criteria were included in the study. Staphylococcus haemolyticus (n=7, 20.5%) was the most common microorganism detected in the cervicovaginal cultures. Births occurred before 37 weeks of gestation in 23 (67.6%) of the 34 patients who tested positive for microbial growth. No difference was observed between the rates of cervicovaginal culture positivity in threatened preterm labor patients with and without PROM (p=0.57). Of the 29 babies born in our hospital, thirteen (54.5%) of the 23 preterm babies were admitted to our hospital’s neonatal intensive care unit. There were no positive indicators of infection or growth in the blood cultures of these infants.
Discussion: Cervicovaginal and urine cultures provide important information that may prevent severe mortality and morbidity during follow-up of patients with threatened preterm labor.
Keywords: Threatened Preterm Labor, Vaginal Culture, PROM
Infants born before 37 weeks of gestation are considered preterm . The preterm birth rate in the United States is 10% . Neonatal complications of preterm birth, associated with 70% of neonatal deaths, include respiratory distress syndrome (RDS), sepsis, intraventricular hemorrhage, necrotizing enterocolitis, hypothermia, hypoglycemia, hyperbilirubinemia, and nutritional disturbances [3,4]. Long-term conditions such as retinopathy of prematurity, cerebral palsy, and neurodevelopmental disorders have been previously studied . Therefore, it is critical to identify, manage, and investigate the etiology of preterm births.
Causes of preterm births include infection, abruptio placentae, placenta previa, history of preterm births, pregnancies under 18 and over 40 years of age, malnutrition, low body mass index (BMI), fetal anomalies, fetal growth retardation, oligo-polyhydramnios, vaginal bleeding, PROM, etc. . Knowledge of the etiology and appropriate interventions are essential to prevent perinatal mortality and morbidity. Forty to fifty percent of preterm births are infection-related [1,6]. Although infections via hematological procedures, invasive procedures have been previously described, infections via the ascending route are most common .
In this study, we aimed to investigate the effects of certain infections on preterm birth by examining the cervicovaginal cultures of patients with and without PROM who were diagnosed with threatened preterm labor.
Material and Methods
We retrospectively reviewed records of patients diagnosed and treated for threatened preterm labor with or without PROM between January 2019 and January 2021 at the Department of Obstetrics and Gynecology, XXX Hospital. Cervicovaginal cultures and laboratory results were obtained from 85 patients, 11 of whom were excluded from the study for various reasons, and the remaining 74 were analyzed for the study.
The inclusion criteria for the study were gestational age between 20 and 36 weeks and 6 days (gestational week confirmed by last menstrual period and first-trimester ultrasound) and a diagnosis of threatened preterm birth. The diagnosis of preterm labor was made based on the Creasy-Herron criteria that involved the detection of uterine contractions at a frequency of four per 20 min or eight per 60 min, and was accompanied by one of the following: PROM [detected by fluid leaking during speculum examination or by the test kit for the detection of alpha-microglobulin-1 in the placenta (Amnisure ROM test, N-Dia Inc, New York, USA)], cervical dilation exceeding 2 cm, effacement exceeding 50 %, or a change in cervical dilation or effacement detected by serial examinations . Patients aged 18-40 years with no other known causes of infection were included. The exclusion criteria were age < 18 years, age > 40 years, and the presence of other known sources of infection. Patients with known conditions that may lead to preterm birth (e.g., uterine anomaly, fetal anomaly, cervical pathology, or fetal growth retardation), abnormalities of the placenta, oligo-polyhydramnios, vaginal bleeding, history of chronic concomitant diseases, smoking, alcohol, and substance use, and those who had taken antibiotics in the last 3 weeks were also excluded.
Medical and obstetric histories, ultrasound examinations, vaginal speculum and digital examinations, and information on non-stress tests were recorded for all the patients. The latency period was calculated using the following formula: gestational week at birth – gestational week at hospital admission.
Cervicovaginal culture results were recorded for all patients. At our hospital, vaginal culture specimens were delivered to the microbiology laboratory using Stuart Transport Swap and Medium (BTR-Gülkimya/Ankara or Fıratmed/Ankara). The samples were seeded on 5% blood agar and MacConkey agar, and the Candida positive samples were seeded on the Sabouraud medium. Microorganisms were identified by preparing fresh saline and performing Gram staining. The presence of trophozoites in fresh saline indicated the presence of Trichomonas vaginalis. Candida was identified based on the appearance of yeast, pseudohyphae and growth in culture. Bacterial vaginosis was diagnosed by Gram staining of coccobacilli with variable staining, detection of epithelial cells that are clue cells to which these bacteria adhere, and Nugent scoring.
This study was approved by the ethics committee of our hospital on October 7, 2020 (approval number: 2467).
The SPSS 26.0 (IBM Corporation, Armonk, New York, United States) and MedCalc 14 (Acacialaan 22, B-8400 Ostend, Belgium) were used to analyze the variables. The Shapiro-Wilk-Francia test determined the fit of the univariate data to the normal distribution. The chi-square test was used to examine the correlations between the quantitative variables. Quantitative variables are reported as mean ± standard deviation (SD) and categorical variables as n (%). Variables were analyzed at a 95% confidence level, and p-values less than 0.05 were considered significant.
A total of 74 patients who met the inclusion criteria were included in the study. Fifty-two patients (70.3%) were multiparous and 22 (29.7%) were primiparous. The ages of the patients ranged between 18-40 y (mean: 22.1 [SD:7.2] years). None of the patients were smokers or had any concomitant diseases. Growth was detected in cervicovaginal cultures from 34 patients (45%). Urine cultures in four patients showed growth, while seven patients (9.4%) presented with urine and cervicovaginal culture positivity simultaneously.
Staphylococcus haemolyticus (n=7, 20.5%) was the most common microorganism detected in the cervicovaginal cultures. Among the microorganisms grown in cervicovaginal cultures, the following types of micrroorganisms were detected: Staphylococcus haemolyticus (n=7), Candida tropicalis (n=4, 11%), Staphylococcus aureus (n=5, 14%), Escherichia coli (n=4, 11%), Staphylococcus intermedius (n=1, 2.9%), Candida albicans (n=3, 8.8%), Streptococcus agalactiae (n=1, 2.9%), Dermacoccus nishinomiyaensis (n=1, 2.9%), Staphylococcus hominis (n=1, 2.9%), Candida glabrata (n=1, 2.9%), Klebsiella pneumonia (n=1, 2.9%), Streptococcus pneumonia (n=1, 2.9%), Staphylococcus lentus (n=1, 2.9%), Pediococcus pentosaceus (n=1, 2.9%), Staphylococcus epidermidis (n=2, 5.8%). The patients’ demographic data are summarized in Table 1. Births occurred before 37 weeks of gestation in 23 (67.6%) of the 34 patients who tested positive for microbial growth. Preterm births were detected in six patients that presented with both urine and cervicovaginal culture growth. In four of these six patients, the same microorganisms were detected in both urine and cervicovaginal cultures (three Escherichia coli and one Pediococcus pentosaceus). Notably, the growth of microorganisms was different between the two patients (patient 1: vagina, Candida tropicalis – urine, Proteus mirabilis; patient 2: vagina; Klebsiella pneumonia – urine; methicillin-resistant Staphylococcus aureus).
In 29 (39.1%) patients, the indication for hospital admissions was threatened preterm labor that developed with or after the PROM, whereas 45 patients (60.9%) did not present with PROM. Of the patients with positive cervicovaginal cultures, 12 presented with PROM, and all delivered before 37 gestational weeks. No correlation was found between cervicovaginal culture positivity and patient age (P =0.85). Additionally, there was no correlation between cervicovaginal culture positivity and BMI (P=0.49). No difference was observed between the rates of cervicovaginal culture positivity in threatened preterm labor patients with and without PROM (p=0.57). There was no significant correlation between cervicovaginal culture positivity and time between liquid leakage and birth (p=0.75). In addition, no correlation was found between cervicovaginal culture positivity, WBC count and CRP levels at birth (p=0.54 and p=0.40, respectively).
Correlation analysis revealed a moderate positive correlation (p=0.04, r=0.24) between age and BMI, and a moderate negative correlation between age and gestational age at hospital admission (p=0.03, r=-0.25). A moderate positive correlation (p=0.04, r=0.35) was found between CRP level at hospital admission and BMI. A strong negative correlation was observed between the gestational week at hospital admission and latency period (p=0.00, r=-0.50). There was a positive correlation (p=0.00, r=0.58) between the latency period and the length of hospital stay. A strong negative correlation (p=0.00, r=-0.37) was also detected between the WBC count at hospital admission and latency period (Table 2).
Of the 74 pregnant women who were monitored for threatened preterm labor, 27 delivered at our hospital and multiple pregnancies were detected in two of these pregnant women. Of the 29 babies born in our hospital, six (20.7%) were term births and 23 (79.3%) were preterm births. The mean birth weight of the 29 babies was 2411.6±681 g, and the mean gestational week was 34.6±2.9. Ten preterm babies were born late preterm and discharged after follow-up with their mothers. Thirteen (54.5%) of the 23 preterm babies were admitted to our hospital’s neonatal intensive care unit. The mean gestational week of the admitted babies was 32.5±2.5 (min-max, 27 GW -34 GW), and the mean birth weight was 1857.3± 498.4 g (min-max, 930 g-2580 g). The patients were hospitalized for premature births, respiratory distress, low birth weight, and sepsis. Four infants were mechanically ventilated for RDS and received intratracheal surfactant. Five infants required follow-up with noninvasive mechanical ventilation. There were no positive infection indicators or growth in the blood cultures of the infants admitted to the neonatal intensive care unit.
This study aimed to investigate the rate of cervicovaginal culture positivity in patients admitted to our hospital with indications of threatened preterm labor with or without the PROM. In our study the cervicovaginal culture positivity was observed in 45% of the patients. Simultaneous urine and cervicovaginal culture positivity was detected in seven (9.4%) of these patients.
The relationship between the vaginal microbiota and preterm birth has been discussed in several studies, with the conclusion that vaginal infections can cause preterm birth [6,8,9]. Lockwood found that ascending genital infections can cause up to 50% of preterm births . Klein et al. revealed that lower genital tract infections can induce preterm birth via cytokine production by leukocytes . Miyoshi et al. found that a positive vaginal Ureaplasma urealyticum/Mycoplasma hominis culture is a predictive factor for preterm births . Arena et al. found that in women diagnosed with premature labor, all patients presented with vaginal dysbiosis . Giraldo et al. found that microbiological examination of urine and genitalia identified an infectious agent in 49% of the cases . The authors recommend early investigation and treatment of these infections.
Gardnerella vaginalis, Candida species, and Trichomonas vaginalis are the causative agents of vaginal infections [12,13]. Bacterial vaginosis increases the incidence of preterm birth two-fold . Ten to fifteen percent of the women with bacterial vaginosis deliver prematurely . Ugwumadu et al. revealed that the risk of preterm birth decreased when bacterial vaginosis was treated with oral clindamycin . Interestingly, Gardnerella vaginalis was detected in only one patient in our study.
In a meta-analysis, Roberts et al. found that the treatment of pregnant women with asymptomatic vaginal candidiasis helped prevent preterm labor; however, further prospective studies are needed on this topic . In contrast, Schuster et al. reported that treatment with asymptomatic vaginal candidiasis had no effect on preventing preterm births . Although there are differing results in the literature, vaginal Candida tends to not affect preterm birth . In our study, Candida species were detected in seven patients (9.4%), four of whom delivered before 37 weeks of gestation.
Trichomonas vaginalis infection is associated with complications such as PROM, preterm birth, low birth weight . Interestingly, treatment of patients with asymptomatic Trichomonas was associated with an increased risk of preterm birth; it was suggested to avoid treatment of these patients . Inflammatory mediators released by deceased Trichomonas might contribute to the increased risk of preterm birth , and treatment is recommended for symptomatic Trichomonas vaginitis . Trichomonas was not detected in our patient group. In recent years, the incidence of Trichomonas in the general population may be decreased, because of timely screening and treatment.
GBS was detected in one of the enrolled patients. Since these bacteria do not cause preterm birth but can cause severe neonatal complications, they must be treated immediately after detection . A 2017 meta-analysis pointed out that maternal GBS colonization may be associated with preterm birth and emphasized that this association was stronger when colonization was detected in urine . In contrast, our patient had a preterm birth at 34 weeks and received prophylaxis against GBS during birth.
Culture positivity was detected in simultaneous vaginal and urine samples from seven of our patients, six of whom delivered preterm babies. Of the three patients in whom culture positivity was detected only in the urine sample, two had preterm births. Since tract infections in pregnancy can lead to severe morbidity and mortality, immediate treatment is recommended after detection . If asymptomatic bacteriuria is not treated, an estimated 30% of the cases develop acute pyelonephritis, which can lead to complications such as preeclampsia, preterm birth, and low birth weight .
Consistent with the few studies published in the literature, we found no association between the latency period and culture positivity in our study . Rouzaire et al. in their study  noted a vaginal culture positivity in 28.2% of the patients with PROM and noted that culture positivity had no effect on the birth time. In a large-scale retrospective study, Dagklis et al. reported that clinical chorioamnionitis reduced the latency period. However, data on culture positivity in these patients were not shared . We also found no statistically significant differences in WBC counts and CRP levels at birth between the culture-positive and culture-negative patients. The time between membrane rupture and birth in patients with PROM did not vary between the culture-positive and culture-negative patients. There was no difference in culture positivity between patients with PROM and those with spontaneous preterm births.
The observed decrease in the latency period with increasing gestational age is consistent with previous reports [22,23]. The negative correlation between the WBC count at hospital admission and latency is consistent with the view that clinical chorioamnionitis shortens the latency period .
Considering the 45% cervicovaginal culture positivity in our study group and the morbidity and mortality caused by infections during pregnancy, the diagnosis and treatment of these infections in pregnant women are important. Tract infections have similar implications.
Additionally, newborns of pregnant women monitored for threatened preterm labor were evaluated for sepsis. None of the patients had sepsis, and the acute-phase reactants tested negative. PROM has been reported to be a risk factor for the development of neonatal sepsis . The incidence of neonatal sepsis in pregnant women with PROM varies from 1 to 13.01%, depending on the duration of membrane rupture [24,25]. Ocviyanti et al. reported that the risk of sepsis increased 18.59-fold in preterm babies born to mothers with PROM compared to full term babies . The authors noted that the group at the highest risk was preterm babies with a gestation period of less than 28 weeks . In their study, only one case of neonatal sepsis was identified in 405 term infants born after PROM. The fact that no newborns developed sepsis in our study suggests that this is related to maternal antibiotic treatment, a smaller number of patients, and at higher gestational age. This is one of the rare studies evaluating vaginal culture outcomes in women with threatened preterm labor and the neonatal outcomes of these pregnancies.
Our study has some limitations. This was a single-center, retrospective study with a relatively small number of patients. Larger prospective studies may yield more significant results.
Cervicovaginal and urine cultures provide important information that may prevent severe mortality and morbidity during follow-ups of patients with threatened preterm labor. Accumulating data on this topic may provide a better understanding of this clinical condition.
The authors would like to thank Dr Mehtap Turfan for her tremendous help.
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Animal and human rights statement
Conflict of interest
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11. Arena B, Daccò MD. Evaluation of vaginal microbiota in women admitted to the hospital for premature labour. Acta Biomed. 2021;92(5):e2021292.
12. Giraldo PC, Araújo ED, Junior JE, do Amaral RL, Passos MR, Gonçalves AK. The prevalence of urogenital infections in pregnant women experiencing preterm and full-term labor. Infect Dis Obstet Gynecol. 2012;2012:878241.
13. Mashburn J. Etiology, diagnosis, and management of vaginitis. J Midwifery Womens Health. 2006;51(6):423-30.
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Download attachments: 10.4328:ACAM.21278
Fehmi Unal, Nursu Kara. Evaluation of vaginal culture results in patients with threatened preterm labor. Ann Clin Anal Med 2022;13(8):937-941
Evaluation of amplitude-integrated EEG use in the neonatal intensive care unit
Sadrettin Ekmen, Yusuf Deniz
Department of Pediatrics, Faculty of Medicine, Karabuk University, Karabuk, Turkey
DOI: 10.4328/ACAM.21284 Received: 2022-06-21 Accepted: 2022-07-28 Published Online: 2022-07-29 Printed: 2022-08-01 Ann Clin Anal Med 2022;13(8):942-946
Corresponding Author: Sadrettin Ekmen, Faculty of Medicine, Karabuk University, Karabuk, Turkey. E-mail: email@example.com P: +90 505 374 70 80 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9031-6361
Aim: Amplitude-integrated electroencephalogram (aEEG) is widely used in neonatal intensive care units (NICU), as it is easier to interpret than conventional EEG and does not prevent invasive procedures in infants. Although it is frequently used in the diagnosis and follow-up of Hypoxic Ischemic Encephalopathy (HIE) and neonatal convulsions developing after perinatal asphyxia, the relationship between neurological examination, aEEG and conventional EEG (cEEG) is still not fully understood.
Material and Methods: This study was carried out by retrospective evaluation of the patient’s files and aEEG records of 59 infants who were followed up with aEEG in the Neonatal Intensive Care Unit of Karabuk University Training and Research Hospital between January 1, 2020 and January 31, 2022. One infant who was beyond the neonatal period was not included in the analysis. The data of 38 infants with perinatal asphyxia and 20 infants who were prediagnosed with convulsions were evaluated.
Results: aEEG results of the infants diagnosed with perinatal asphyxia were found to be highly consistent with neurological examination in the early and late periods (84.2%). However, convulsion was detected in aEEG only in 20% of 20 infants with abnormal movements clinically suggestive of convulsions.
Discussion: Our study revealed that the use of aEEG is beneficial in infants who develop HIE after perinatal asphyxia but its benefit in the diagnosis and follow-up of neonatal seizures is not clear. We believe that the use of multi-channel aEEG and/or the use of aEEG together with conventional EEG in neonatal convulsion follow-up will provide more useful information.
Keywords: Hypoxia-Ischemia, Seizures, Newborn, Hypothermia, Electroencephalography
Amplitude-integrated electroencephalogram (aEEG) has found widespread use in neonatal intensive care units (NICUs) in recent years. The fact that it is easier to interpret than conventional EEG and that it does not prevent invasive procedures in infants are the main reasons why it is preferred by neonatal physicians .
There are studies showing that its use is beneficial in many cases such as the diagnosis, follow-up and prognosis prediction of perinatal asphyxia-related hypoxic ischemic encephalopathy (HIE) , diagnosis and treatment of subclinical convulsions , intraventricular hemorrhage in premature infants , prediction of neurological sequelae secondary to hyperbilirubinemia [5,6] and meningitis .
However, the main disadvantages are the risks of skipping short-term convulsions due to a compressed time scale and skipping focal seizures due to the use of a small number of electrodes .
The Turkish Neonatology Society, in its neonatal encephalopathy guideline, which was updated in 2018, recommended the use of aEEG for diagnosis and follow-up in centers that apply hypothermia treatment .
However, the relationship between neurological examination, aEEG and conventional EEG (cEEG) is still not fully understood .
Our aim in this study is to evaluate the practical correlation of aEEG with clinical and laboratory results and whether the use of aEEG can help clinicians in the presence of movements suggestive of convulsions in newborns.
Our study was designed in our unit that provides 3rd level neonatal intensive care service at Karabuk University, Faculty of Medicine, Training and Research Hospital. We use the aEEG as a helpful tool, together with clinical and laboratory results, in decision making for hypothermia in infants with hypoxic ischemic encephalopathy (HIE); for the termination of hypothermia treatment until the infant is fully warmed; and to initiate anticonvulsant treatment and evaluate the response to treatment in cases where movements that can be confused with convulsions are observed in newborn infants.
Material and Methods
This study was carried out by retrospective evaluation of patient files and aEEG records of 59 infants who were followed up with aEEG in the Neonatal Intensive Care Unit of Karabuk University Training and Research Hospital between January 1, 2020 and January 31, 2022.
Infants with major congenital malformations who were beyond the neonatal period when aEEG was performed were not included in the study.
Neonatal hypoxic ischemic encephalopathy (HIE) was defined as a clinical syndrome accompanied by neurological findings and acute peripartum-intrapartum event (uterine rupture, cord prolapse, placental abruption, etc.), requiring postnatal neonatal resuscitation, and presenting with metabolic or mixed acidosis in cord blood gas or in blood gas measured within the first 1 hour .
The severity of the HIE was assessed using the Modified Sarnat Staging.
aEEG monitoring was performed for the diagnosis and follow-up of infants with stage 2 or stage 3 HIE due to perinatal asphyxia (PNA), after hypothermia and until the end of rewarming (until the infant’s rectal temperature rises to 37°C), infants who were candidates for hypothermia but not fully meeting the criteria (HIE Stage 1), and infants with movements thought to be convulsions other than HIE.
DigiTrack Elmiko (made in Poland) was used as the aEEG device.
aEEG was evaluated by the relevant neonatal specialist.
aEEG monitoring was evaluated based on amplitude, electrographic seizure, and sleep-wake cycle. Normal amplitude was accepted as >10 μV for the upper limit and >5 μV for the lower limit. Abnormal aEEG was defined as background activity other than continuous normal voltage or immature sleep-wake cycle. Electrographic seizure was defined as an abrupt rise in the minimum amplitude with or without a simultaneous rise in the maximum amplitude, followed by a short period of decreased amplitude, and simultaneous repetitive spikes or sharp waves of at least 5-10 seconds of duration in the aEEG [11-13]
After hypothermia was decided, active hypothermia was applied for 72 hours with a rectal temperature of 33-34°C. Then the rectal temperature was increased to 37°C within 6-12 hours, not exceeding 0.5°C per hour.
When convulsions were detected, phenobarbital was started as the first option in line with the recommendation by The Turkish Neonatology Society. When no response was obtained, phenytoin was added as the second option, and midazolam or levetiracetam treatments were added as the third option .
In addition, fluid therapy was limited to 50 cc/kg. Fentanyl infusion was started for pain and a combination of ampicillin and gentamicin was started for infection prophylaxis. Glucose levels, urine output, blood pressure and other vital functions were closely monitored. Specific treatments were started for the detected conditions.
Cord blood gas or arterial blood gas samples were taken within the first 1 hour from all our asphyxic patients.
Our study was approved by the Ethics Committee of Karabuk University, Faculty of Medicine with the decision dated 11/04/2022 and decision number 831. The study was performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.
The SPSS software for Windows® version 26.0 (IBM Corporation, Armonk, New York, United States) was used in the analysis of variables. The data showed a normal distribution, given the Skewness and Kurtosis values of the data remained within the +2.0/-2.0 limit range (George, 2011). Socio-demographic characteristics and mean blood gas values in the study were given as mean and percentage values. For normally distributed values, the Independent Sample Test was used for paired samples, and the one-way ANOVA test was used for samples of two or more. The Mann-Whitney U test was used for paired samples that did not show normal distribution, and the Kruskal-Wallis H test was used in samples of two or more. Pairwise comparison samples were evaluated with the Chi-square test.
The socio-demographic characteristics of the infants included in our study are presented in Table 1. Initially, 59 infants were included in the study. A patient who was beyond the neonatal period at the time of analysis was excluded. The mean week of delivery was 34.29 ± 2.38 and the mean birth weight was 2970.42 ± 724.387. The mean maternal age of the infants was 27.36 ± 4.80 and the number of pregnancies was 2.41 ± 1.53; 61% were born by cesarean section, 61% were male, and 64.4% were hospitalized with perinatal asphyxia.
Sociodemographic characteristics of the infants diagnosed with perinatal asphyxia are given in Table 2.
Thirty-eight infants with perinatal asphyxia had an average of 37.58 ± 2.17 weeks of birth and a mean birth weight of 3103.82 ± 661.19. The mean maternal age of the infants was 27.05 ± 4.74 and the number of pregnancies was 2.16 ± 1.24; 60.5% of the infants were born by cesarean section, 71.1% were male, 84.2% had no maternal disease history, and diabetes was the most common maternal disease in those with a maternal disease history.
The aEEG results of the infants diagnosed with perinatal asphyxia are given in Table 3. According to this:
a) Neurological examination and aEEG were found to be highly consistent in the early and late periods (84.2%).
b) Completely inconsistent neurologic examination and aEEG in the early and late periods were detected in only 1 case.
It was observed that the infant who was brought to the emergency room at the age of 2 months due to cardiorespiratory arrest and was diagnosed with postnatal asphyxia had a birth week of 39, a birth weight of 2800 g, a maternal age of 22, and number of maternal pregnancies was 2. It was determined that the delivery type was cesarean section, the gender was male and the mother did not have a chronic disease. When the aEEG characteristics of the baby were examined, aEEG in the first 6 hours was seen to present Burst Suppression, clinical examination in the first 6 hours was seen to present with HIE Stage 3, and aEEG in the 6-24 hours period was seen to present Burst Suppression. It was determined that the clinical examination and aEEG were consistent from the beginning. This patient was not included in the analysis because of being beyond neonatal period.
While convulsion was detected in 20% of the 20 infants with abnormal movements suggesting clinical convulsions in aEEG, 80% of them were evaluated as normal by aEEG.
The definition of HIE severity remains a subject of debate, and there is no clear consensus in the literature about mild, moderate, and severe injury-staging definitions . The original 1976 American PMID (987769) report, in which HIE staging was first introduced, led to modification and different versions of the Sarnat examination. Therapeutic hypothermia (TH) has an extremely critical importance in children who need TH treatment. According to the results of Cochrane meta-analysis evaluating TH studies, it was determined that TH reduces neurodevelopmental disability and mortality after 18 months .
Today, in addition to the severity of HIE, aEEG is one of the more common methods by which clinicians try to estimate the severity of brain damage in the first few hours or days of life . However, the relationship between neurological examination, aEEG and conventional EEG (cEEG) is still not fully understood . In order to apply the critically important TH treatment to the patients in need, it is necessary to correctly stage the severity of encephalopathy and to determine the best method for staging.
Neonatal seizures are the most common neurological emergency in the neonatal period and frequently pose diagnostic and management challenges for clinicians worldwide .
In our study, a high level of consistency was found between aEEG and neurological findings in infants diagnosed with HIE (84.2%), but the rate of evaluation of abnormal movements suggesting clinical convulsions as convulsions was only 20% with aEEG. We think that this is related to the facts that aEEG skips short and focal convulsions, the sensitivity of aEEG is low due to the use of single-channel aEEG, and the fact that most cases that are considered as convulsions in the neonatal period are actually not convulsions when evaluated electrographically.
In a study by Massaro et al. in which they reviewed the aEEG data of 75 encephalopathic newborns to predict the short-term outcomes of infants with HIE, they reported that the detection of an abnormal aEEG background predicted a negative outcome during the course of hypothermia . The results of this study support our findings.
Similar to the study by Vegda H. et al., our results suggest that aEEG has a low success rate in demonstrating neonatal convulsions. As they stated, this result suggests that aEEG often misses short seizures (<30 sec) or low-amplitude seizures. There is also a risk of misinterpretation of artifacts as seizures, and therefore the annotation should be appropriately noted .
Moreover, the American Society of Clinical Neurophysiology recommends 24-hour EEG monitoring rather than aEEG in all newborns at high risk for seizures, such as newborns with acute brain injury, clinical encephalopathy, or abnormal paroxysmal events .
According to the results of a meta-analysis evaluating aEEG in the diagnosis and treatment of seizures in 2015, which supports the results of our study, it has been reported that aEEG has relatively low sensitivity and specificity for the diagnosis of neonatal seizures, and therefore, aEEG is not suitable for the diagnosis and treatment of neonatal seizures .
Today, the accuracy of aEEG is still not fully determined. Different results continue to be shown in different studies. In a recent systematic meta-analysis, results were obtained showing that the sensitivity of aEEG varies significantly and the seizure detection rate is lower than that of cEEG . In another study, Shankaran et al. reported that aEEG background pattern did not significantly increase the value of encephalopathy stage at study entry in predicting death and disability in infants with HIE . In our study, an abnormal aEEG pattern was detected in only one (2.6%) of the newborns with Stage 1 encephalopathy scores, which would not typically be considered for TH.
In another recent study , in line with our results, the inter-rater reliability of aEEG for detecting neonatal seizures was “moderate”, the inter-rater reliability of aEEG for detecting seizure duration was “weak”, and aEEG has been shown to be unsuccessful to detect multiple seizures and underestimate the duration of the seizure.
In addition, there are studies in the literature reporting that the use of multi-channel aEEG has a better sensitivity to detect seizures than single-channel aEEG .
Therefore, it should be noted that one of the reasons for the low seizure detection rate in our study may be due to the use of a single channel aEEG.
As emphasized by Herzberg et al , we suggest using aEEG as an additional modality to neurological examination in the diagnosis and treatment of HIE, since it allows a more accurate assessment of the severity of encephalopathy when combined with neurological examination.
Our study revealed that the use of aEEG in infants developing HIE in perinatal asphyxia is beneficial but its benefit in the diagnosis and follow-up of neonatal seizures is not clear. We believe that the use of multi-channel aEEG and/or its use together with conventional EEG in neonatal seizure follow-up will provide more useful information.
The limitations of our study:
The small sample size due to its single-center design, the use of single-channel aEEG, the lack of simultaneous cEEG monitoring, the inability to compare with neuroimaging, and the failure to evaluate its effect in predicting long-term neurodevelopment can be counted as limitations of our study.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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