Effectiveness of sodium picosulfate/magnesium citrate without diet vs. sennoside with diet in bowel preparation
Ramazan Saygın Kerimoğlu 1, Süleyman Kargın 2, Alpaslan Şahin 1
1 Department of General Surgery, Konya City Hospital, Konya, 2 Department of General Surgery, Medical Faculty, Karatay University, Konya, Turkey
DOI: 10.4328/ACAM.20810 Received: 2021-08-07 Accepted: 2022-04-18 Published Online: 2022-04-27 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):592-596
Corresponding Author: Süleyman Kargın, Department of General Surgery, Medicana Konya Medical Faculty, Karatay University, Feritpasa Street, Konya, Turkey. E-mail: email@example.com P: +90 332 221 80 80 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4597-8654
Aim: A three-day diet in bowel preparation before undergoing colonoscopy is an important factor that affects patient compliance. This study aimed to compare the effectiveness of sodium picosulfate/magnesium citrate without a diet and rectal enema application protocol and conventional sennoside protocol before colonoscopy.
Material and Methods: This is a prospective, single-centre, investigator-blinded, randomized study. A total of 60 patients were recruited: 30 in the sennoside group and 30 in the sodium picosulfate/magnesium citrate group. All procedures were performed by an experienced endoscopist who was blinded to the bowel preparation protocol. The Ottawa Bowel Preparation Scale was used by the endoscopist to assess the bowel preparation state.
Results: The effectiveness of bowel cleansing regimens was similar in the entire, right, transverse, descending, and rectosigmoid colon according to the Ottawa Bowel Preparation Scale (p>0.05). There was no difference between the groups in terms of cecal intubation rates, the detection of polyps, and the number of polyps.
Discussion:The use of sodium picosulfate/magnesium citrate is an effective bowel cleansing agent and can provide both successful colonoscopy and patient compliance without a three-day fiber-free diet.
Keywords: Bowel Preparation, Sodium Picosulfate/Magnesium Citrate, Diet-Free Colonoscopy, Sennoside
Colonoscopy is a widely used procedure for diagnosing and treating colon and terminal ileum pathologies. Adequate bowel cleansing is essential for the detailed visualization of the mucosa of the entire large intestine and the quality of the colonoscopy procedure .
An ideal bowel preparation method should be effective in cleansing the bowel and be well tolerated by the patients. Factors that adversely affect patient compliance are the need for a three-day diet and high fluid intake during the bowel cleansing process, unexpected symptoms such as abdominal pain, vomiting, cramps after drug intake, and enema applications. Polyethylene glycol (PEG), sodium phosphate, and sennoside group drugs are commonly used for bowel cleansing before colonoscopy. Although PEG is seen as the gold standard in bowel cleansing, some patients cannot tolerate it well due to its taste and need for high volume ingestion . Sodium phosphate group agents are a better option in terms of patient compliance, but they bring concerns due to possible negative adverse effects [3,4]. In our country, sennoside and sodium phosphate groups are frequently used for colon preparation and these protocols require a three-day diet and enema application.
The sodium picosulfate/magnesium citrate (SMPS) protocol is a well-tolerated intestinal cleansing agent due to low volume fluid requirement and good taste. The European Gastrointestinal Endoscopy Association  recommends SPMS as an alternative to PEG solutions because of its less frequent adverse effects and an equivalent colon cleansing rate. The effects of sodium picosulfate/magnesium citrate agents on bowel cleansing in both classic protocols and divided doses have been compared in many studies [6-8]. However, we found no study in the literature that evaluated the effects of SMPS agents on bowel cleansing without a fiber-free diet.
The aim of our study was to compare the effectiveness of the SPMS protocol, which is used without diet and enema, and the sennoside protocol, which requires a three-day diet and a rectal enema for bowel preparation before colonoscopy.
Material and Methods
This was a prospective, single-center, investigator-blinded, randomized study evaluating the effect of two different bowel preparation protocols on adequate bowel preparation. Our study was conducted in accordance with the ethical standards of the World Medical Association Helsinki Declaration Principles. This study was approved by the KTO Karatay University Medical Faculty Ethics committee (approval number: 2021/035).
The study included patients aged 18-80 years who presented to the general surgery outpatient clinic due to colorectal cancer screening or nonspecific gastrointestinal symptoms between January and April 2021. Exclusion criteria were pregnancy or breastfeeding, history of colon resection, intestinal obstruction, presence of serious comorbid diseases (e.g. heart, kidney and hepatic failure), presence of psychiatric disease, and unwillingness to participate in the study. Written informed consent was obtained from all patients who agreed to participate in the study. Before the colonoscopy procedure, patient information including age, sex, colonoscopy indications, previous surgery, and colonoscopy procedures were collected.
The participants were enrolled by a clinical coordinator nurse. The coordinator nurse randomly assigned the patients into two bowel preparation protocol groups (1:1) according to the order of patient arrival. Numbered sealed envelopes were used to ensure confidentiality of distribution. The endoscopists and researchers were unaware of the distribution of the groups. The diet protocols and the bowel cleaning agents to be used were explained to each patient in detail by the coordinator nurse. The patients were advised not to ask any questions or give information to the endoscopists and the endoscopy staff about the bowel preparation protocol.
Patients in the first group (sennoside group) were given a list of foods they could and could not eat, and a clear diet was recommended for three days before the colonoscopy. Patients were told to drink a total of 500 ml sennoside solution (250 mL X-M Diet Solution Laxative® (containing 0.5 g Sennosid A + B calcium), Yenişehir, Turkey) 250+250 mL the day before the colonoscopy, at 14:00 and 18:00 PM. Patients were also warned to apply a total of two bottles of 210 mL rectal enema (B.T. enema® 210 mL, Mediterranean Lab Tic. Ve San CO., LTD, Ankara, Turkey) the night before the colonoscopy at 22.00 PM and in the morning of the procedure at 08.00 AM. Patients in the second group (SPMS group) were given two sachets of SPMS, each containing sodium picosulfate (10 g), magnesium oxide (3.5 g) and citric acid (12 g) (Picoprep®, Ferring Arzneimittel Ges.mbH, Vienna, Austria). They were told to prepare each sachet by mixing it with 150 mL of water and to drink it at 16:00 PM and 22:00 PM on the day before the colonoscopy procedure. Patients were also advised to consume at least five glasses of water after each solution. The patients in this group did not receive a rectal enema.
Patients in both groups were instructed to consume clear liquids such as water or tea, until the consistency and color of the stool became like water until 24:00 PM. Patients were advised to have a liquid diet breakfast on the morning of the colonoscopy. All colonoscopies were performed between 13:00 PM and 18:00 PM.
All colonoscopy procedures were performed under propofol-based sedation. A Fujinon System 4400XI© (Fujinon Inc, Tokyo, Japan) colonoscopy device was used in the procedures. During the colonoscopy, the patients’ blood pressure, heart rate, and peripheral oxygen saturation were monitored, and their stability was ensured. All procedures were performed by an experienced endoscopist who was blinded to the bowel preparation method. The quality of bowel cleansing was scored by the endoscopist immediately after colonoscopy according to the Ottawa Bowel Preparation Scale (OBPS), which is scored from 0 to 4 (Table 1) . The adequacy of colon cleansing was evaluated both as the entire colon and separately (ascending, transverse, descending, and rectosigmoid colon) according to the OBPS. In OBPS scores, 3 and 4 are accepted as insufficient bowel cleansing. In addition, the data of whether cecal intubation was performed, detection of polyps, and the number of detected polyps were added to the form. The data from the colonoscopies were written on a form and put in a sealed envelope and handed over to the coordinator nurse.
In statistical calculations, the mean, standard deviation, median, lowest, highest, and ratio values were used. The distribution of variables was measured using the Kolmogorov-Smirnov test. The Mann-Whitney U test was used to compare numerical variables between groups. The Chi-square or Fisher’s exact test was used to compare categorical variables. Statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 21.0 software package (2012 Armonk, NY: IBM Corp). The level of statistical significance was accepted as p<0.05.
A total of 67 patients were included in the study. Seven patients (three in the sennoside group and four in the SPMS group) whose colonoscopies could not be completed were excluded from the study. Accordingly, 60 patients (30 in the sennoside group and 30 in the SPMS group) were included in the study. The mean age of the patients was 49.31 ± 17.70 (range, 20-80) years, and 56.7% were male. There were no significant differences between the groups in terms of age, sex, and colonoscopy indication (p=0.344, p=0.435, and p=0.264, respectively, Table 2). Most (65%) of the patients were referred to colonoscopy because of nonspecific gastrointestinal symptoms. In the SPMS group, more colonoscopies were performed for colorectal cancer screening (40% vs. 30%), whereas in the sennoside group, more colonoscopies were performed for gastrointestinal symptoms (70% vs. 60%).
All patients were able to tolerate both protocols. The most common problem in the sennoside group was enema intolerance, but this was not observed in the SPMS group because the patients did not receive a rectal enema. The most common adverse effect in both groups was abdominal pain. The number of patients with adverse effects was similar in both groups (p=0.532).
The intestinal cleansing results are summarized in Table 3. Although the number of patients with adequate bowel cleansing in the entire colonoscopy evaluation was slightly higher in the sennoside group, there was no statistically significant difference between the groups (83.3% vs. 76.7%, respectively, p=0.748). The mean OBPS scores were 1.46 ± 1.07 in the sennoside group and 1.43 ± 1.27 in the SPMS group and were similar between the two groups (p=0.903). Regarding bowel preparation scores for the entire colon and each colon segment separately (ascending, transverse, descending, and rectosigmoid colon), there was no significant difference between the groups.
The cecal intubation rate was higher in the SPMS group than in the sennoside group, but the difference was not statistically significant [25(83.3%) vs. 21(70%), p=0.360]. In addition, although fewer patients were detected to have polyps in the SPMS group, the average number of polyps detected was relatively higher than in the sennoside group. There was no significant difference between the groups in terms of the number of patients with polyps detected, and the average number of polyps (p=0.596, p=0.454, respectively).
In this prospective study, the efficacy of the classic sennoside protocol with a fiber-free diet for 3 days and SPMS solutions without diet on intestinal cleansing was evaluated. It was observed that the use of SPMS without dieting and the use of sennoside with a 3-day diet and rectal enema in preparation for colonoscopy yielded similar results. In addition, we found that rectal enemas caused discomfort to patients and more adverse effects were observed with the sennoside protocol.
Although the purpose of an ideal bowel cleansing method is to remove all fecal material sufficiently to clearly evaluate pathologic lesions, patient compliance with intestinal cleansing agents should not be ignored. Polyethylene glycol is accepted as the gold standard in bowel cleansing, but the need for a fiber-free diet and plenty of fluid consumption makes patient compliance difficult and unsuccessful bowel cleansing results can be seen . Indeed, many studies have been conducted comparing the effects of protocols involving PEG [10-12], Na-P [10,13], SMPS [11,14] and sennoside [12-14] agents. In most protocols, due to the negative aspects (3-day diet and bad taste of the agents), patient compliance problems are at high levels. This situation has led physicians to look for protocols that both provide effective bowel cleansing and increase patient compliance.
The pre-colonoscopy diet type is crucial for bowel cleansing, but surprisingly few studies have been conducted on this topic. Among the risk factors for inadequate bowel cleansing, dietary restriction is often seen as an integral component of bowel preparation, but can sometimes be overlooked. Current guidelines recommend the use of a low-fiber diet in addition to a full liquid diet the day before the colonoscopy .
Although most patients state that they understand their fiber diet and laxative practices, less than 20% follow a low fiber diet and approximately 75% follow a clear liquid diet only one day before the colonoscopy .
Therefore, it is becoming increasingly important to develop intestinal cleansing protocols that do not require a diet. The taste of the agents used and the adverse effects related to the drug also affect compliance . For this reason, besides acceptable bowel cleansing, there is a need for a bowel preparation protocol that is easy to drink, requires less dieting, and has minimal drug-related adverse effects.
Sodium picosulfate/magnesium citrate solutions are becoming more popular in colonoscopy preparation. Similar or even better bowel cleansing results have been reported, especially when compared with PEG solutions. It has been reported in many studies that there is better patient compliance with this protocol due to its better taste and lack of need for large amounts of fluid intake [15,17-20]. We compared the use of diet-free SPMS with the sennoside protocol, which is widely used in our country. To our knowledge, the current study is the first randomized, prospective clinical study to investigate the effect of diet liberalization (diet free vs. clear liquid diet) during bowel preparation using SPMS in colonoscopy in healthy outpatients. Furthermore, our study had several distinct advantages over previous studies. Our study compared polyp detection and cecal intubation rates, which are accepted as important quality indicators for colonoscopy, as well as bowel cleansing quality between the two study groups. Similar results were obtained in a study comparing SPMS and sennoside agents; however, no dietary restriction was applied in the use of either agent . In our study, no difference was found between the two protocols when we compared rates of both individual colon segments, entire colon cleansing assessments, and polyp detection rates (Table 3). Also, the rates of adverse effects were similar (p=0.532). The most important limitation of our study was the small number of patients. We planned our study as a preliminary study because there was no previous experience with the dietless SPMS protocol. Satisfactory results will encourage this prospective study to be strengthened by larger series.
According to the preliminary results of this study, the use of the SPMS protocol without dieting provides high patient compliance and sufficient bowel cleansing equivalent to the sennoside protocol. If our results are confirmed in larger series, the use of SPMS without a diet protocol could be considered the preferred bowel cleansing protocol.
Thank you to Akif ALTINBAS for his contibutions.
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.20810
Ramazan Saygın Kerimoğlu, Süleyman Kargın, Alpaslan Şahin. Effectiveness of sodium picosulfate/magnesium citrate without diet vs. sennoside with diet in bowel preparation. Ann Clin Anal Med 2022;13(6):592-596
Factors affecting outcome and morbidity in pulmonary hydatid cyst surgeries
Bulent Ozturk 1, Atilla Durkan 1, Tahir Sevval Eren 2, Muharrem Cakmak 3
1 Department of Thoracic Surgery, Gazi Yasargil Education and Research Hospital, Diyarbakir, 2 Department of Thoracic Surgery, Faculty of Medicine, , Istanbul Medeniyet University, Istanbul, 3 Department of Thoracic Surgery, Faculty of Medicine, Fırat University, Elazig, Turkey
DOI: 10.4328/ACAM.20938 Received: 2021-11-05 Accepted: 2021-12-08 Published Online: 2021-12-09 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):597-600
Corresponding Author: Muharrem Cakmak, Department of Thoracic Surgery, Faculty of Medicine, Fırat University, Elazig, Turkey. E-mail: firstname.lastname@example.org F: +90 424 233 35 55 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9504-2689
Aim: Hydatid cyst disease is an important health problem due to its endemic, progression, serious complications, and rarely spontaneous regression.
Material and Methods: The files of 143 patients who were operated for hydatid cysts in our clinic between January 2000 and December 2010 were analyzed retrospectively. The effects of parameters such as age, gender, symptom, number of cysts, cyst size, whether the cyst is perforated, leukocyte count, and localization of the cyst on mortality and morbidity were investigated.
Results: Morbidity rates were high in perforated cysts. However, gender, cyst size, and localization had no effect on morbidity (p<0.05).
Discussion: We determined that perforated pulmonary hydatid cysts significantly prolonged hospital stay and increased postoperative morbidity. Pulmonary hydatid disease, which is a public health problem in our country, should be treated surgically when diagnosed.
Keywords: Lung, Hydatid cyst, Morbidity, Perforation
Hydatid cyst disease, also known as hydatidosis, is a disease characterized by the emergence of cysts as a result of the transmission of Taenia echinococcus larvae to humans. There are four species of Taenia echinococcus, of which Echinococcus granulosus and Echinococcus multilocularis are disease agents in humans . Due to its social conditions and geography, our country is among the places where the disease is common . The prevalence of hydatid cyst disease in Turkey, which is seen in all regions, especially in rural settlements, has been reported to be around 50 in 100,000 and its incidence is around 2 in 100,000 . Following the liver, the organ most affected by the disease, lung involvement is observed in 10-30% of patients .
Clinical findings are variable and are mostly related to the growing cyst. As long as it is not perforated, it does not cause a special complaint in the patient. It is usually alone and asymptomatic in humans . Findings are variable, but mostly related to the growing cyst. Rarely, it is related to the rupture of the cyst, the spread of the parasite, and the formation of inflammation and allergic findings .
Conventional radiology is mostly used in diagnosis. Sometimes the diagnosis can be made on the basis of anamnesis, while sometimes they can be diagnosed intraoperatively . Radiological methods provide the diagnosis in 98% of cases, but sometimes it can be confused with abscess, malignant tumors or cysts of other origin .
Surgical intervention is an effective primary treatment for pulmonary hydatid cyst disease. Perforated cysts should be treated immediately as they can be life-threatening . Anthelmintic therapy is recommended in cases where the cysts are inoperable due to the presence of recurrent hydatid cysts or widespread or difficult localization of the cyst, or when surgery involves a high morbidity and mortality risk .
In our study, we investigated some factors that may affect morbidity and mortality in lung hydatid cysts. These include age, gender, location of the cyst, size of the cyst, whether it is perforated, symptom, number of cysts, localization of the cyst, and white blood cell values. We aimed to evaluate the relations of these determined parameters with postoperative complications using appropriate statistical tests.
Material and Methods
After approval of the ethics committee (18.03.2011/58), the files of the patients diagnosed with hydatid cyst who were operated in our clinic between 2000-2010 were evaluated retrospectively. The patients were divided into two groups as those without morbidity (group 1; 106) and those with morbidity (group 2; 37). The age, gender, symptoms of the patients, whether the cyst was perforated, the size of the cysts, the number of cysts, the number of leukocytes, and the treatment methods applied to the patients were recorded. The effects on morbidity and mortality were evaluated.
In statistical analysis, continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as number-ratio. The results were evaluated with the Student-t and Chi-square tests, p<0.05 was considered significant.
A total of 143 patients were included in the study. Fifty-three were males and 90 were females. In group 1, 39 patients were male and 67 were female. In group 2, 14 patients were male and 23 were female. The gender difference was not significant in the development of morbidity (p>0.05).
The mean age in Group 1 was 20.84±15.98 years, the mean cyst size of the right lung was 4.23±4.42, the mean cyst size of the left lung was 3.15 ± 4.50, perforation rate was 0.29±0.49, and mean leukocyte was 12.26±6.06. On the other hand, the mean age in Group 2 was 20.46±15.53, mean cyst size of the right lung; 3.32±4.55, the mean cyst size of the left lung was 4.84±5.68, perforation rate was 0.5±0.5, and the mean leukocyte was 12.1±5.10. When compared, a significant difference was found between the perforation rate and morbidity in Group 2 (p<0.05) (Table 1).
In Group 1, 90 patients underwent cystotomy+capitonnage, 4 underwent cystotomy+capitonnage+decortication, 3 underwent cystotomy, 2 had primary closure, 1 underwent wedge resection, 1 underwent decortication, 1 had cystotomy+enucleation, 1 underwent cystotomy+excision, 1 underwent cystotomy +capitonnage+wedge resection, 1 underwent cystotomy+ capitonnage+enucleation, and 1 had cystotomy+wedge resection+decortication. On the other hand, 21 patients from Group 2 underwent cystotomy+capitonnage, 9 underwent cystotomy+capitonnage+decortication, 4 patients had wedge resection, and 3 had cystotomy+capitonnage+frenotomy. The most common morbidities in Group 2 were atelectasis (n: 18), expansion defect (n: 10), and postoperative air leak (n: 9). However, the difference in surgical techniques in the development of morbidity was not statistically significant (p>0.05) (Table 2).
In Group 1, 44 patients had lower cyst localization, 35 had upper localization, 8 had both upper and lower localization, and 19 had localization outside the lower and upper lobes. In Group 2, 14 had lower localization, 13 had upper localization, 6 had both upper and lower localization, and 4 had localization outside the lower and upper lobes. In Group 2, postoperative atelectasis was more common in cysts located in the lower lobes, while postoperative expansion defect was more common in cysts located in the upper lobes (p<0.05).
When evaluated in terms of the number of cysts, in Group 1, 1 cyst in was found in 81 patients, 2 cysts in 17 patients, 3 cysts in 5 patients, 4 cysts in 1 patient, and 5 cysts in 2 patients were detected. In Group 2 patients, 1 cyst was identified in 28 patients, 2 cysts in 6 patients, 3 cysts in 1 patient, 4 cysts in 1 patient, and 5 cysts in 1 patient. Statistically, there was no significant effect of the number of cysts on morbidity (p>0.05).
While the number of giant cysts (>10cm) was 33 in Group 1, it was 15 in Group 2. There was no significant difference in terms of morbidity (p>0.05).
While hepatic hydatid cysts are more common in females, pulmonary hydatid cysts are more common in males . In a study with 13000 pulmonary hydatid cysts, 45% of the patients were females and 57% were males . In our study, contrary to the literature, 62% of the patients were females and there was no statistical difference in terms of postoperative morbidity according to gender.
Although hydatid cyst disease can be seen at any age, it is more common in adulthood. In many studies, it has been reported that hydatid cyst disease is more common in the 15-35 age group . In our study, the youngest age was 4 years old, while the oldest was 67 years old, and the mean age was 20.46 years. We found that age did not significantly affect postoperative morbidity.
Although hydatid cysts can be seen in many organs of the body, the most frequently involved organs are liver and lung, respectively . The coexistence of lung and liver involvement is between 20-40% .
Cough-sputum, pain, hemoptysis, dyspnea, and fever are the most common symptoms of pulmonary hydatid cyst . The most common symptoms in our study were chest pain (46.5%), shortness of breath (25%), cough (8.3%), and fever (8.3%). We found that these symptoms did not affect postoperative morbidity.
There are no specific clinical and laboratory findings in the diagnosis of hydatid cyst disease. Radiological evaluation is much more important and the first step is direct chest radiography. On the radiograph, intact lung cysts appear as round, homogeneous, and well-circumscribed opacities. However, complicated cysts can mimic many other lung lesions. Computed tomography of the thorax is very successful in imaging both intact and complicated cysts . In our study, the diagnosis was mostly made by direct radiography, computed tomography of the thorax, and ultrasonography.
While no mortality was reported in the hydatid cyst study of 279 cases, mortality was reported in one case in the giant cyst series of 50 cases by the same authors . Karaoglanoglu et al. reported one death due to respiratory failure in their series of 67 cases of giant hydatid cyst . In our study, there was no mortality in 48 patients with giant cysts.
Regardless of whether the pulmonary hydatid cysts are symptomatic or not, the surgical treatment method is still up-to-date . VATS can be applied in selected patients, but it should be kept in mind that control of the cyst content may be difficult in this method, and daughter vesicles may spread to the surrounding tissue . If the cyst fills a lobe, becomes infected, alveolar cyst is present, and the exocyst is calcified, resection is recommended. . In their series consisting of 100 cases, Aytac et al. performed 4% wedge resection, 1% segmentectomy and 11% lobectomy . In our study, 78.3% of patients underwent cystotomy capitonnage, 7.9% had cystotomy+capitonnage+decortication, 3.5% underwent wedge resection, 3.5% had cystotomy, and 3% had enucleation.
Among the postoperative complications, those seen within the first seven days are primarily hemothorax, wound infection, atelectasis, pneumonia and respiratory failure, empyema, sepsis, and thrombophlebitis. Post-cystectomy residual cavity and bronchopleural fistula are more common after the seventh day . In their series of 240 cases with pulmonary hydatid cyst, Raul B. et al. demonstrated pneumothorax in 24 cases (8.8%), pleural effusion in 20 cases (7.4%), wound infection in 18 cases (6.6%), bronchopleural fistula in 12 cases (4.4%), empyema in 10 cases (3.7%), atelectasis in 6 cases (2.2%), phrenic nerve palsy in 2 cases (0.7%), bleeding in 2 cases (0.7%), and deep vein thrombosis in 1 case (0.4%) . In their pulmonary hydatid cyst series of 139 cases, Ulku et al. found atelectasis as the most common postoperative complication . In our study, we found empyema, bronchopleural fistula, atelectasis, prolonged air leakage, expansion defect, and hemoptysis as postoperative complications. Consistent with the literature, the most common postoperative complication in our study was atelectasis.
Celik et al. reported that 80% of 13,006 cases had a single cyst, and in half of those with multiple, cysts were bilaterally located . Although pulmonary cysts are found in every lobe of the lung, they are more common in the right hemithorax and lower lobes . When studies on pulmonary hydatid cysts are examined, the rate of localization of pulmonary cysts in the right hemithorax is between 52.7% and 63.2% . Studies have also reported that 50.1% and 76.7% of the cysts are located in the lower lobes . Bilateral lung localization of hydatid cysts ranges from 2% to 14% in patient series . In our study, 51% were localized in the right hemithorax, 43% were in the left hemithorax, and 6% had bilateral localization. In accordance with the literature, we detected hydatid cysts mostly in the right lower lobe with a rate of 38%. We found that the number and size of the localization of the cyst did not statistically affect the postoperative morbidity.
In perforated cases, infection and inflammation of the adjacent lung parenchyma may affect wound healing and lead to postoperative complications such as prolonged air leak, empyema, and pneumonia. In addition, patients with perforated pulmonary hydatid cysts require preoperative antibiotic and supportive treatment. These are the main reasons why perforated cases have higher mortality and morbidity. Perforated cases require longer hospital stays than non-perforated cases. In the studies by Kuzucu et al., they found higher morbidity in patients with perforated cysts . In our study, we found that perforated hydatid cysts increased postoperative morbidity and prolonged hospital stay, consistent with the literature.
Hydatid cyst should be considered in undiagnosed lung lesions in areas where Echinococcus granulosus is endemic. Evaluation of CT findings together with serology is useful in confirming the diagnosis. Patients with pulmonary hydatid cysts most frequently present with complaints of shortness of breath, cough and chest pain, and these patients are mostly diagnosed with a single and intact (non-perforated) cyst. Postoperative morbidity is more common in perforated lung hydatid cysts, so the importance of diagnosis and treatment of pulmonary hydatid cysts before perforation increases.
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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2. Sahin EM, Yuksek YN, Daglar G, Gozalan U, Kama NA. Diagnosis and treatment of hydatid cyst: results of 120 patients. Journal of Trakya Univ Medical Faculty. 2008;25:6-14.
3. Koktürk O, Guruz Y, Akay H, Akhan O, Biber C, Cagırıcı U et al. Diagnosis and Treatment Guidelines for Thorax Society Parasitic Pulmonary Diseases. Thorax Journal. 2002;3:1-10.
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16. Karaoglanoglu N, Kurkcuoglu I. C, Gorguner M, Eroglu A, Turkyilmaz A. Giant hydatid lung cysts. Eur J Cardiovasc Surg. 2001;19(6):914-17.
17. Shabb BR, Abiad F. Hydatid cysts of the lung. In: Yim APC, Hazelrigg SR, Izzat MB, Landreneau RJ, Mack MJ, Naunheim KS ( eds). Minimal Access cardiothoracic surgery (4. ed). Philadelphia: Saunders WB; 2000. p.335-40.
18. Santivanez S, Garcia HH. Pulmonary cystic echinococcosis. Curr Opinion Pulmon Med. 2010;16(3):257-61.
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24. Kuzucu A, Soysal O, Ozgel M, Yologlu S. Complicated hydatid cysts of the lung: clinical and therapeutic issues. An Thorac Surg. 2004;77(4):1200-4.
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Bulent Ozturk, Atilla Durkan, Tahir Sevval Eren, Muharrem Cakmak. Factors affecting outcome and morbidity in pulmonary hydatid cyst surgeries. Ann Clin Anal Med 2022;13(6):597-600
Socio-demographic, clinical and care pathway profile of colorectal cancer patients at the National Institute of Oncology, Rabat, Morocco
Fatima Zahra Ben Fouıla 1,2,3, Zakariae Cherrat 2,3, Fatima Zahra Meskı 4, Mohammed Adnane Tazı 1, Majdouline Obtel 2,3
1 Directorate of Epidemiology and Diseases Control, Ministry of Health and Social Protection, 2 Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), 3 Department of Public Health, Laboratory of Social Medicine, Faculty of Medicine and Pharmacy of Rabat, Mohamed V University, 4 National School of Public Health, Ministry of Health and Social Protection, Rabat, Morocco
DOI: 10.4328/ACAM.21003 Received: 2021-12-16 Accepted: 2022-01-18 Published Online: 2022-02-05 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):601-605
Corresponding Author: Zakariae Cherrat, 21, Crown Prince City, Inezgane, Morocco. E-mail: email@example.com P: +66 215 50 65 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1463-0874
Aim: In Morocco, colorectal cancer (CRC) is the third most common cancer considering both sexes. Its diagnosis at an advanced stage is often associated with a poor prognosis and reduced survival rates. However, the time from symptom onset to diagnosis or treatment has also been considered as a predictor of stage and survival. This study aims to investigate the sociodemographic, clinical and care pathway profile of CRC patients.
Material and Methods: A retrospective cross-sectional study with analytical goals was conducted on CRC cases admitted to the National Institute of Oncology (NIO) during 2015-2016. Three hundred twenty-one CRC cases were included. Socio-demographic, clinical profile and care pathway data of the patients were collected from the medical records using a collection form. The Kish formula was used to determine the study population. Statistical analysis was performed using Epi-Info software (version 7).
Results: The mean age was 58 years and the female/male sex ratio was 1.09; 73.7% of CRCs were diagnosed at a late stage (stage III or VI). Also, 73.0% of the cases were married, 67.3% were from urban areas, and 77.9% were mainly covered by RASED. The most frequent histological type was adenocarcinoma (93.4%). In 21.9% of cases, urgent surgery was the mode of discovery of the tumor. Surgery was the first treatment considered for CRC patients (55.5%). For colon cancer, surgery was the first treatment in 82.6% of cases; and for rectal cancer, radiotherapy and concomitant chemotherapy were the first treatment received in 46% of cases.
Discussion: The results of the present study show that the onset of clinical signs was not in favor of an early diagnosis. It would then be essential to study the delays of diagnosis and treatment in the horizon to support early management of CRC before the appearance of alarming signs.
Keywords: Colorectal Cancer, Socio-Demographic Profile, Clinical, Care Pathway, Morocco
Colorectal cancer (CRC) is one of the leading causes of mortality and morbidity worldwide . It is the third most common malignancy and the fourth most common cause of cancer-related death worldwide with 1,400,000 new cases and approximately 700,000 deaths all over the world . Over the past few decades, there has been a significant increase in the incidence of CRC. In fact, the number of newly diagnosed CRC cases increased from 783,000 in 1990 to 1,361,000 in 2012 . In terms of geographical distribution, the incidence of this cancer has increased in industrialized countries with a medium or high human development index (HDI) .
In Morocco, colorectal cancer is the third most frequent cancer considering both sexes with a proportion of 8.3% in men and 7.8% in women. Its frequency increases with age, with the most affected age group between 65 and 74 . As for mortality attributable to CRC, it was estimated at 1699 (7.5%) deaths in 2012 . According to the TNM classification , 49.5% of CRC cases are diagnosed at stage III or IV, and only 8.9% of cases are diagnosed at stage I .
The objective of this study is to investigate the sociodemographic, clinical and organizational characteristics of colorectal cancer patients at the National Institute of Oncology in Rabat during the years 2015 and 2016.
Material and Methods
Type, population and location of the study
This is a retrospective cross-sectional study with an analytical focus that took place at the National Institute of Oncology in Rabat. A total of 321 records were reviewed between December 2017 and March 2018. We included in the study patients admitted for CRC management whose diagnosis was confirmed by anatomopathological examination. Patients with a personal history of other cancers were excluded from the study.
Data on socio-demographic characteristics (age, gender, employment status, number of children, place of residence, type of social security coverage, drug habits, family history of cancer), clinical characteristics (tumor location, clinical signs, date of onset, stage histological type, differentiation, tumor markers, comorbidities) and data on the treatment pathway (examinations performed, institution, place of examination, extension assessment, type of treatment, place of treatment, the start date of the treatment) were collected using a data collection form.
The analysis included a description of the study population according to different socio-demographic, clinical and organizational characteristics. Determination of the study population was performed using the Kish formula. The database was created in Excel and statistical analysis was performed using Epi-Info software (version 7).
Our study was approved by the Biomedical Research Ethics Committee of the Faculty of Medicine and Pharmacy of Rabat. Authorization for data collection was granted by the management of NIO in Rabat. The study was conducted in compliance with the rules of confidentiality and professional secrecy, in accordance with law 09-08 on the protection of individuals with regard to the processing of personal data.
A total of 365 records were reviewed during the period December 2017 – March 2018, of which 44 cases not meeting the inclusion criteria were excluded. Three hundred twenty-one patients involved were admitted to NIO for CRC management, including 149 colon cancer cases, 157 rectal cancer cases, and 15 dual-site (colon and rectal) cancer cases.
Table 1 presents the demographic characteristics of the study population. The mean age was (58 ± 15) years, and 74.0% of patients were 50 years or older. The female to male sex ratio was 1.09. The majority of cases were married (73.0%). Two out of three patients (67.3%) were from urban areas. With regard to employment status, only 45 of the 259 patients were employed at the time of diagnosis. The patients were mainly covered by RASED (77.9%). Among 197 patients, nearly a quarter (22.3%) were current or former smokers. A family history of cancer was reported in 24 (13.3%) of 180 cases, including 5.5% of CRC. Table 2 describes the clinical characteristics of the patients. The most reported clinical signs were: rectal bleeding in 164 (51.1%) patients, including 119 cases of rectal cancer, followed by abdominal pain in 141 (43.9%) patients, including 81 cases of colon cancer, and transit disorders in 123 (38.3%) patients. Intestinal obstruction, which constitutes a surgical emergency, was reported in 70 patients, 57 of whom had colon cancer.
According to the TNM classification, the majority of CRCs (73.7%) were diagnosed at a late stage (stage III or VI), including 125 (41.5%) with metastasis, often liver (42.4%) and/or lung (23.2%). The most frequent histological type was adenocarcinoma (93.4%). In 30.2% of cases, the patient had a comorbidity. The most frequent comorbidities were hypertension (13.7%) and diabetes (11.5%).
The management pathway of CRC patients.
The presence of warning signs was the main mode of discovery of CRC (78%), and emergency surgery for occlusion was the second mode of discovery, found in 70 of 320 patients, including 57 with colon cancer (Table 3).
Admission to NIO was in 35.9% following an intra CHIS transfer and in 23.3% following a transfer from a public institution. Endoscopy with biopsy was performed in 231 (70%) patients, 50% of them within 4 months of the onset of symptoms.
The initial biological workup included tumor markers: carbohydrate antigen (CA19-9) and carcinoembryonic antigen (CEA), which was performed in 129 patients, 55.8% of whom had a value greater than or equal to 5 µg/l. The initial extension work-up was performed in 299 (93.2%) patients, with CT being the most frequently requested examination with a proportion of 96.3% (Table 3).
A total of 283 patients, of the 321 cases included in our study, received therapeutic management initially with NIO. The cases that did not receive any treatment for their cancer were either lost to follow-up (34 patients) or only palliative care was considered in their case (4 patients). In general, surgery was the first treatment considered for CRC patients (55.5%). In the specific case of colon cancer, surgery was the first treatment in 82.6% of cases and for rectal cancer, radiotherapy and concomitant chemotherapy was the first treatment received in 46% of cases (Table 3).
In this retrospective cross-sectional study, we tried to trace the history of discovery of CRC cancer and its treatment in patients admitted to NIO during the period 2015-2016 in order to identify the socio-demographic, clinical and management pathway characteristics of patients.
Our study included 321 patients in whom the diagnosis of CRC was confirmed by anatomopathological examination, including 149 cases of colon cancer and 157 cases of rectal cancer. Our study population was younger compared to European or American populations. The mean age in our study was 58 years with extremes ranging from 18 to 90 years, close to what is reported in previous studies nationwide [5,6], while it is on average 61.7 years in Brazil , between 65 and 71 years in Europe [8, 9]. In the majority of countries in Europe, America, Asia and Oceania, where the incidence of CRC is high, a screening program targeting the population aged 50 to 74 years is already in place . This age group represents 58% of our study population. However, in Morocco, no early detection program for CRC has yet been established despite the fact that it is the second most common cancer in both sexes.
The female/male sex ratio in our study was 1.09, while the incidence rate of CRC was higher in men than in women in Morocco , as in most regions of the world . All patients included in our study had social security coverage, three quarters of whom were subject to RASED, this could be justified by the free management at NIO for patients affiliated to RASED, and the low attractiveness of NIO, compared to private institutions, for patients with MHI or insurance.
According to the TNM classification, the proportion of CRC cases diagnosed as stage IV in the present study was very high (41.5%, 39.3% and 44.2% for CRC, colon and rectum, respectively). These figures are consistent with those reported in the RCR (2017), but far higher than those reported internationally, which do not exceed 30% [11,12]. Occlusion was the main revealing complication of CRC cancer in general (21.9%) and colonic cancer (38.3%) in particular, requiring emergency intervention. This finding is confirmed by published studies that indicate a proportion of occlusion ranging from 10% to 40% of CRC cancer cases [13,14]. Endoscopy is the key examination in the diagnosis of CRC. It is performed by a medical specialist and can detect even precancerous lesions (polyps). This examination should be indicated in any patient with persistent signs of CRC after symptomatic treatment or following a positive screening test . In our study it was performed in the majority of patients (71.9%).
Regardless of the stage of the tumor at the time of diagnosis, the main treatment was surgery, which was considered in more than half of the cases for all CRC patients (55.5%) and more specifically for colon cancer (82.6%). But for rectal cancer, the proportion of surgery as initial treatment did not exceed 28.8%. For this location, concomitant radio-chemotherapy was the first-line treatment in 46% of cases. The proportions of surgery were lower than those observed in France, where it represents more than 90% and 38% for colon and rectal cancers, respectively . The most radical surgery involves the removal of the large intestine and the rectum, leading to the need for a colostomy with its social, physical and psychological impact . This difference can be explained by the lack of information on patients diagnosed with CRC for whom surgery was indicated, but they were lost to follow-up. Our study has strengths that can be summarized as follows:
– It provides indicators for future research to address ACC in Morocco.
– It is the first study in Morocco, having gathered three aspects (Socioeconomic, clinical and care pathway) of CRC patients.
– The power of our sample size
– The respect of ethical considerations
On the other hand, our study has a point to improve: it could not study the geographical distribution of patients according to the regions of Morocco.
In conclusion, the results of the present study show that the onset of clinical signs was not in favor of an early diagnosis. It would then be essential to study the delays of diagnosis and treatment in the horizon to support early management of CRC before the appearance of alarming signs.
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.21003
Fatima Zahra Ben Fouıla, Zakariae Cherrat, Fatima Zahra Meskı, Mohammed Adnane Tazı, Majdouline Obtel. Socio-demographic, clinical and care pathway profile of colorectal cancer patients at the National Institute of Oncology, Rabat, Morocco. Ann Clin Anal Med 2022;13(6):601-605
The use of prostate-specific antigen mass ratio in prostate cancer
Alper Nesip Manav 1, Mehmet Dündar 2, Abdullah Akdağ 2
1 Department of Urology, Aydın State Hospital, Aydın, 2 Department of Urology, School of Medicine, Adnan Menderes University, Aydın, Turkey
DOI: 10.4328/ACAM.21024 Received: 2021-12-25 Accepted: 2022-04-16 Published Online: 2022-04-19 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):606-610
Corresponding Author: Alper Nesip Manav, Urology Clinic of Aydın State Hospital, Kızılay Cd., No:13, 09100, Efeler, Aydın, Turkey. E-mail: firstname.lastname@example.org P: +90 256 213 90 00 F: +90 256 212 14 30 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3783-3861
Aim: Our goal in this study is to investigate the use and advantage of prostate-specific antigen mass ratio (PSAMR) in prostate cancer.
Material and Methods: Data of patients who underwent prostate biopsy were reviewed prospectively. Body mass index and PSAMR were calculated using height, weight, prostate-specific antigen (PSA) and prostate volume. Patients were divided into benign and prostate cancer. Subgroups were formed according to body mass index. The area under the curve of PSAMR was compared with PSA.
Results: One hundred seventy-one patients were included in the study; 72% of patients were benign and 28% were prostate cancer; 45% of patients were overweight and 20% were obese. PSAMR cut-off value was calculated as 0.37 μg/mL. PSAMR was statistically significant higher than PSA in all patients and subgroups for prostate cancer in area under the curve of receiver operating characteristic analysis.
Discussion: PSAMR avoids unnecessary biopsy by 42%. Especially in overweight and obese patients, PSAMR was found to be statistically significant than PSA for indication of biopsy and prostate cancer diagnosis. This study is the only one in the literature with a high obesity rate.
Keywords: Obesity, Prostate Biopsy, Prostate Cancer
Prostate-specific antigen (PSA) has been used as an adjunct test for screening and diagnosis. Due to its organ-specific nature, the serum level of PSA increases in some cases. These include prostate massage, prostate biopsy, urethral instrumentation, inflammation, trauma and benign prostatic hyperplasia . It is still controversial to mention the cut-off value of PSA. Studies have been conducted to obtain an age-related cut-off for PSA that increases with aging . Free PSA, free prostate-specific antigen percentage, PSA density (PSAD), transition zone PSA density, PSA velocity and PSA doubling time were discovered to detect localized disease and to identify patients who would benefit from curative treatment, but there were insufficient data to replace PSA .
Obesity increases the risk of prostate cancer (PCa). Every 5 kg/m2 increase in body mass index (BMI) increases the risk of PCa by 1.05 times . Obesity was found to be a low risk factor for low-risk PCa and a high risk factor for high-risk PCa [5, 6]. Interestingly, early-onset obesity was associated with aggressive PCa, whereas it was found to be poorly associated with late-onset obesity .
Obesity is known to cause an increase in the amount of both total and intravascular fluid [8, 9]. It was concluded that PSA was inversely proportional to BMI and measured as low due to hemodilution [10-15]. Prostate-specific antigen mass ratio (PSAMR) is thought to eliminate the hemodilutional effects [16-19]. In addition, PSAMR values have been shown to be unaffected by obesity, metabolic syndrome, and insulin resistance [9, 11, 12, 14]. With this aspect, PSAMR is considered as an alternative to PSA and PSA derivatives, which are used in the diagnosis of PCa and which can give different results due to non-cancerous diseases.
The aim of this study was to investigate the usage of PSAMR in the diagnosis of PCa, whether it has a positive predictive value for individuals with high BMI and its superiority to PSA.
Material and Methods
The study was initiated after obtaining approval from the local ethics committee (Committee’s reference number: 2015/745). Patients whose first prostate biopsy was planned in our clinic were included in the study after receiving informed consent forms. Age, PSA, free PSA, height, body weight, BMI, body surface area and plasma volume were recorded, prospectively. Routine 12-quadrant prostate biopsies were performed with a transrectal procedure in the left lateral decubitus position after local anesthesia infiltration. Prostate volume (PV) of patients was calculated by an ellipsoid formula using transrectal ultrasonography (TRUS) during the biopsy. PSAD and PSAMR values were calculated.
Prostate biopsy was planned for patients with suspected digital rectal examination (DRE) findings or PSA ≥ 2.5 ng/mL for those aged younger than 60 years and PSA ≥ 4 ng/mL for those older than 60 years.
Patients with PSA values greater than 20 ng/mL were excluded because of locally advanced or metastatic disease. We excluded from the study diseases and conditions that increase PSA (urinary tract infections, catheterisation, traumatic rectal examination). Patients who received medical treatment, minimally invasive or surgical treatment for benign prostate hyperplasia were excluded from the study because of the effect on PV. Patients who received systemic chemotherapy or radiotherapy were excluded. Patients using glucocorticoids and mineralocorticoids, heart and kidney failure, malabsorption and short-bowel syndrome, inflammatory bowel disease, chronic diarrhea and bowel resection were excluded from the study because of affecting fluid and electrolyte distribution and excretion.
Clinical variables were calculated as follows.
Body Surface Area (m2) = Body weight (kg)0,425 x length (cm)0,725 x 0.007184
Plasma Volume (L) = Body surface area (m2) x 1.67
Prostate Specific Antigen Density = PSA (ng/mL) / prostate volume (mL)
Prostate Specific Antigen Mass Ratio (µg/mL) = PSA (ng/mL) x plasma volume (L) / prostate volume (mL)
Patients were divided into benign groups (BG) and prostate cancer groups (CaG) according to pathology results. Patients were divided into subgroups as BMI < 25 kg/m2 of normal weight, 25 to 29.9 kg/m2 of overweight and BMI ≥ 30 kg/m2 of obese. Age, BMI, PV, PSA, PSAD and PSAMR values of the groups and subgroups were compared. BMI, PSA and PSAMR were compared with the Gleason score. Receiver operating characteristic curve (ROC) of PSA and PSAMR values were prepared in all patients and subgroups. The area under the curve (AUC) values of PSA and PSAMR were compared. Sensitivity and specificity analyzes were performed in all patients and subgroups for PSAMR. The cut-off value of PSAMR was calculated for diagnosis of PCa. The rates of patients who were indicated for biopsy and who would not need biopsy were calculated, when PSAMR was used instead of PSA for age.
PASW Statistics 18.0.0 (SBAS Hong Kong Headquarters, HK) was used for statistical analysis. Pearson’s test, Anova test and Student’s t-test were used for variables with normal distribution; Spearman’s rho, Chi-square, Kruskal Wallis, and Mann-Whitney U tests were used for variables not showing normal distribution. MedCalc software (MedCalc Software Ltd, Ostend, Belgium) was used for ROC analysis comparisons. As a result of statistical analysis, p < 0.05 was considered significant.
One hundred seventy-one patients were included in the study. The number and proportion of patients in the groups and subgroups, relation of descriptive statistics and variables with groups and subgroups are shown in Table 1. The incidence of PCa among subgroups according to BMI was not statistically significant (p = 0.638). BMI and age were higher in the CaG but not statistically significant. In the BG, the age of the obese subgroup was lower and statistically significant (p = 0.022). PV was lower and statistically significant in the CaG and in all subgroups within the PCa (p = 0.002). In addition, PV in obese subgroup was high and statistically significant in both BG and CaG, respectively (p = 0.014, p = 0.046). PSA was found to be significantly higher only in the CaG (p = 0.015). PSA was found to be high in patients with PCa in subgroups but not statistically significant. PSAD was found to be high and statistically significant in all patients, normal weight, overweight and obese subgroups, in CaG, respectively (p < 0.001, p = 0.001, p < 0.001, p = 0.005). PSAMR was found to be high and statistically significant in all patients, normal weight, overweight and obese subgroups, in CaG, respectively (p < 0.001, p < 0.001, p < 0.001, p = 0.006).
Only Gleason scores 6, 7 and 8 PCa were detected. The Gleason scores of 9 and 10 were not detected. There was no correlation between Gleason score and BMI, PSA and PSAMR (Table 2).
Specificity, sensitivity, AUC calculations of PSA and PSAMR, and PSAMR cut-off were performed for groups and subgroups and are shown in Table 3. PSA was significantly higher only in the CaG (p = 0.015). PSA was higher in patients with PCa when evaluated separately in normal weight, overweight and obese subgroups, but not statistically significant. However, PSAMR was high and statistically significant in all patients and all subgroups with PCa. AUC of PSAMR was higher and statistically significant in all patients and subgroups in patients with PCa than AUC of PSA. In this study, PSA cut-off was not specified because PSA level was considered for age. In overweight and obese subgroups, the number of patients was low and ROC curve results were similar. Therefore, overweight and obese subgroups were combined for PSAMR cutoff and AUC calculation. In the combined overweight + obese subgroup, the PSAMR cut-off value was 0.37 µg/mL and it was shown in Table 3. The AUC of PSAMR and PSA were compared. The AUC of PSAMR for PCa was high and statistically significant in the combined normal weight and overweight + obese subgroup, respectively (MedCalc p < 0.023, MedCalc p = 0.001), (Figure 1, 2).
Prostate biopsy was performed in 165 patients who had increased PSA for age and 6 patients with suspicious DRE findings. One hundred thirteen of 171 patients would have a biopsy when PSAMR at a cut-off of 0.37 µg/mL was used instead of PSA for age. If PSAMR was used for biopsy indication instead of PSA, there would have been 3 patients with undetected PCa and they had active surveillance criteria (Gleason 6 prostate adenocarcinoma, PSA < 10 ng/mL).
Obesity was detected in 31.2% of women and young people especially, in the TURDEP II study in Turkey. In our study, 35% of all patients were of normal weight, 45% were overweight and 20% were obese. This rate is lower in our study because it was performed in patients older than 45 years. It is thought that the prevalence of obesity will increase over the years, including urologic patients . In the BG, the mean age decreased with increasing BMI and it was statistically significant (p = 0.022). However, BMI increase with age was not observed in the CaG (p = 0.490). Although the mean age was higher in the CaG, it was not statistically significant (p = 0.101). It is thought to have prevented the age difference between the subgroups because there were fewer young patients in the CaG.
The incidence of obesity in the BG was higher at younger ages, which is consistent with the literature, but the reason for the statistical insignificance in the CaG was the effect of the number of patients included in the study. Further studies with large series are needed in the following years.
An increase of PV with increasing BMI has been shown in previous studies [9, 11-13, 21]. In this study, PV is high and statistically significant in overweight and obese patients in BG and CaG, respectively. Because of the inclusion of early-stage patients with PCa, PV is thought to be low in PCa patients. Obesity has been shown to increase the amount of serum estradiol and insulin, alter sex hormone-binding globulin metabolism, and consequently reduce the amount of free testosterone . These studies help explain why PV is high in individuals with a high BMI.
PSAD was found to be high for PCa in all subgroups and statistically significant (Table 1). However, PSAMR and PSAD have not been compared because, although PSAD corrects this confusion in some sense, it does not eliminate the effect of obesity [13, 22-24]. Correlation between the Gleason score and BMI, PSA and PSAMR is not statistically significant. We thought that this result was achieved because, methodologically, the patients who could benefit from curative treatment were included in the study.
In the second biopsy, the probability of cancer detection increases by 1.038 in PSA height and by 3.449 in PSAMR height. It was shown that 59.6% of unnecessary biopsies were avoided with PSAMR and PSAMR was shown to be superior to other PSA derivatives in making a second biopsy decision. The study has been criticized for not including different races . In another study, 0.4 µg/mL was accepted as the cut-off value for PSAMR, and a high risk for biochemical recurrence was shown above this value . According to the results of TURDEP II study, the BMI of patients will increase in the following years, and it may be thought that there will be more problems in measuring serum markers due to dilutional effects. It is thought that the new PSA cut-off value for obese patients would not provide accurate results and would increase the number of unnecessary biopsies .
PSAMR is thought to be a more stable and usable parameter in obese patients. In our study, the positive predictive value of PSAMR in CaG was higher than PSA and it was statistically significant. The data of our study are similar to the largest study on this subject, but the fact that the proportion of obese people in South Korea is less than 2% was negatively criticized by the author . Our study was conducted with a heterogeneous population consisting of different ethnicities, races, 45% overweight and 20% obese. Our study is the only study with a high rate of overweight and obese patients compared to previous studies.
In the BG, there were 117 patients with high PSA and underwent biopsy. Using PSAMR, a biopsy would have been performed for 68 patients and 49 patients (42%) would have been protected from the unnecessary biopsy. Three out of 48 PCa patients would not have been detected if PSAMR was used instead of PSA. It was found that they had active surveillance criteria, when the data of these patients were examined. Patients can be protected not only from biopsy but also from overtreatment, with the use of PSAMR. Furthermore, the prevalence of obesity is increasing. PSAMR may be more useful than PSA to detect PCa at an early stage, in people with high BMI .
PSAMR can be used as indication criteria for prostate biopsy. Especially in overweight and obese patients, PSAMR is more predictive than PSA. Although the superiority of PSAMR over PSAD has not been demonstrated, PSAMR is more useful than PSA. It also avoids unnecessary biopsy by 42%. Our study should be supported by large prospective randomized controlled trials.
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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Alper Nesip Manav, Mehmet Dündar, Abdullah Akdağ. The use of prostate-specific antigen mass ratio in prostate cancer. Ann Clin Anal Med 2022;13(6):606-610
Effects of esmolol on lung injury induced by lower extremity Ischemia-reperfusion
Ulku Sabuncu 1, Saban Cem Sezen 2, Aysegul Kucuk 3, Nevriye Salman 4, Timucin Sabuncu 5, Gulay Kip 6, Omer Kurtipek 6, Mustafa Kavutcu 7, Mustafa Arslan 6
1 Department of Pain Management, Health Sciences University, Ankara City Hospital, Ankara, 2 Department of Histology and Embryology, Kırıkkale University, Kırıkkale, 3 Department of Physiology, Kutahya Health Sciences University, Kutahya, 4 Department of Anesthesiology and Reanimation, Health Sciences University, Ankara City Hospital, Ankara, 5 Department of Cardiovascular Surgery, School of Medicine, Hacettepe University, Ankara, 6 Department of Anesthesiology and Reamination, Gazi University, Ankara, 7 Department of Medical Biochemistry, Gazi University, Ankara, Turkey
DOI: 10.4328/ACAM.21025 Received: 2021-12-24 Accepted: 2022-03-22 Published Online: 2022-04-18 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):611-615
Corresponding Author: Ulku Sabuncu, Department of Pain Management, Health Sciences University, Ankara City Hospital, Ankara, Turkey. E-mail: email@example.com P: +90 533 708 52 12 / +90 312 552 60 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9031-2088
Aim: After hind limb ischemia-reperfusion (I/R), impairments in remote organs are frequent. Lung tissue is the organ most affected by the remote organ damage. The lung damage increases ventilatory support, the need for inotropic agents and mortality. Many drugs and methods have been used in attempts to prevent or reduce this damage. The aim of this study is to investigate the protective effects of esmolol infusion on lung tissue prior to I/R created in the lower extremity.
Material and Methods: The study was performed between 11 and 14 April 2018 in Gazi University Experimental Animal Research Center, Ankara, Turkey. After obtaining ethics committee approval, 24 rats were randomly divided into 4 groups: Control (Group C), Esmolol (Group E), Ischemia-reperfusion (Group I/R), and I/R-Esmolol (Group I/RE). Esmolol (200 µg/kg/min intravenous) was applied 30 minutes before the procedure. The biochemical and histopathological parameters of lung tissue samples were compared.
Results: Neutrophil infiltration/aggregation, alveolar wall thickness, and total lung injury scores were significantly higher in the I/R group than in the C and E groups. In addition, neutrophil infiltration/aggregation, alveolar wall thickness, and total lung injury scores in the I/R group were statistically higher than in the I/R-E group (p=0.030, p=0.010, p=0.001, respectively). Malondialdehyde levels, catalase (CAT) and paraoxonase (PON) enzyme activities in the I/R group were significantly higher than in the C, E, and I/R-E groups. Glutathione S- transferase ( GSH) enzyme activity was similar in all groups.
Discussion: It was found that esmolol infusion at 200 µg/kg/min intravenously-reduced oxidative stress when administered 30 minutes before ischemia in rats and partially corrected the damage caused by I/R in lung histopathology.
Keywords: Reperfusion Damage, Ischemia-Reperfusion, Lung Injuries, Beta-Antagonists
Following an ischemic period, oxygen supply is not sufficient to meet the metabolic needs of cells in the ischemic area, and anaerobic metabolism is therefore activated. When blood flow is regenerated after ischemic period, tissue damage increases with the reestablishment of oxygen supply. Additionally, an inflammatory cascade that affects the distant organs begins. Blood, kidney, and lung tumor necrosis alpha (TNF-α), interleukin (IL) IL-1 and IL-6, as well as cytokines, all play a role in inflammatory cascade and cause local and distant organ damage via oxygen free radicals and leukocytes . The lungs are the most affected remote organs by ischemic damage. As a result, noncardiogenic pulmonary edema is observed and alveolar membrane permeability increases. Partial atelectasis with collapsed-pinched alveoli and thicker -felted alveolar walls lead to decreased PaO2/ FIO2 ratio and impaired oxygenation, which increases patient mortality [2,3] .
Recently, various agents that reduce lower extremity-mediated lung injury have been studied [4-8] . Esmolol, however, which is a selective beta (β)-1 adrenoreceptor blocker, has not been studied. Esmolol has been proven to reduce ischemia-reperfusion (I/R) injury in cardiac surgery settings and spinal cord I/R injuries [9,10] . This study aimed to evaluate the protective effects of esmolol on lower extremity mediated lung I/R injury. Our hypothesis was that esmolol might reduce the lung damage caused by I/R injury. Lung injury was evaluated by catalase (CAT), glutathione S-transferase (GST) and paraoxonase (PON) enzyme activities, and malondialdehyde (MDA) levels. Additionally, histopathological evaluation of the tissue samples was performed.
Material and Methods
The study was performed between April 11 and April 14, 2018; in Gazi University Experimental Animal Research Center, Ankara, Turkey. The procedures were performed in accordance with the proper use and care of laboratory animals, approved by the ethics committee of GUDAM ( G.U.E. T-17.082-07.11.2017). Experiments were performed on 24 male Wistar rats weighing 250-330 g. The animals were maintained under standard conditions such as stable room temperature (24 ± 3 0C) and a 12-hour light-dark cycle and were allowed access to rat pellets and water.
Rats were anesthetized with intraperitoneal (ip) ketamine (100 mg/kg) in all groups. Maintenance of anesthesia was done with ip ketamine 20 mg/kg during the procedures. The tail vein was cannulated for hydration, if necessary, with a 24 Gauge cannula. Esmolol (200 μg /kg) was administered 30 minutes before the operation and esmolol infusion duration was 15 minutes without a bolus dose. A middle abdominal incision was done and the intestines were removed to maintain a clear vision of the infrarenal aorta. An atraumatic microvascular bulldog clamp was placed on the infrarenal abdominal aorta, in the I/R and I/R-E groups. The surgery took 10±3minutes. After 120 minutes, the clamp was removed and reperfusion was performed for 120 minutes  . Sodium heparin (500 IU/kg) was administered through the peripheral vein in the tail for the maintenance of reperfusion after occlusion  . All rats were euthanized by drawing blood intracardially and tissue samples were obtained.
Group C: Control group (n=6)
Group E: Esmolol group (n=6)
Group IR: Ischemia-reperfusion group (n=6)
Group IR-E: Ischemia-reperfusion- esmolol group (n=6)
Group C: In this group, anesthesia was induced with ketamine followed by iv cannulation. Abdominal incision without intestinal removal was applied, and no further application was performed. Blood samples were obtained 120 minutes after the commencement of reperfusion by drawing blood intracardially, and tissue samples were obtained.
Group E: Following anesthesia, the rats’ tail veins were cannulated. After this, esmolol (200 μg/kg) was administered 30 minutes before the operation and esmolol infusion duration was 15 minutes. Thirty minutes after the infusion, the I/R model was performed. Blood samples were obtained after 120 minutes of reperfusion by drawing blood intracardially, and tissue samples were obtained.
Group I/R: Rats were given 100 mg/kg of ketamine, and their tail veins were cannulated. Following 15 minutes without any application, the I/R model was performed. Blood samples were obtained at the end of the I/R model by drawing blood intracardially. Subsequently, tissue samples were obtained.
Group I/R-E: Rats were given 100 mg/kg of ketamine, and their tail veins were cannulated. After the cannulation, esmolol (200 μg/kg) was administered 30 minutes before the operation and esmolol infusion duration was 15 minutes. Then I/R model was performed. Blood samples were obtained at the end of the I/R model by drawing blood intracardially. Finally, tissue samples were obtained.
After this reperfusion time, biochemical and histopathological evaluations of lung tissue specimens were performed. The right lung was used for histopathological evaluation and the left was used for biochemical evaluation. Histopathological assessment was performed in the Kırıkkale University Medical Faculty Histology and Embryology Department. Paraffin blocks were formed by the specimens after a routine fixation process. Tissue sections were mounted on slides for staining with hematoxylin and eosin (H&E).
Histopathological Assessment of the Lung
A researcher uninvolved in the study examined lung samples histopathologically using light microscopy. Worst and best areas were evaluated using microscopy in H&E stained sections. Neutrophil infiltration and alveolar thickness were measured in each specimen to expose the degree of lung injury. Each parameter was scored as none (0 points), quite little (1 point), medium (2 points), or severe (3 points). Two scores were added and noted as the final lung injury score .
The biochemical analysis was done in the Gazi University Medical Faculty Biochemistry Department. The lung tissue was first washed with cold deionized water to discard blood contamination and then homogenized in a homogenizer.
Measurement of MDA levels, thiobarbituric acid (TBA) reactive substances assay was performed using the method described in the study by Van Ye et al . The CAT activity is based on the measurement of absorbance decrease due to H2O2 consumption at 240 nm by Aebi H method . GST enzyme activity was measured using the method described by Habig et al.  . PON-1 activity was measured at the rate of hydrolysis of paraoxon by monitoring the increase of absorbance at 405 nm and at 25 °C by Brites FD. Method  .
The sample protein amount was determined by the Lowry O method, and BSA was used as the standard protein .
All data were expressed as mean and standard deviation (SD). Comparisons between multiple groups were performed using the Kruskal–Wallis test. Differences were identified using the Bonferroni corrected Mann–Whitney U test. SPSS 12. 0 for Windows (SPSS Inc., Chicago, IL, USA) was used to complete all the analyses, and P < 0.05 was considered statistically significant.
Histopathologically, neutrophil infiltration/aggregation, alveolar wall thickness and total lung injury score were significantly higher in the I/R group when compared to the C and E groups. In addition, neutrophil infiltration/aggregation, alveolar wall thickness, and total lung injury scores in the I/R group were statistically higher than in the I/R-E group (p=0.030, p=0.010, p=0.001, respectively) (Table 1, Figures 1-3).
CAT and PON enzyme activities and MDA levels were significantly higher in the I/R group compared to the C, E and I/R-E groups. GST enzyme activity was similar between the groups (Table 2).
Our experimental study on hind-limb I/R injury-induced lung injury in rats showed that esmolol was effective in preventing the I/R induced lung injury. Esmolol (200 μg/kg) administration 30 minutes before the operation for 15 minutes of infusion reduced the neutrophil infiltration/ aggregation and alveolar wall thickness in lung tissue induced by hind-limb I/R.
Dupeng et al. have studied the protective effects of esmolol and its possible mechanism of protection on lungs in septic rats. They established the sepsis model with cecal ligation and infused esmolol for six hours in a dose of 15mg/kg per hour continuously. They measured the levels of catecholamine (CA) in plasma and levels of NF-κB and TLR4 in lung tissue. Additionally, they evaluated the protein content of alveolar lavage fluid, wet/dry weight ratio (W/D) of lung tissue, lung coefficient and lung water content, finding that protein content of alveolar lavage fluid, W/D in lung tissue, lung coefficient, and lung water content were significantly lower in the esmolol groups. They conclude that esmolol can promote the secretion of catecholamine, inhibit the release of inflammatory cytokines, reduce lung permeability, and reduce pulmonary edema. The mechanism may be that esmolol improves the responsiveness of the β-adrenergic receptor to catecholamine, and regulates the level of inflammatory cytokines by inhibiting TLR4-NF-κB-TNF-α signaling pathways, thus exerting a protective effect on the lungs . We observed similar results in our study on lung tissue histopathologically.
Esmolol has been previously studied in lung resection surgery (LRS) in porcines. The researchers analyzed the effect of a continuous perioperative iv infusion of esmolol on postoperative pulmonary edema in an experimental model of LRS, requiring periods of one-lung ventilation (OLV). They studied lung biopsies and plasma samples to analyze the levels and expression of inflammatory mediators, and the animals also received a bronchoalveolar lavage. The authors concluded that the esmolol treated group had less lung edema and lower expression of the proinflammatory biomarkers TNF and IL-1 compared to the control group for both lung lobes. They suggest that esmolol reduces lung edema and inflammatory responses in intraoperative and postoperative periods in animals that underwent LRS with OLV . In our study we did not analyze the same biomarkers, but we observed decreased MDA, CAT, and PON levels in rats. Likewise, we observed less lung injury in histopathologic evaluation.
Esmolol has been studied for its effects in early sepsis for multiple organ functions and has been shown to reduce apoptosis and inflammation and decrease serum IL-6, HMGB-1 and TNF- α levels. Moreover, it protected key organs . The protective effect of esmolol on lung tissue has been shown in a model of severe acute pancreatitis, the esmolol treatment reduced bronchoalveolar lavage fluid protein and proinflammatory cytokines TNF-α and IL-6 levels, decreased pancreatic/lung MPO activities. Furthermore, they showed clinical improvement in rats, concluding that esmolol has protective effects both on the lung and pancreas .
Increased levels of superoxide radicals (SOR) have an important role in the I/R injury caused by infrarenal occlusion of the aorta. These SORs are aligned as superoxide (O2-), hydrogen peroxide (H2O2) and hydroxyl (OH-) ions. The superoxide is converted to H2O2 with the catalyst of superoxide dismutase and then the H2O2 is converted to H2O and CO2 with the catalysts of glutathione peroxidase and CAT and H2O2 is therefore inactivated. Thus CAT is an intracellular enzyme, which has a key role in deactivating SORs. Also, MDA is a sensitive marker and a final product of cell membrane lipid peroxidation. Gulmen et al. concluded in their study with lower extremity I/R model that MDA and CAT levels were increased in I/R injury groups . Kapan et al. also observed increased levels of CAT and MDA in their lung injury model induced by their infrarenal abdominal aorta I/R injury model. In their model, they applied 30 minutes of ischemia and 60 minutes of reperfusions and observed increased MDA and CAT levels . In our study, in I/R injury groups, we observed increased CAT and MDA levels, which are defined as important and delicate markers of injury, also in esmolol treated groups we observed decreased levels of these indicators. In our study, the GST levels were higher in I/R injury groups and lower in esmolol treated groups but these levels were not significant.
Current knowledge about the dosage varies in research. Umehara et al. infused 200 µg/kg/min, and Zhang et al. infused 15 mg/kg per hour. We used the same dosage as Umehara et al. and obtained beneficial effects [9,22]. Umehara et al. infused esmolol 30 minutes before the I/R model, as we did, but they continued infusion for the subsequent 24 hours . We prefer not to infuse for 24 hours to observe the effects of infusion when done only prior to surgery and observed beneficial effects.
In this study, esmolol reduced lung injury significantly in the I/R-E groups when compared to I/R group. Zhang et al. induced severe acute pancreatitis in rats and they evaluated the effects of esmolol in these rats on lung tissue. In these rats they observed increased diffuse edema formation, interstitial infiltration by neutrophils and reduced alveolar spaces in the SAP group. Histology scores, based on the number of areas with congestion, edema, inflammatory cells, and hemorrhaging were lower in esmolol-treated animals than in SAP animals .
There are some limitations in the research. We only studied GST, CAT, PON enzyme activities and MDA levels because of technical incapability, but TNF-α, IL 1, IL 6 could be studied as well to support our findings. Also, different doses of esmolol have been defined to be effective in lung injury, but we infused 200 µg/kg/min dose and found it to be effective, other doses can be studied as well. The lack of data about hemodynamical changes in rats regarding esmolol infusion is another limitation of the study.
In conclusion, in our experimental study, hind-limb I/R injury-induced lung injury in rats showed that esmolol was effective in preventing the IR-induced lung injury. Esmolol (200 μg/kg) administration 30 minutes before the operation for 15 minutes reduced the neutrophil infiltration/aggregation and alveolar wall thickness in lung tissue induced by hind-limb I/R. Increased levels of GST, CAT, MDA and PON in lung tissues supported by I/R are mediated via oxidative reactions and decreased levels of CAT, MDA and PON in esmolol treated groups supported our histopathological findings. Such lung injury treatments can be used to enhance lung functions following hind-limb I/R.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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9. Umehara S, Goyagi T, Nishikawa T, Tobe Y, Masaki Y. Esmolol and landiolol, selective β1-adrenoreceptor antagonists, provide neuroprotection against spinal cord ischemia and reperfusion in rats. Anesth Analg. 2010; 110(4):1133-7.
10. Oyama Y, Blaskowsky J, Eckle T. Dose-dependent effects of esmolol-epinephrine combination therapy in myocardial ischemia and reperfusion injury. Curr Pharm Des. 2019; 25(19):2199-206.
11. Gürcün U, Kurtoğlu T, Dişcigil B, Özkısacık E, Boğa M, Yenisey Ç. Ischemic preconditioning and N-acetylcysteine in a rat model of skeletal muscle ischemia-reperfusion: does antioxidant therapy have an impact on ischemic preconditioning? Turkish Journal of Thoracic and Cardiovascular Surgery. 2012;20: 862-8.
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13. Peng CK, Huang KL, Wu CP, Li MH, Hu YT, Hu CW, et al. Glutamine protects ischemia-reperfusion induced acute lung injury in isolated rat lungs. Pulm Pharmacol Ther. 2011; 24(1):153-61.
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Download attachments: 10.4328.ACAM.21025
Ulku Sabuncu, Saban Cem Sezen, Aysegul Kucuk, Nevriye Salman, Timucin Sabuncu, Gulay Kip, Omer Kurtipek, Mustafa Kavutcu, Mustafa Arslan. Effects of esmolol on lung injury induced by lower extremity Ischemia-reperfusion. Ann Clin Anal Med 2022;13(6):611-615
Investigation of the relationship between early pregnancy losses and urinary iodine concentration
Özgül Özgan Çelikel 1, Tufan Arslanca 2, Banu Arslanca 3, Nurkan Aksoy 4, Filiz Yildirim 5
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Lokman Hekim University, Ankara Education and Research Hospital, 2 Department of Obstetrics and Gynecology, Faculty of Medicine, Ufuk University, 3 Department of Obstetrics and Gynecology, Faculty of Medicine, Ankara University, 4 Department of Biochemistry, Yıldırım Beyazıt University, Yenimahalle Education and Research Hospital, 5 Department of Internal Medicine, Polatlı Duatepe Goverment Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.21040 Received: 2022-01-03 Accepted: 2022-02-10 Published Online: 2022-04-11 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):616-620
Corresponding Author: Filiz Yildirim, Clinic of Internal Medicine, Polatlı Duatepe Goverment Hospital, 06900, Polatlı, Ankara, Turkey. E-mail: firstname.lastname@example.org P: +90 544 411 22 89 F: +90 312 243 10 12 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6151-2697
Aim: The aim of this study was to evaluate the relationship between the development of spontaneous abortion (SpA) and hypothyroidism developing during pregnancy in patients who were euthyroid before pregnancy.
Material and Methods: This prospective study included 44 women with singleton pregnancies with a history of pregnancy loss and 43 women with singleton pregnancies with no history of loss. All patients were in the first 12 weeks of pregnancy. Age, gestational age, number of miscarriages, gravida, body mass index, free triiodothyronine (FT3), free thyroxine (FT4), thyroid stimulant hormone (TSH), and urinary iodine concentration levels (UIC) were measured. Parameters were compared between the groups using the independent samples t-test. Correlation analysis was performed to determine relationships between the parameters in the groups. The Pearson correlation coefficient was calculated. A value of p<0.05 was considered statistically significant.
Results: The mean UIC (145.3±56.01 µg/L) in the SpA group was lower than in the non-abortus group (186.9±68.80 µg/L) (p= 0.001). In the SpA group, there more hypothyroidic patients, and FT4 values were statistically significantly low (p=0.004). Correlation analysis determined a significant correlation between UIC and SpA (r: -0.438*, p<0.001). As a result of the binary logistic regression analysis, recurrent SpA and moderate and severe iodine deficiency were seen to have contributed to the development of SpA in the current pregnancy.
Discussion: The results of this study showed that even in patients who were euthyroid before pregnancy, with the increasing iodine requirement in pregnancy, iodine deficiency can emerge and this can cause hypothyroidism and increase the risk of the development of SpA.
Keywords: Abortion, Iodine, Thyroid Hormones, Pregnancy
Spontaneous abortion (SpA), also called miscarriage, is one of the most common pregnancy complications, and is associated not only with morbidity or mortality , but also has important social and psychological impacts on women . The incidence of SpA has been reported to be as high as 15%, and at least 80% of these events occur in the first trimester of pregnancy . Advanced maternal age and previous SpA are among the risk factors for the development of SpA [4, 5].
Hypothyroidism in pregnancy is known to be associated with SpA, low birth weight, reduced cognitive functions, and an increased rate of stillbirths . Maternal thyroid hormones are of vital importance especially in the early weeks of pregnancy because of the risk of underdevelopment of fetal thyroid tissue, and deficiencies can cause SpA. As a result of this increased requirement for thyroid hormone, the need for maternal iodine shows an increase by more than 50% in pregnancy .
Several recent studies have shown that pregnancies may be at risk of mild iodine deficiency, not only in iodine-deficient regions, but also in regions where iodine is sufficient. These studies have also emphasized that hypothyroidism can develop without any known thyroid pathology associated with the need to meet the increased requirement in pregnancy [7, 8]. However, to date, there has been no evaluation of the relationship between maternal iodine status and hypothyroidism developing in pregnancy and the occurrence of SpA in patients who were euthyroid before pregnancy.
Therefore, the aim of this study was to evaluate the relationship between the development of SpA and hypothyroidism developing during pregnancy in patients who were euthyroid before pregnancy.
Material and Methods
The study was conducted between April 2018 and July 2018 in the gynecology and obstetrics clinic of a second-level state hospital. Approval for the study was granted by the Ethics Committee of Yıldırım Beyazıt University, Yenimahalle Education and Research Hospital (decision no: 2018/01). All included patients were informed in writing about the study. Written consent was obtained from those who agreed to participate in the study. All procedures performed in studies involving human participants 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. In order to determine the sample size, a power analysis was performed using G * Power software. To obtain a power of 0.80 and α error of two-way 0.05, it was determined that the lowest number of patients to be included was a total of 90 patients as 45 patients in the SpA group and 45 patients in the non-SpA group. The effect width was calculated to be at least 0.80, and the power of the study over this effect width was determined as 95%.
The study included patients with no thyroid nodules observed ultrasonographically before pregnancy and normal thyroid hormone levels (45 SpA patients) and a control group of 45 age and gestational week-matched patients with no SpA.
To exclude factors that may affect urinary iodine concentration (UIC), patients with diabetes mellitus diagnosed before pregnancy, chronic hypertension, liver disease, kidney disease, heart disease, or a cancer diagnosis were excluded from the study. To exclude factors that may cause SpA, pregnant women with uterine anomalies, previous uterine surgery, or chronic drug use were also excluded from the study. Those with hypertension, gestational diabetes mellitus, heart disease, or fetal anomaly detected on ultrasonography were not included in the study. None of the study participants were taking multivitamins or iodine supplements during pregnancy. Pregnant women with thyroid dysfunction who were diagnosed before pregnancy or who had to be diagnosed and used medication during pregnancy and/or patients with autoimmune thyroid disease or nodule detected ultrasonographically were excluded from the study. All pregnant women were measured hemogram, fasting blood glucose, liver function tests, renal function tests, Toxoplasma IgG, IgM, Rubella IgG, IgM, and VDRL. The blood samples of 3 pregnant women (1 in the SpA group and 2 in the non-SpA group) were found to be hemolysed, and these patients were excluded from the study. A 5 mL urine specimen routinely collected at -20°C was collected from all the study participants who were admitted to the gynecology outpatient clinic and were healthy in the first 12 weeks of gestation. The study group comprised 44 pregnant women who underwent clinical examination and were determined with SpA or without fetal cardiac activity on ultrasonographic examination up to the 12th week. The control group comprised 43 pregnant women with fetal cardiac activity at the end of the 12th week. Age, gravida, gestational week, number of spontaneous abortions, body mass index (BMI) were recorded, as well as the values of the routinely studied free T3 (FT3), free T4 (FT4), total thyroid-stimulating hormone (TSH) levels, and hemoglobin and fasting blood glucose (FBG) levels. The flow chart of the study is shown in Figure 1.
The previously collected spot urine samples were stored at -20°C and then brought to room temperature for assay when the number of patients required was met. Using urine brand colorimetric method / Italy kit, the urine iodine level was examined in the 5 mL urine samples of each patient. By drawing a graph, the 405 nm (nanometer) absorbance and calibrator values were calculated. The UIC values for pregnant women defined by the World Health Organisation (WHO) are adequate iodine=median UIC of 150–249 μg/L, mild iodine deficiency (ID)=UIC of 100–150μg/L, moderate and severe ID=UIC<100 μg/L, and excessive iodine = UIC ≥250 μg/L.
Data obtained in the study were analyzed statistically using the SPSS vn. 22 software (Statistical Package for the Social Sciences). Conformity of the data to a normal distribution was assessed with the Shapiro-Wilk test, and a normal distribution of variables in the groups was found. Parametric tests were used to analyze the data. To compare parameters between these two groups that are homogeneous and have non-homogeneous data, the Independent Samples t-test and the Mann-Whitney U test were used. To examine correlation coefficients between the examined parameters, correlation analysis was applied to both groups and the Pearson correlation coefficients were calculated. A value p<0.05 was considered statistically significant.
The demographic variables of the patients evaluated in this study are shown in Table 1 and Figure 1. No difference was determined between the groups in respect of demographic variables such as age and gestational week (p>0.05 for all). Multiparity and ≥1 miscarriage were determined at a statistically significant higher rate in the SpA group (p=0.035, p<0.001, respectively).
Thyroid hormone levels and UIC values of the patients were compared (Table 2). The thyroid hormone levels were classified taking the ranges in the test kit as a reference. FT4 values were determined to be below the normal reference value in 27.3% of the SpA group patients and in 7% of the non-SpA control group (p=0.004). High TSH values consistent with hypothyroidism were determined in 20.4% of the SpA group and in 4.7% of the control group (p=0.023).
The median UIC values of the SpA group (145.38±56.01) were statistically significantly lower than those of the control group (186.95±68.80) (p<0.001) (Figure 2). When the UIC values were evaluated with subgroup analysis, moderate and severe ID was determined in 15.9% of the SpA group and in 2.3% of the control group. Mild ID was determined in 54.6% of the SpA
group and in 23.3% of the control group. The difference between the groups in respect of the UIC values was statistically significant.
When the factors related to the development of SpA were evaluated, the strongest relationship was seen to be the development of SpA in a (≥1) previous pregnancy (r: 0.545, p<0.001). A strong negative correlation was determined between the development of SpA and UIC values (r:-0.438, p=0.001). The factors related to SpA are shown in Table 3.
When the rates of the effect on SpA development of the factors showing a relationship in correlation analysis were evaluated with binary logistic regression analysis, it was determined that a history of SpA increased the probability of SpA development in the current pregnancy 1.249-fold (95% confidence interval: 1.098-0.0407, p=0.005). UIC was determined to be another factor affecting SpA development (odds ratio: 1.065, 95% CI: 1.024-1.283, p=0.019). The analysis results are shown in Table 3.
SpA is a common complication occurring in 1-2 % of pregnant women . Inadequate maternal iodine stores during pregnancy cause insufficient thyroid hormone production, which has serious adverse effects on the fetus. The thyroid gland of a fetus is not completely functional until 12 weeks of gestation. Some studies have shown that subclinical maternal hypothyroidism increases early pregnancy losses and abnormal fetal development [10, 11], although conflicting results have been reported related to ID as a reason for fetal loss .
In a study from China that included 1569 previously euthyroid pregnant women in the ≤12th week of pregnancy, participants were separated into four groups based on the WHO criteria for iodine levels during pregnancy . Post-pregnancy outcomes such as spontaneous abortion, gestational hypertension, pre-eclampsia, gestational diabetes mellitus, placenta previa, placental abruption, preterm delivery, low birthweight infants, macrosomia, breech presentation, and cord entanglement were followed. Both iodine insufficiency and excessive iodine intake in the first trimester were shown to have adverse effects on pregnancy outcomes .
In two older studies, it was shown that severe maternal ID increased neonatal deaths, recurrent miscarriages and early labour, and that outcomes improved with iodine supplementation [13, 14]. The prevalence of mild to moderate iodine deficiency in pregnant women is an important reason to determine whether iodine contributes to early pregnancy losses . In a study that examined 171 patients with spontaneous abortion and normal thyroid function test results, ID was detected in >50% of the women . In contrast, some studies have reported different results on this subject. A population-based, prospective, cohort study examined the urine iodine of 501 women planning to be pregnant within 2 months. Of these, 329 women became pregnant, and 196 had live births (59.5%), 92 (28.0%) experienced pregnancy loss, and 41 (12.5%) were withdrawn from the study or their data were not available. The UIC values of only 59.6% of the study participants could be determined. The risk of loss, however, was not elevated in the mildly deficient group (hazard ratio 0.69, 95% CI 0.34, 1.38), the moderately deficient group (hazard ratio 0.81, 95% CI 0.43, 1.51), or the severely deficient group (hazard ratio 0.69, 95% CI 0.32, 1.50). According to the results of that study, moderate ID and even at a severe level was not related to pregnancy loss . In another study, UIC values were examined in 3140 singleton pregnancies and 42 patients with early pregnancy loss. Maternal mild or moderate ID was not found to be associated with adverse pregnancy outcomes .
In the current study, the UIC values of the pregnant women in the SpA group were determined to be significantly lower than those of the control group. However, there are specific boundary values in biochemical parameters, and if the results are within the normal range values, the individual is not negatively affected by the results. For more detailed clarification, in the current study, UIC values were classified according to the WHO values. Accordingly, moderate and/or severe deficiency was seen in 15.9% of the SpA group patients and as this rate was 2.3% in the control group, the difference between the groups was seen to be significant. In the correlation analysis, there was determined to be a significant relationship between low UIC values and the development of SpA. In the regression analysis, low UIC values were seen to increase the probability of SpA by 1.065-fold (95%CI 1.024-1.283).
Although the development of SpA is affected by many factors, these were excluded as far as possible by the extremely strict patient selection criteria of this study. For example, advanced maternal age has been shown to be directly associated with SpA as an important factor in many studies, but in the current study no relationship was determined with age. This can be attributed to the matching of patient age in the groups, as stated in the Materials and Methods section.
The most important limitation of the current study was the relatively low number of patients. However, the number was deemed to be sufficient according to the power analysis applied. The main factor preventing the inclusion of a greater number of patients was the exclusion of patients with known thyroid pathologies before pregnancy.
The results of the study clearly showed that when the increased need for iodine in pregnancy is not met in patients who were euthyroid before pregnancy, ID may emerge and this can cause hypothyroidism and increase the risk of SpA. This increased risk is even more important in recurrent miscarriages. Therefore, patients with a history of pregnancy loss must be clinically evaluated in respect of iodine status, even if they were euthyroid before the pregnancy, and patients determined with deficiency must be treated.
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Conflict of interest
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Download attachments: 10.4328.ACAM.21040
Özgül Özgan Çelikel, Tufan Arslanca, Banu Arslanca, Nurkan Aksoy, Filiz Yildirim. Investigation of the relationship between early pregnancy losses and urinary iodine concentration. Ann Clin Anal Med 2022;13(6):616-620
Ganglion cell complex thickness and optical coherence tomography findings in stargardt macular dystrophy and retinitis pigmentosa
Eşay Kıran Yenice 1, Ahmet Şengün 2
1 Department of Ophthalmology, University of Health Sciences, Etlik Zübeyde Hanım Maternity and Women’s Health Teaching and Research Hospital, 2 Department of Ophthalmology, Faculty of Medicine, Ufuk University, Dr Rıdvan Ege Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.21048 Received: 2022-01-10 Accepted: 2022-02-11 Published Online: 2022-02-19 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):621-625
Corresponding Author: Eşay Kıran Yenice, University of Health Sciences, Etlik Zübeyde Hanım Maternity and Women’s Health Teaching and Research Hospital, Varlık Mahallesi, Etlik Caddesi, No:55, Keçiören, Ankara, Turkey. E-mail: email@example.com P: +90 312 567 40 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7164-4837
Aim: In this study, we aimed to assess ganglion cell complex (GCC) thickness with spectral domain optical coherence tomography (SD-OCT) and to detect changes in retinal layers in eyes with Stargardt macular dystrophy (SMD) and retinitis pigmentosa (RP) patients.
Material and Methods: Fifty-four eyes of 27 patients with RP and 46 eyes of 23 patients with SMD were enrolled. Each subject underwent a complete ophthalmic examination before SD-OCT was obtained. Macular scans were taken with software version 6.0 of the ganglion cell analysis (GCA) algorithm. Patients were divided into 3 grades according to photoreceptor layer integrity. GCC thickness was evaluated automatically as the average, minimum and six sectors by SD-OCT, and parameters were compared between groups.
Result: The mean age was 41.66±19. 77 years in group 1 (RP patients), and 28.00±10.37 years in group 2 (SMD patients). There were no significant differences in mean age, gender distribution, intraocular pressure and spherical equivalent at imaging between the groups (p>0.05). The mean (±SD) GCC thicknesses were evaluated and there were no significant differences between the two groups in each segment (Mann-Whitney U, p>0.05), but there were significant differences between patients in each grade (Kruskal-Wallis, p<0.05).
Discussion: This study showed that progressive degeneration and loss of function in the outer retinal layers are accompanied by damage to the inner retinal layers in patients with RP and SMD. However, some of the ganglion cells are protected after photoreceptor cell death, which may point us to the target tissue for future treatment modalities.
Keywords: Ganglion Cell Complex, Optical Coherence Tomography, Stargardt Macular Dystrophy, Retinitis Pigmentosa, Hereditary Retinal Dystrophy
Hereditary retinal dystrophies (HRD) are genetic diseases that occur in childhood or adolescence and cause severe visual loss .
Photoreceptor cell damage, progressive degeneration and loss of function in retinal pigment epithelial cells (RPE) are observed in bilateral and symmetrical in HRD .
There are many genes responsible for the formation of retinal dystrophies: ABCA4, ELOVL41, PROML1, VMD2, peripherin/RDS, TIMP3 and XLRS. Mutations in these genes result in different clinical forms .
Various diagnostic methods such as visual field tests, electroretinography (ERG), electrooculography (EOG), fundus fluorescein angiography (FFA), OCT and genetic analysis tests are performed after detailed ophthalmic examination of the diseases .
The Cirrus OCT (Carl Zeiss Meditec, Inc., Dublin, CA), two-dimensional cross-sectional retinal images consisting of 512 A-lines with axial resolutions of 10 mm can be obtained in 1.28 s . A-scans per second, pupil dilation is necessary for optimal measurement also GCC and other retinal layer thickness. The GCC thickness comprises the retinal ganglion cell layer (GCL) and inner plexiform layer (IPL), which are directly influenced by several potentially blinding eye diseases, such as glaucoma, retinitis pigmentosa .
The aim of this study was to assess GCC thickness in patients with RP and SMD and to investigate whether progressive degeneration and loss of function in the outer retinal layers are accompanied by damage to the inner retinal layers with retinal dystrophy.
Material and Methods
Participants and Patient Groups
This retrospective, comparative study was approved by the Ethical Review Committee of Ufuk University and adhered to the provisions of the Declaration of Helsinki for research involving human subjects. The medical records of 50 patients with SMD and RP were enrolled. Informed consent form was taken from all patients. Patients were divided into two groups; fifty-four eyes of 27 patients with RP group 1 and forty-six eyes of 23 patients with SMD group 2.
All eyes underwent full ophthalmic evaluation, including best-corrected visual acuity (BCVA) test, slit lamp examination and fundus examination. In all cases, the disease was diagnosed by examination findings and confirmed by ERG (to rule out other potential dystrophies). Cases with cataract and media opacity, which prevent SD-OCT image, retinal edema and serous detachment, pigmentary epithelial detachment in SD-OCT, glaucoma, spherical equivalent > 6D were excluded.
After detailed ophthalmic examination, macular scans were taken with SD-OCT (Cirrus; Carl Zeiss Meditec, Dublin, CA, USA). GCC thickness (GCL and IPL) was measured automatically as average (A), minimum (Min), temporal-superior (TS), superior (S), nasal-superior (NS), nasal-inferior (NI), inferior (I), temporal-inferior (TI) segments by SD-OCT, and results were compared between groups.
Also, patients were divided into 3 grades according to the study of Aizawa et al. ; patients with interruption in the photoreceptor layer grade 1, patients with abnormal photoreceptor layer grade 2 and patients with normal photoreceptor layer grade 3 and GCC thickness results were compared between 3 grades.
Spectral Domain Optical Coherence Tomography
The image was obtained using an SD-OCT device (Cirrus; Carl Zeiss Meditec). Macular scanning (macular cube 512×218) was performed through a dilated pupil with the SD-OCT. The GCC analysis algorithm was used to automatically measure the macular GCA thickness. Software version 6.0 of the GCA algorithm (Carl Zeiss Meditec) was used to process the data and detect and measure macular GCIPL thickness within a 6x6x2 mm cube centered on the fovea. The following macular GCIPL thickness measurements were analyzed: A, min, and sectorial (TS, S, NS, NI, I, TI) .
In SD-OCT technology, light from the reference arm interferes with light reflected back from the different layers of the retina, generating spectral interference fringes. This fringe pattern is processed by a high-speed spectrometer, and then undergoes transformation to create a reflectivity profile in depth. Two-dimensional cross-sectional retinal images consisting of 512 A-lines with axial resolutions of 10 mm can be obtained in 1.28 s. For GCC measurement scan was centered 1mm temporal to the fovea. It covers a 7×7 mm area of the central macula . GCC thickness parameters indicate the retinal GCL and IPL in the area above the horizontal meridian. The software analyzes the values, compares them with the device’s internal normative database, and generates a color-coded significance map. An instrument provided classification is indicated in a color-coded manner: sectors classified as “within normal limits” (p>5%) are printed in green, sectors classified as “borderline” (p<5% but >1%) in yellow, and sectors classified as “outside normal limits” (p<1%) in red.
The SPSS 21.0 program package was used for statistical analysis. Normal distribution fitting was checked with the Kolmogorov-Smirnov test. The Mann-Whitney U-test was used to compare the measured GCL parameter values between groups, respectively. The Pearson x2 test was used to evaluate systemic disease between two groups. The Kruskal-Wallis test was used to compare the measured GCL parameter values between grades, respectively. P-values of 0.05 or lower were considered to indicate statistical significance.
One hundred eyes of 50 participants were examined retrospectively. Fifteen of the 27 patients were men and 12 were women in group 1 and 9 of the 23 patients were men and 14 were women in group 2. The mean (±SD) age was 41.66±19.77 years in group 1 and 28.00±10.37 years in group 2. The mean (±SD) intraocular pressure (IOP) and BCVA of the participated eyes were 14.22±2.97 mmHg and 0.49±0.34 in group 1. The corresponding values in group 2 were 13.97±3.63 mmHg and 0.31±0.26, respectively. There was no significant difference between the groups for age, gender distribution, intraocular pressure and refraction (p>0.05). Demographic and ophthalmic examination data of the participants are shown in Table 1.
One of the 27 patients had hypertension, 1 of the 27 patients had diabetes mellitus and 4 of the 27 patients had hypertension and diabetes mellitus together in group 1. On the other hand, 1 of the 23 patients had hypertension, 1 of the 23 patients had diabetes mellitus in group 2. There were no significant differences between systemic diseases and GCC thickness between the groups (Mann-Whitney U test, p>0.05).
GCC thickness was A 51.14±16.77µm, Min 33.00±19.89µm, TS 52.85±19.16µm, S 50.18±18.75µm, NS 51.94±21.37µm, NI 51.90±19.89µm, I 49.35±16.34µm and TI 52.14±19.44µm in group 1. The corresponding values in group 2 were 50.58±22.72µm, 33.54±25.25µm, 51.28±23.88µm, 51.06±23.34µm, 50.45±24.47µm, 52.69±23.89µm, 48.28±22.97µm and 49.36±25.82µm respectively. There were no significant differences between the two groups in each segment (Mann-Whitney U-test, p>0.05). The GCC thickness examination data of the groups are shown in Table 2, Figure 1.
On the other hand, when we evaluated the relationship between retinal layer integrity and GCC thickness, the average GCC thickness was 48.67±19.23µm, min 29.60±19.25µm, TS 49.47±21.27µm, S 49.07±20.40µm, NS 48.68±22.72µm, NI 50.28±21.80µm, I 46.34±18.80µm and TI 48.45±22.43µm in grade 1 patients.
GCC thickness was A 56.00±22.60µm, Min 46.66±26.81µm, TS 56.33±22.77µm, S 56.50±23.30µm, NS 56.83±22.86µm, NI 56.33±23.42µm, I 55.33±25.16µm and TI 55.16±23.97µm in grade 2 patients.
GCC thickness was A 61.86±21.17µm, Min 48.26±29.07µm, TS 64.23±21.38µm, S 56.76±23.36µm, NS 63.10±23.17µm, NI 63.13±22.66µm, I 60.13±20.99µm and TI 62.23±22.61µm in grade 3 patients.
There were significant differences between GCC thickness and grade 1, 2 and 3 patients (Kruskal-Wallis, p=0.015(A), p=0.007(Min), p=0.010(TS), p=0.028(S), p=0.021(NS), p=0.038(NI), p=0.012(I), p=0.015(TI)). GCC thickness values were highest in grade 3 patients.
At the same time, visual acuity was highest in grade 3 patients. The GCC thickness examination data in grade 1, 2, 3 patients are shown in Figure 2.
Hereditary retinal dystrophy, one of the most common causes of genetic blindness, was first described by Donders at the beginning of the 1855s. It is possible to classify these group diseases according to genetic mutation or inheritance pattern, or to classify according to the anatomical localization of the primary lesion .
Retinal ganglion cells allow visual information produced by photoreceptor cells to be transmitted to the brain. Retinal ganglion cells are composed of 3 layers; retinal nerve fiber layer (RNFL), GCL and inner plexiform layer (IPL). These three layers are called GCC . GCC is affected by multiple diseases such as glaucoma and macular degeneration, which cause structural changes in retina and choroid .
In some studies comparing age-related macular degeneration (AMD) and RP, it has been shown that although the clinical findings of the patients concern the outer retinal layers, there are functional and structural changes in the inner retinal layers in the later stages of the disease , and on the other hand, the GCL is preserved in 50-75% of the eyes, and there is a positive correlation between the loss of ganglion cell neurons and the level of photoreceptors [10,11].
In some studies on human and animal eyes with retinal degeneration, it has been reported that the progression of the disease and decreased visual acuity lead to intraretinal and photoreceptor layer abnormalities [12-14], and loss of RGC was secondary to dystrophy .
Santos et al. analyzed macular sections of 21 eyes with RP and age-matched 19 healthy individuals histopathologically. Compared with the control group, there was a significant reduction in photoreceptor cell count in RP group. However, 30% of the GCL was preserved in the severe RP group. The results support that current treatment modalities such as retinal transplantation and retinal implantation in RP patients require ganglion cells preserved after photoreceptor cell death .
Similarly, in another study by Stone et al., eyes with RP and healthy individuals were compared and degeneration in ganglion cells secondary to photoreceptor cell death was analyzed by evaluating macular sections. Photoreceptor cell count was significantly lower in RP group, and transneuronal ganglion cell degeneration was observed. This study supports the hypothesis that current treatment methods, including stimulation and transplantation of photoreceptors aimed to increase visual acuity require ganglion cells .
In our study, there was no difference between the RP and SMD patient groups in terms of GCC thickness, but we found that the GCC thickness was higher in grade 3 patients where the photoreceptor layer integrity was not affected, but it was lower in grade 1 patients. At the same time, visual acuity was the highest in grade 3 patients.
In some studies, GCC thickness maps were obtained from OCT images of glaucomatous patients, and GCC thickness has been found to be affected in this group of patients .
In our study, there was no significant difference between IOP and GCC thickness.
Histopathological studies and HD-OCT studies in healthy subjects showed a linear relationship between increased age and thinning in GCT [19-21].
In our study, there was no significant difference between GCT+IPL-A, GCT+IPL-min and six sectors and age.
In systemic diseases such as hypertension and diabetes mellitus, morphological changes are seen in RGC and may result in visual loss accompanying retinopathy development. Tham et al. found that GCC is thinner in eyes with hypertensive retinopathy . It is thought that the increase of retinal venous tortuosity disrupts tissue perfusion and causes degenerative changes in ganglion cells.
In our study, there was no significant difference between hypertensive and diabetes mellitus and GCC thickness.
In HRD, in which ganglion cell damage occurs after photoreceptor cell death, it is aimed to increase the level of vision with current treatment methods such as retinal prostheses .
It is known that retinal prostheses were developed to increase visualization of the inner retinal layers in patients with visual loss. For this purpose, there are multiple prosthetic systems and their working mechanisms. It is possible to increase visual acuity, detect different light patterns, localize objects, localize door-window, distinguish light and dark clothes and walk easily in pedestrian crossings in patients who have prosthetics [2,24].
We know that current treatment methods require the presence of the GCL. Although there are animal studies on this subject, the lack of adequate human studies limits the applicability of these treatments to humans. In the future, large studies are needed to investigate the effect of HRD on the ganglion cell layer.
This study showed that progressive degeneration and loss of function in the outer retinal layers are accompanied by damage to the inner retinal layers in patients with RP and SMD. However, some of the ganglion cells are protected after photoreceptor cell death, which may point us to the target tissue for future treatment modalities.
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6. Cifuentes-Canorea P, Ruiz-Medrano J, Gutierrez-Bonet R, Pena-Garcia P, Saenz-Frances F, Garcia-Feijoo J, et al. Analysis of inner and outher retinal layers using spectral domain optical coherence tomography automated segmentation software in ocular hypertensive and glaucoma patients. PLoS One. 2018; 13(4). DOI: 10.1371/journal.pone.0196112
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8. Rimayanti U, Kiuchi Y, Yamane K, Latief MA, Mochizuki H, Hirata J, et al. Inner retinal layer comparisons of eyes with exudative age-related macular degeneration and eyes with age-related macular degeneration and glaucoma. Grafes Arch Clin Exp Ophthalmol. 2014; 252(4): 563-70.
9. Sustar M, Perovsek D, Cima I, Stirn-Kranjc B, Hawlina M, Brecelj J. Electroretinography and optical coherence tomography reveal abnormal post-photoreceptoral activity and altered retinal lamination patients with enhanced S-cone syndrome. Doc Ophthalmol. 2015; 130(3): 165-77.
10. Kim YK, Ha A, Na KI, Kim HJ, Jeoung JW, Park KH. Temporal relation between macular ganglion cell-inner plexiform layer loss and peripapillary retinal nerve fiber layer loss in glaucoma. Ophthalmology. 2017; 124(7): 1056-64.
11. Chua J, Tan B, Ke M, Schwarzhans F, Vass C, Wong D, et al. Diagnostic Ability of individual macular layers by spectral-domain oct in different stages of glaucoma. Ophthalmol Glaucoma. 2020; 3(5): 314-26.
12. Ryals RC, Andrews MD, Datta S, Coyner AS, Fischer CM, Wen Y, et al. Long-term characterization of retinal degeneration in Royal Collage of Surgeons rats using spectral-domain optical coherence tomography. Invest Ophthalmol Vis Sci. 2017; 58(3): 1378-86.
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Eşay Kıran Yenice, Ahmet Şengün. Ganglion cell complex thickness and optical coherence tomography findings in stargardt macular dystrophy and retinitis pigmentosa. Ann Clin Anal Med 2022;13(6):621-625
Relationship between thyroid function tests and mortality in severe Covid-19 pneumonia cases admitted to the intensive care unit
Öznur Demiroluk, Yıldız Yiğit, Sevgi Alagöz, Arzu Yıldırım Ar
Department of Anesthesiology and Reanimation, University of Health Sciences, Fatih Sultan Mehmet Health Research and Application Center, Istanbul, Turkey
DOI: 10.4328/ACAM.21052 Received: 2022-01-11 Accepted: 2022-02-14 Published Online: 2022-02-16 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):626-629
Corresponding Author: Öznur Demiroluk, Department of Anesthesiology and Reanimation, University of Health Sciences, Fatih Sultan Mehmet Health Research and Application Center, E-5 Highway, İçerenköy Street, 34752 Ataşehir, İstanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 533 522 95 08 F: +90 216 575 04 06 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6427-5148
Aim: In severe COVID-19 infection, most organs are affected, including the thyroid gland. A decrease in thyroid functions can be seen in relation to the severity of the disease. We aimed to retrospectively analyze the relationship between thyroid function tests and mortality in patients admitted to the intensive care unit (ICU) with severe COVID-19 pneumonia.
Material and Methods: The study was performed retrospectively on 46 adult patients admitted to the intensive care unit with severe COVID-19 pneumonia. Demographic, clinical, laboratory data were recorded. Patients were grouped into two according to mortality. Laboratory data were compared between groups. Additionally, the correlation of free triiodothyronine (fT3), free thyroxine (fT4), and thyrotropin (TSH) with infection parameters was investigated.
Results: At the time of ICU admission, fT3 levels below the normal range were present in 91.3%, fT4 levels were below normal in 39.13%, and TSH levels were below normal in 52.17% of the study patients. There was a positive correlation between fT4 and CRP (r=0.315, p<0.05), while there were no significant correlations between other parameters. TSH, fT3, or fT4 did not differ between patients with and without mortality. Partial arterial oxygen pressure/fraction of inspired oxygen was lower in patients with mortality (p=0.015).
Discussion: Low thyroid hormone levels and TSH are common occurrences in patients admitted to the ICU with severe COVID-19 pneumonia. No relationship could be shown between low thyroid function test levels and mortality in patients with severe COVID-19 pneumonia.
Keywords: COVID-19, Thyroid Function Tests, Thyroid Hormones, SARS-CoV-2, Intensive Care Units
The novel coronavirus infection (COVID-19) has a plethora of effects on the organ systems and can lead to severe respiratory insufficiency following pneumonia. Similar to other organs, the thyroid gland and its functions are affected during the COVID-19 infection. Among patients with COVID-19 infection, hypothyroidism is reported at a rate of 6.7%. A quarter of hypothyroidism cases in these patients are attributed to autoimmune thyroiditis, while 66% are attributed to central hypothyroidism due to corticotroph deficiency that has been shown in long-term follow-up to be transient . Thyroid stimulating hormone (thyrotropin, TSH) levels are lower in severe COVID-19 patients, both during the initial course of the disease and during the recovery period . The pituitary-adrenal axis is disrupted directly by viral infection of pituitary cells and indirectly by the proinflammatory cytokines .
Besides thyroid diseases, abnormal levels of thyroid hormones are seen in severe infection, hepatic or renal failure, malignancies, and severe malnutrition. These are collectively referred to as non-thyroidal illness (NTI) or euthyroid sick syndrome [2,3]. NTI is characterized by low plasma triiodothyronine (T3), low or normal plasma thyroxine (T4), and low or normal TSH levels. COVID-19 pneumonia patients differ from non-COVID pneumonia cases in that severe COVID-19 patients have lower serum TSH levels [2,4]. The decrease in TSH and T3 in COVID-19 patients is positively correlated with the severity of infection and the levels of interleukin-6 (IL-6), which increase with associated cytokine storm [1,2]. Based on these reports, serum TSH and thyroid hormone changes may be important markers in the course of COVID-19 disease. In this study, we aimed to investigate the relationship between thyroid function tests and mortality in patients admitted to the ICU with COVID-19 pneumonia.
Material and Methods
Following the local ethics committee (FSM EAH KAEK 2021/13) and the Ministry of Health approval, the study was conducted retrospectively in a single center. Data of 46 patients aged >18 admitted to the ICU between April 2020 – March 2021 with COVID-19 pneumonia confirmed with reverse-transcriptase polymerase chain reaction (RT-PCR) tests were collected and analyzed. RT-PCR specimens for COVID-19 testing were collected with nasopharyngeal swabs. Patients aged <18, with negative COVID-19 tests, known thyroid dysfunction, or under treatment for thyroid diseases, or who received treatment with steroids prior to ICU admission were excluded. The presence of at least one of the following criteria, together with unilateral or bilateral ground-glass images on lung computed tomography (CT), while classifying patients for severe COVID-19 pneumonia was used for inclusion: respiratory rate ≥30 breaths/minute, peripheral oxygen saturation (spO2) ≤93%, partial arterial oxygen pressure/fraction of inspired oxygen ratio (PaO2/FiO2) ≤ 300 mmHg, or need for high-flow oxygen or mechanical ventilation.
Demographic parameters [age, gender, comorbidities, Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores], clinical data [lung CT reports prior to ICU admission, symptoms at admission, peak heart rate (HR), blood pressure (BP), SpO2], ICU data [invasive mechanical ventilation (IMV) requirement, IMV duration, mortality], laboratory results at the time of ICU admission [fT3, fT4, TSH, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), procalcitonin (PCT), lactate dehydrogenase (LDH), ferritin, interleukin-6 (IL-6), D-Dimer, PaO2/FiO2] were recorded. Fever was defined as body temperature ≥ 38 C0, tachycardia as HR ≥ 100 beats/min, hypertension as systolic blood pressure ≥ 140 mmHg, and hypotension as systolic blood pressure < 90 mmHg. Neurological worsening was defined as an acute decrease in ≥ 2 points in the Glasgow Coma Scale score. Patients received IMV when hypoxia (SpO2 ≤ 92% or PaO2 < 60 mmHg), tachypnea (respiratory rate ≥ 30/min), and dyspnea persisted with clinical deterioration, hemodynamic instability, or worsening consciousness despite oxygen via reservoir mask, high flow nasal cannula, or non-invasive mechanical ventilation.
Patients were grouped into two according to mortality. Recorded data were compared between groups to investigate their relationship with mortality. The correlation of fT3, fT4, and TSH at the time of ICU admission with NLR, CRP, PCT, and IL-6 that represent the severity of infection were also investigated .
Statistical analysis was performed using IBM SPSS Version 26.0 (IBM Corp, 2019, Armonk NY). Categorical data are given in numbers and percentages, while continuous data are given as mean ± standard deviation or median (minimum-maximum). The Kolmogorov-Smirnov test was applied to test the normality of continuous variables. The Mann-Whitney U test was performed as continuous variables did not show a normal distribution. The correlation of thyroid hormones with infectious parameters was tested using Spearman’s Rho Correlation. Statistical significance was set at p<0.05.
A total of 46 patients admitted to the ICU with severe COVID-19 infection were retrospectively analyzed. None of the patients had any missing data among the parameters included in the analysis. The demographic parameters, symptoms, clinical findings at ICU admission, ICU outcomes, and laboratory parameters data are presented in Table 1 and Table 2.
At the time of ICU admission, relative to the normal ranges of laboratory, 91.3% of the patients had low fT3 (isolated low fT3 in 8, low fT3 and TSH in 16, low fT3 and fT4 in 8, low fT3, fT4, and TSH in 6, low fT3, fT4 with high TSH in 4 patients), and 39.13% had low fT4. Higher than normal fT3 or fT4 was not observed in any of the patients; 52.17% of the patients had low TSH and 8.7% had high TSH levels. In only two patients (4.34%), fT3, fT4, and TSH were within the normal ranges (data are not presented in the Tables). Laboratory results at the time of ICU admission were compared between patients with and without mortality. PaO2/FiO2 was significantly lower in patients with mortality. fT3, fT4, and TSH did not differ significantly between the groups (Table 3).
The correlation of fT3, fT4, and TSH with NLR, CRP, PCT, and IL-6 was investigated. There was a significant positive correlation between fT4 and CRP (r=0.315; p<0.05), while other parameters were not found to be correlated.
In our study, we investigated the relationship of thyroid hormones and thyroid stimulating hormone levels with mortality in patients who required ICU treatment due to severe COVID-19 pneumonia. In 95.6% of the study patients, at least one thyroid function test was outside of the normal range at the time of ICU admission. The most frequent thyroid dysfunction was low fT3 (91.3%), followed by low TSH (52.17%). In patients with mortality, thyroid hormone and thyroid stimulating hormone levels were lower than in patients without mortality albeit insignificantly. Among thyroid hormone levels at the time of ICU admission, only fT4 and CRP were positively correlated.
Studies have shown that there is a decrease in T3 levels in the acute period of critically ill patients, mainly due to the decrease in the conversion of T4 to T3 in peripheral tissues. In this period, short-term increases in TSH and T4 can also be observed. In the long-term critical illness period, central suppression of the thyroid axis may cause a decrease in T3, T4 and TSH concentrations [6,7]. Wang et al. have shown that in the acute phase of the SARS-CoV infection the thyroid functions are disrupted and in the majority of the patients a decrease in T3, T4, and TSH is observed . They have also shown a correlation between disease severity and a decrease in fT3. Chen et al. have demonstrated a decrease in total T3 and TSH concentrations in COVID-19 pneumonia patients compared to their control group or patients with pneumonia of other causes . Zou et al. have reported a 27.52% rate of NTI in COVID-19 patients and a higher risk of severe disease in patients with NTI . Our study patients were admitted to the ICU with severe COVID-19 pneumonia and respiratory insufficiency. Most of our patients had low fT3 levels and most of these cases also had accompanying low TSH levels. We believe the thyroid dysfunction in our patients resulted from NTI arising from their severe acute infection.
Boelen et al. reported that the changes in thyroid hormone levels correlate with the severity of the disease resulting in NTI and that thyroid dysfunction recovered after treatment of the primary disease . Chen at al. have shown that thyroid dysfunction, especially the decrease in T3, is more evident in patients with mortality . Khoo et al. did not find a difference in TSH levels between patients with and without mortality, but slightly higher levels of fT4. Neither fT4 nor TSH was associated with mortality in their study . C-reactive protein is accepted as a risk factor that correlated with disease severity in COVID-19 infections . Zou et al. have found higher CRP, erythrocyte sedimentation rate, and procalcitonin in patients with NTI. In their patients, NTI was associated with inflammatory parameters of disease severity, however, did not affect mechanical ventilation requirement, time to discharge, or mortality . In contrast, Muller et al. reported significantly higher CRP and free thyroxin levels in COVID-19 patients with mortality when compared to patients who survived. . In our study, only fT4 and CRP were correlated among thyroid function tests and infectious parameters at the time of ICU admission. Free T3 and TSH levels were not correlated with infectious parameters. Although not statistically significant, we observed lower median fT3, fT4, and TSH levels in patients with mortality, while no association could be made between thyroid function tests and mortality. Of the parameters associated with disease severity, only PO2/FiO2 was associated with mortality.
Our study has certain limitations. Our study design did not include a control group, therefore, we could not make a comparison with healthy individuals or patients with non- COVID-19 pneumonia. Another limitation is that prior thyroid disease was questioned only with patient history and was not confirmed with radiological imaging when excluding patients. Since mortality was considerably high in the studied patient population, our study groups were noticeably different in size. We regard our study as a guide for future studies that can be designed with a higher number of patients.
In conclusion, although low levels in thyroid function tests, especially fT3, are frequently encountered in patients admitted to the intensive care unit with severe COVID-19 pneumonia, we think that there is no direct relationship with mortality in our study.
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Conflict of interest
1. Caron P. Thyroid disorders and SARS-CoV-2 infection: From pathophysiological mechanism to patient management. Ann Endocrinol (Paris). 2020;81(5):507-10.
2. Chen M, Zhou W, Xu W. Thyroid function analysis in 50 patients with COVID-19: a retrospective study. Thyroid. 2021; 31(1):8-11.
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Öznur Demiroluk, Yıldız Yiğit, Sevgi Alagöz, Arzu Yıldırım Ar. Relationship between thyroid function tests and mortality in severe Covid-19 pneumonia cases admitted to the intensive care unit. Ann Clin Anal Med 2022;13(6):626-629
Optic nerve sheath diameter measured by point-of-care ocular ultrasound in glaucoma patients
Turgay Yılmaz Kılıc 1, Yeşim Eyler 1, Bediz Ozen 2, Berna Yuce 2, Murat Yesılaras 1, Ozge Duman Atılla 1
1 Department of Emergency Medicine, 2 Department of Ophthalmology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
DOI: 10.4328/ACAM.21058 Received: 2022-01-18 Accepted: 2022-02-21 Published Online: 2022-02-22 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):630-634
Corresponding Author: Turgay Yılmaz Kilic, Department of Emergency Medicine, University of Health Sciences, Tepecik Training and Research Hospital, Gaziler Caddesi, Yenisehir, 35120, Izmir, Turkey. E-mail: email@example.com P: +90 232 469 69 69 F: +90 232 459 47 88 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3494-5120
Aim: In this study, we aimed to investigate the relationship of optic nerve sheath diameters measured by point-of-care ocular ultrasound between glaucoma patients with normal or high intraocular pressure and control subjects.
Material and Methods: All patients underwent a detailed ophthalmic examination for intraocular pressure measurement, anterior segment examination, and fundus examination. Optic nerve sheath diameter measurements with point-of-care ocular ultrasound were performed in B-mode with a linear probe. The ophthalmologists and emergency medicine attending physicians did not share any information about the examination findings and ultrasonographic measurements.
Results: Ninety-four glaucoma patients and 21 control subjects were included in the study. Optic nerve sheath diameters of glaucoma patients and control subjects were 4.2 mm (IQR=1.3) versus 4.3 mm (IQR=0.9) for the right eye (p=0.617), and 4.3 mm (IQR=1.1) versus 4.2 mm (IQR=1) for the left eye (p=0.728). Optic nerve sheath diameters of patients with high and those with normal intraocular pressure were 4.1mm (IQR=1.1) versus 4.2 mm (IQR=1.4) for the right eye (p=0.911), and 4.4 mm (IQR=1.4) versus 4.3 mm (IQR=1.2) for the left eye (p=0.221).
Discussion: Recent studies have reported that intracranial pressure may be effective in glaucomatous optic neuropathy. Ultrasonographic measurements of optic nerve sheath diameter for detecting elevated intracranial pressure were similar in patients with glaucoma and control subjects.
Keywords: Glaucoma, Intracranial Pressure, Optic Nerve Sheath Diameter, Ultrasound
Glaucoma is a multifactorial, chronic, and progressive optic neuropathy that can cause permanent blindness [1,2]. Although high intraocular pressure (IOP) plays an important role in the development and progression of glaucoma, the mechanisms of damage to the optic nerve are not fully known.
Since the optic nerve is surrounded by cerebrospinal fluid in the subarachnoid space, it is exposed not only to IOP but also to intracranial pressure (ICP). The authors reported different opinions on the role of ICP in glaucoma patients. While some of the studies have shown that ICP is lower in glaucoma patients than in healthy individuals, other studies have reported no difference in ICP in patients with and without glaucoma [3-8].
Ultrasonographic measurement of optic nerve sheath diameter (ONSD) is a rapid and non-invasive method for detecting elevated ICP in acute settings [9-11]. In this study, we aimed to investigate the relationship of ONSDs measured by point-of-care ocular ultrasound (PoCOUS) between glaucoma patients with normal (<20 mm Hg) or high (20 mm Hg) IOP and control subjects.
Material and Methods
This prospective, cross-sectional study was conducted between November 2018 and June 2019 in a tertiary urban training and research hospital. Ethical approval was obtained prior to the study (2018/7-15). Patient consent was obtained to participate in the study.
Study Setting and Population
Patients were included in the study by convenience sampling method. Patients aged 18 years and older who were admitted to the ophthalmology clinic and underwent a detailed ophthalmological examination by two ophthalmologists, experienced in glaucoma, were included in the study.
Patients with chronic steroid use, a diagnosis of pseudotumor cerebri, intracranial mass, major head trauma, a history of traumatic brain injury, and a history of cranial surgery, those younger than 18 years old and those who did not agree to participate in the study were excluded from the study. Patients with a history of previous eye surgery, neurological disease, eye trauma, any anterior or posterior segment disease other than glaucoma, patients with optically significant cataracts, > +3 dioptric or <-5 dioptricity refractive errors, patients whose IOP could not be measured and patients whose ONSD could not be measured by PoCOUS for any reason were also excluded from the study.
The control group was selected from those who admitted to the ophthalmology clinic, had no known family history of glaucoma, and had no eye surgery, including cataracts. There were no pathological findings in the ophthalmological examinations of the control group. In this study, ONSD was measured by PoCOUS in glaucoma patients and control subjects.
All patients (glaucoma patients and conrol subjects) underwent a detailed ophthalmic examination by two ophthalmologists (BY, BO) experienced in glaucoma. Intraocular pressure measurements were performed with Goldmann applanation tonometer, anterior segment examination was performed with a slit-lamp biomicroscope (Topcon; Tokyo, Japan), and fundus examination was performed with a 90 diopter lens. Intraocular pressure value of 20 mm Hg and above was considered high. Central corneal thickness (CCT) was measured using Topcon (Topcon CT-1P; Tokyo, Japan) automatic optical pachymetry. In order to avoid the diurnal variation effect, measurements were made between 9:00 and 11:00 a.m. and the median value of 3 measurements was taken. Central retinal nerve fiber layer (RNFL) thickness was measured with Spectralis optical coherence tomography (Heidelberg Spectralis; Heidelberg, Germany). Patients with previously defined characteristic optic nerve changes and visual field loss were considered glaucoma .
Ultrasonographic ONSD Measurement
Sonographic measurements of the ONSD were carried out by one of the two EM attending physicians (TYK, YE). Emergency medicine attending physicians participating in the study were experienced in ultrasonography and received a 4-hour theoretical and practical training on ocular ultrasonography before the study. These EM doctors also performed measurements of ONSD. To improve the competency of the sonographers, each sonographer performed ONSD measurement in predeﬁned test patients (in 25 cases).
The sonographer who carried out the ultrasonographic measurement was blind to the diagnosis and examination of the patient. Each sonographer recorded their results on independent data collection forms and did not know each other’s measurements. Before the ultrasonographic measurement, all patients were informed about the procedure and their written and verbal consents were obtained.
Optic nerve sheath diameter measurements with PoCOUS were performed in B-mode with a 10 MHz linear probe (Mindray M5; Mindray, Shenzhen, China). The measurements were made in the transverse plane, and the settings were adjusted to allow optimal visualization (frequency=7.5-10 MHz; depth=4-5 cm). With the patient supine (head of bed 0°), and the eyes closed and in the neutral position (the patients were asked to keep their eyes as steady as possible throughout the procedure), an ultrasound gel was applied on the eyelid and ultrasound imaging was performed without applying pressure on the eye. After imaging of the optic nerve sheath, 3 mm behind the optic disc was marked and ONSD measurement was carried out from the marked area (Figure 1).
The ophthalmologists and EM attending physicians did not share any information about the examination findings and ultrasonographic measurements. The first part of the patient data form (ophthalmic examination) was filled out by ophthalmologists and the second part (ONSD measurement) by the EM attending physicians. After the decision to terminate the study, all measurements were collected in a database and analyzed.
All statistical analyses were performed by two authors (MY, ODA) using Statistical Package for the Social Sciences version 24.0. Qualitative data were expressed as number of observations and percentages (%). Quantitative data were expressed as medians (minimum-maximum) and interquartile range (IQR). The Fisher’s Exact test was used for the analysis of qualitative data, and the Mann-Whitney U test was used for the comparison of continuous variables. All statistical analyses were performed at a 95% confidence interval. A p-value less than 0.05 was considered statistically significant.
Ninety-four glaucoma patients and 21 control subjects were included in the study (Figure 2).
The median age of glaucoma patients and the control group was 64 years (IQR=13 years; range=43–86 years) and 62 years (IQR=12 years; range=49–76 years), respectively (p=0.635). Fifty-four (57.4%) of the glaucoma patients and 13 (61.9%) of the control group were women. Intraocular pressure, ultrasonographic ONSD measurements and ophthalmic examination of glaucoma patients and control group are shown in Table 1. The data of glaucoma patients with high (≥20 mm Hg) and those with normal IOP (<20 mm Hg) are presented in Table 2. A comparison of ONSD and ophthalmic examination data is shown in Table 3.
In this study, we investigated the relationship between ONSDs measured by PoCOUS in glaucoma patients with normal (<20 mm Hg) or high (≥20 mm Hg) IOP. However, we did not find a significant difference between ONSDs measured by ultrasonography in glaucoma patients with normal or high IOP. Also, there was no statistically significant difference in measured ONSDs between glaucoma patients and control subjects.
Although glaucoma is the second leading cause of blindness globally, its pathogenesis is not fully understood. However, high IOP is still considered to be the most important risk factor for glaucoma. Normally, IOP is between 10 to 20 mm Hg. The increase in IOP (> 20 mm Hg) may cause damage by disrupting the perfusion of the optic nerve. Increased IOP causes glaucomatous damage by directly damaging the nerve fibers (mechanically) or by disrupting the microcirculation in the optic nerve head (ischemic), resulting in a decrease in optic nerve diameter. Although we found that IOP values in glaucoma patients were higher than in the control group, we did not find a statistically significant difference between the two groups. However, this result should not be interpreted as IOP does not contribute to the pathogenesis of glaucoma. The most likely reasons for this result may be that some of the patients receive glaucoma treatment, or the patients in the glaucoma group are normal tension glaucoma (NTG).
Although IOP is considered the main risk factor in glaucoma, authors have recently focused on the role of the ICP in glaucomatous optic neuropathy . Invasive techniques including lumbar puncture, the insertion of external ventricular drains or intraparenchymal monitors represent the gold standard in measuring ICP. Especially when repeated evaluations are required, difficulties in application, the complications such as bleeding, infection and pain, and the presence of contraindications such as coagulopathy cause non-invasive methods to be preferred over invasive methods in the evaluation of ICP. However, non-invasive gold standard ICP measurement techniques are not currently available. These non-invasive measurement techniques are based on the correlation between ICP values and physiological biomarkers. In recent years, ultrasonographic ONSD measurement has been the most studied option for screening measurements to detect elevated ICP . Due to impaired autoregulation in glaucoma patients, fluctuations in ICP may affect ocular blood flow and cause damage to the optic nerve. In several studies, it has been reported that reduced ICP causes progression in glaucoma patients [3,5,13]. The authors noted that patients with NTG had lower ICP compared to primary open angle glaucoma (POAG) and healthy controls. However, Lindén et al. stated that ICP is normal in patients with NTG . In this study, we did not find any difference in ultrasonographic ONSD measurements between glaucoma patients and control subjects. Although this result can be interpreted as no significant difference between the ICPs between the two groups, since the ultrasonographic ONSD measurement is known to be a sensitive indicator of ICP in acute settings, the time when measurements are made (acute vs chronic setting) should be considered. Therewithal, it should not be forgotten that effects of the drugs used by patients may also cause these results.
One of the most important factors in the evaluation of IOP is CCT . However, CCT can be affected by many factors, including age, treatment and subtype of glaucoma. Intraocular pressure can be measured lower in thin corneas and higher in thicker corneas. Although CCT was found to be thinner in glaucoma patients compared to the control subjects in this study, there was no statistically significant difference.
The main limitations of our study are that the patients in the study group were not divided into subgroups (POAG, NTG), the low number of subjects in the control group, and the high number of exclusion patients. Statistical analysis was not performed between newly diagnosed glaucoma patients and patients with a known history of glaucoma. Another important limitation of our study is that ICP measurement is not performed in patients by any invasive method, such as lumbar puncture.
The ONSDs measured by ultrasonography in glaucoma patients and control subjects, and in glaucoma patients with normal or high IOP were similar to each other in this study. Although this result can be interpreted as no significant difference between the ICPs, the time when ONSD measurements are made (acute vs chronic setting) and the drugs used by the patients should be considered.
The authors thank the patients who participated in this study and their relatives.
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Animal and human rights statement
Conflict of interest
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6. Lindén C, Qvarlander S, Jóhannesson G, Johansson E, Östlund F, Malm J, et al. Normal-Tension Glaucoma Has Normal Intracranial Pressure: A Prospective Study of Intracranial Pressure and Intraocular Pressure in Different Body Positions. Ophthalmology. 2018;125(3):361–8.
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8. Pircher A, Remonda L, Weinreb RN, Killer HE. Translaminar pressure in Caucasian normal tension glaucoma patients. Acta Ophthalmol. 2017;95(7):e524–31.
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15. Mansoori T, Balakrishna N. Effect of central corneal thickness on intraocular pressure and comparison of Topcon CT-80 non-contact tonometry with Goldmann applanation tonometry. Clin Exp Optom. 2018;101(2):206-12.
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Turgay Yılmaz Kılıc, Yeşim Eyler, Bediz Ozen, Berna Yuce, Murat Yesılaras, Ozge Duman Atılla. Optic nerve sheath diameter measured by point-of-care ocular ultrasound in glaucoma patients. Ann Clin Anal Med 2022;13(6):630-634
The effect of childbirth fear and anxiety in the Turkish population on maternal self-efficacy for breastfeeding: A survey study
Bakiye Akbaş 1, Gülten Sağır 2, Sevim Atalar 2, Özgür Özdemir 3, Zeliha Aydın Kasap 4
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Istinye University, Istanbul, 2 Department of Obstetrics and Gynecology, Trabzon Kanuni Training and Research Hospital, Trabzon, 3 Department of Obstetrics and Gynecology, Trabzon Private 7 M Hospital, Trabzon, 4 Department of Biostatistics and Medical Informatics, Karadeniz Technical University, Trabzon, Turkey
DOI: 10.4328/ACAM.21064 Received: 2022-01-14 Accepted: 2022-02-15 Published Online: 2022-04-05 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):635-639
Corresponding Author: Bakiye Akbas, Department of Obstetrics and Gynecology, Faculty of Medicine, Istinye University, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 0532 240 81 07 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2480-1374
Aim: The aim of the present study was to investigate the effects of childbirth fear and anxiety experienced by pregnant patients in the prenatal period on breastfeeding self-efficacy of mothers in the postpartum period.
Material and Methods: This prospective cross-sectional study included pregnant patients at later stages of pregnancy between the 38th and 42nd weeks who had regular pregnancy follow-ups at the Obstetrics Outpatient Clinic in Turkey, who had no problems with pregnancy, had no psychiatric disorders, gave vaginal birth and agreed to participate. Under the physician’s supervision, the patients were asked to complete the Visual Analog Scale (VAS) to measure fear of childbirth and the Beck Anxiety Inventory to assess their anxiety. In addition, the breastfeeding and breast milk arrival status of the patients were evaluated using Breastfeeding Self-Efficacy Scale on the first day of the postpartum period. Correlations of the obtained data were analyzed with Pearson’s or Spearmen’s correlation tests.
Results: It was observed that the Beck Anxiety Inventory score and VAS score measured in the prenatal period in 211 patients who participated in the study had negative correlations with breastfeeding status of patient in the postpartum period. Based on the results of this study, patients with intense fear of childbirth and patients with high anxiety during the prenatal period had low breastfeeding self-efficacy during the postpartum period.
Discussion: It is necessary that pregnant patients with fear of childbirth and with a high level of anxiety should be identified by their physicians during the prenatal follow-ups. Education programs should be organized to meet the needs of the parents, and support groups should be established for these parents. Further studies are needed in this regard.
Keywords: Beck Anxiety Inventory Score, Pregnancy, Postpartum Period, VAS
Pregnancy is a unique process in which biopsychosocial changes occur and a woman prepares for birth action and parenthood by adapting to these changes. In parallel with the developments in healthcare today, pregnancy, childbirth and postpartum processes result in relatively few complications, but many women experience fear of these processes . Women who are afraid of the pain during childbirth and who do not receive adequate support from healthcare personnel in this regard experience pain during childbirth more intensely. Previous studies indicated that sensory, emotional and psychosocial factors are associated with pain experienced at birth [2-4]. One of these psychosocial factors is anxiety .
It is important for the health of the baby that the mother can take care of, communicate with and breastfeed the baby in a healthy way during the postpartum period. Previous studies showed that mothers who experience anxiety and depression during pregnancy are more unsuccessful in managing the breastfeeding process [5-6]. Breastfeeding self-efficacy perception is the competence the mother feels about breastfeeding. It was reported that mothers with low breastfeeding self-efficacy are much more prone to depression in the postpartum period . Zubaran et al. indicated that prenatal anxiety and depression caused mothers to have a much lower level of confidence in breastfeeding during the postpartum period . We hypothesized that prenatal childbirth fear and anxiety would negatively affect postpartum breastfeeding self-efficacy.
Thus, the aim of the present study was to investigate the effects of the childbirth fear experienced by pregnant patients in the prenatal period and the patient’s anxiety on mother’s breastfeeding self-efficacy in the postpartum period.
Material and Methods
The study was prospective cross-sectional and was conducted between September 2018 and September 2020 after receiving the approval of the local ethics committee. The study consisted of female patients over the age of 18 who had been followed up in the Obstetrics and Gynecology outpatient clinic of Medical Park Yıldızlı Hospital, Trabzon/Turkey who gave vaginal birth and who met the inclusion criteria for the study. The study was started after obtaining written and oral consent from the patients. The patients who had coagulopathy and infection during their prenatal follow-ups, problematic pregnancy period, psychiatric disorder or additional systemic disease, treated for a chronic pain disorder, who received long-term opioid treatment, who did not have regular pregnancy follow-ups, and who were not willing to participate in the study were excluded. Pregnant patients who did not meet the above-defined exclusion criteria in the 38-42 weeks of pregnancy were included.
Evaluation of the Patients for mentioned scores and scales
The patients were questioned in the room where the outpatient examination was performed during a period before the labor was started. They were asked about their age, number of pregnancies, gestational week, educational status, employment status, income level, whether the pregnancy was planned, whether the patient was trained for pregnancy, whether the patient had regular follow-ups, whether maternal and/or fetal diseases due to pregnancy developed, previous birth features, if any, (first birth, normal birth, cesarean delivery, etc.), the desired delivery method for the present pregnancy (vaginal birth) and whether the patient had problems with previous pregnancies. In addition, under the supervision of a physician, patients were asked to complete the Visual Analog Scale (VAS) to measure fear of childbirth and the Beck Anxiety Inventory to assess their anxiety. The delivery method (normal birth, epidural birth, cesarean delivery), the onset of the act of childbirth (spontaneous or induction), duration of labor in normal births (latent stage, active stage) were recorded by the physician during the peripartum period. In addition, the breastfeeding and milk arrival status of the patient on the first day of the postpartum period was evaluated using the Breastfeeding Self-Efficacy Scale. All measurements and evaluations were made by a physician who was an obstetrician.
Visual Analog Scale (VAS) used to measure fear of childbirth
VAS is a scale, and it can be used to measure the fear of childbirth in pregnant patients. VAS consists of a 10-cm long line with two ends named differently and is quite easy to use. Women were asked to rate pain from zero to 10. A zero point means no pain, while 10 refers to the most severe pain experienced. VAS is also a valid and reliable tool for measuring other subjective emotions such as pain and mood . For this reason, VAS can be easily used to measure women’s fears both during pregnancy and at birth.
Beck Anxiety Inventory (BAI)
BAI measures the frequency of anxiety symptoms experienced by an individual. It is a Likert- type self-evaluation scale consisting of twenty-one items, scored between 0 and 3. Higher total scores indicate higher anxiety levels experienced by the individual. It was developed by Beck et al . and a Turkish validity and reliability study was carried out by Ulusoy et al . The aim of the Beck Anxiety Inventory is to perform screenings rather than making diagnoses. The questions in the Beck Anxiety Inventory are related to anxiety symptoms. The person who takes the scale answers the questions by selecting one of four options: “not at all”, “mildly”, “moderately or “severely”. The options were decided in the final week. The sample of the scale used in this study Cronbach’s Alpha coefficient was found to be .93 for.
Breastfeeding Self-efficacy Scale
The early form of the scale developed by Dennis et al  to assess the breastfeeding self-efficacy levels of mothers consisted of 33 items. A short form of the scale was later created in 2003. This scale consists of a total of 14 items that evaluate the mother’s breastfeeding self-efficacy. Dennis recommends this short form for use. It is easier to apply and evaluate self-sufficiency correctly. The scale is a five-point Likert type and the items of the scale are rated from 1: “not at all confident” to 5: “always confident”. The lowest score on the scale is 14 and the highest is 70. Higher scores indicate higher breastfeeding self-efficacy. Dennis stated that it is appropriate to use the scale in the postpartum period. Aluş et al.  performed the Turkish reliability – validity study of the short form of breastfeeding self-efficacy scale and found a Cronbach’s alpha value of 0.86, indicating that the scale is suitable for Turkish culture.
In the study, the Visual Analog Scale (VAS) was used to evaluate the fear of childbirth, the Beck Anxiety Inventory was used to measure the anxiety levels, and the Breastfeeding Self-Efficacy Scale was used to evaluate the breastfeeding self-sufficiency levels of mothers. The conformity of the data to the normal distribution was evaluated by considering the Kolmogorov- Smirnov test, and then the coefficients of skewness and kurtosis. Descriptive statistics of continuous variables were expressed as mean ±standard deviation, while the distribution of categorical variables was expressed as numbers and percentages. Parametric tests (Independent Samples t-test and One-Way ANOVA test) were used to compare the means of the variables. The relationships between the variables were analyzed using correlation test. Multiple linear regression models were established to predict breastfeeding self-efficacy using independent variables. Dummy variables were created for the categorical variables and included in the model, and assumptions of multiple linear regression analysis were shown in a step-wise fashion. P values obtained as a result of statistical analyses were evaluated at α= 0.05 significance level and 95% confidence interval. Comparisons were considered statistically significant when p-values were less than 0.05. For statistical analyses of the data set, IBM SPSS Statistics 22 software was used.
The study included 211 pregnant women aged 18-42 who gave birth (Table 1). The data showed that factors such as the educational and employment status of the mother, whether the pregnancy was planned, whether a previous pregnancy was problematic, whether the mother received training about breastfeeding, and whether the baby received additional food had no significant effect on the mother’s breastfeeding self-efficacy status (p>0.05) (Table 2). However, the income level affected average breastfeeding self-efficacy scores. Breastfeeding self-efficacy scores of mothers with higher income levels were also higher (p=0.047) (Table 2).
Pearson’s correlation analysis showed a significant positive relationship between the VAS score used to measure fear of childbirth and Beck Anxiety Inventory score (r=0.877, p<0.001) (Table 3) (Figure 1A). On the other hand, there was a negative significant relationship between VAS scores and Breastfeeding Self-Efficacy scale scores (r=-0.858, p<0.001) (Table 3, Figure 1B). Similarly, the correlation between the Beck Anxiety Inventory score and Breastfeeding Self-Efficacy scores was also significant and negative (r = -0.853, p<0.001) (Table 3, Figure 1C).
In the present study, it was observed that factors such as the employment status, whether the pregnancy was planned, whether the previous pregnancy was problematic, whether training for breastfeeding was received, and whether the baby had additional food, did not have significant effect on breastfeeding self-efficacy levels of women. However, mothers with higher income levels had significantly higher breastfeeding self-efficacy scores. Breastfeeding self-efficacy measured during the postpartum period had significant negative correlations with the Beck Anxiety Inventory score, measured in the prenatal period and the VAS score, used to measure fear of childbirth.
Fear of childbirth refers to the fears related to childbirth experienced before, during and after childbirth. While the acceptable levels of fear in the prenatal period could help stimulate mother to prepare for childbirth, a pathological level of fear is called tokophobia . Fear of childbirth is common in society, and most women experience mild to moderate fear of childbirth especially in the prenatal period. Severe fear of childbirth is less common, but it is very important for maternal health in terms of its outcomes [15,16]. A Swedish study by Zar et al. in 2001 indicated that one in five pregnant women suffered from the fear of childbirth, and 5% experienced serious psychological problems such as anxiety and depression due to fear of childbirth . Poikkeus et al. , on the other hand, reported that 6-13% of women had severe fear of childbirth, and that women could not cope with this fear. Similarly, Fenwick et al. found that 26% of women experienced low birth anxiety, 48% had moderate and 26% high levels of childbirth fear and consequent anxiety . In a study conducted in Turkey, 38.8% of the participants experienced severe fear and 8.2% experienced clinical level of fear .
Gao et al.  found that a high level of patient anxiety during the prenatal period increases the fear of childbirth. In patients who were psychologically weak but whose anxiety and depression statuses were improved with supportive treatment, this fear decreased . In a similar study, Fairbrother et al.  reported that post-traumatic stress disorder during pregnancy increases the fear of childbirth. Soderquist et al. , on the other hand, mentioned that this fear decreased in patients treated for stress-related anxiety and depression. Fear of childbirth has many negative consequences in prenatal, pregnancy, and postpartum periods for the mother-child relationship. There are numerous studies in the literature reporting that the fear of childbirth observed in the prenatal period causes negative consequences in pregnant women such as excessive tension, absent-mindedness, anxiety, depression and premature birth [23,24]. This may also affect the postpartum period, with negative consequences such as delayed mother-baby interaction, breastfeeding problems, newborn-related problems and postpartum depression . In their study, Rouhe et al.  stated that one of the two most important factors for poor mother-infant interaction, inability to provide milk and need to take psychiatric care in postpartum period, is fear of childbirth. Thus, the results of the present study appear to be compatible with the literature. We observed that the Beck Anxiety Inventory score of our pregnant patients measured in the prenatal period had a significant positive correlation with the VAS score used to measure fear of childbirth. In addition, we observed that the maternal breastfeeding self-efficacy level measured to evaluate the breastfeeding status of postpartum patients had significant negative correlations with anxiety and fear of childbirth measured in the prenatal period.
The most important limitation of the study is that it was conducted in a single center and with a small number of patients. Prospective randomized studies on this subject will provide great benefits in terms of maternal and child health in the postpartum period.
Based on the results of the present study, the patients with high childbirth fear and anxiety levels during the prenatal period had low breastfeeding self-efficacy during the postpartum period. For this reason, pregnant patients with high levels of childbirth fear and with high anxiety levels should be identified by physicians during the regular follow-ups in the prenatal period, and education programs should be organized and support groups should be established to meet the needs of parents. It is recommended that the education programs to strengthen the perception of breastfeeding self-efficacy should start in the antenatal period, and physicians should be aware of this situation, be more sensitive to this group and organize more intensive training programs towards them. Further studies are needed in this regard.
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Animal and human rights statement
Conflict of interest
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14. Alus T, Okumuş H. Emzirme öz-yeterlilik algısını güçlendirmeye temelli antenatal eğitimin emzirme öz-yeterlilik algısına ve emzirme başarısına etkisi (The effect of antenatal education based on strengthening the perception of breastfeeding self-efficacy on breastfeeding self-efficacy perception and breastfeeding success). Hemşirelikte Eğitim ve Araştırma/ Education and Research in Nursing. 2013;10(1):21-9.
15. Zar M, Wijma K, Wijma B. Pre- and Postpartum Fear of Childbirth in Nulliparous and Parous Women. Scandinavian Journal of Behaviour Therapy. 2001 May;30(2):75–84.
16. Larsson C, Saltvedt S, Wiklund I, Andolf E. Planned vaginal delivery versus planned caesarean section: short-term medical outcome analyzed according to intended mode of delivery. J Obstet Gynaecol Can. 2011; 33(8): 796-802.
17. Poikkeus P, Saisto T, Unkila-Kallio L, Punamaki R-L, Repokari L, Vilska S, et al. Fear of childbirth and pregnancy-related anxiety in women conceiving with assisted reproduction. Obstetrics and gynecology. 2006 Jul;108(1):70–6. 18. Fenwick J. Gamble J, Nathan E, Bayes S, Hauck Y. Pre and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs. 2009; 18(5):667-77.
19. Bülbül T, Özen B, Çopur A, Kayacık F. Gebelerin doğum korkusu ve doğum şekline karar verme durumlarının incelenmesi (Examination of the pregnant women’s fear of birth and their decision to give birth method). Sağlık Bilimleri Dergisi/ Journal of Health Sciences. 2016; 25:126-30.
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Bakiye Akbaş, Gülten Sağır, Sevim Atalar, Özgür Özdemir, Zeliha Aydın Kasap. The effect of childbirth fear and anxiety in the Turkish population on maternal self-efficacy for breastfeeding: A survey study. Ann Clin Anal Med 2022;13(6):635-639
Investigation of CerbB2 at mRNA level in patients with gastric adenocarcinoma
Ezgi Işıl Turhan 1, Seçil Ak Aksoy 2, Nesrin Uğraş 3, Berna Aytaç Vuruşkan 3, Berrin Tunca 2, Özgen Işık 4, Ömer Yerci 3
1 Department of Pathology, Bursa City Hospital, 2 Department of Medical Biology, Faculty of Medicine, Uludag University, 3 Department of Pathology, Faculty of Medicine, Uludag University, 4 Department of General Surgery, Faculty of Medicine, Uludag University, Bursa, Turkey
DOI: 10.4328/ACAM.21065 Received: 2022-01-15 Accepted: 2022-02-21 Published Online: 2022-03-01 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):640-644
Corresponding Author: Ezgi Işıl Turhan, Department of Pathology, Bursa City Hospital, Bursa, Turkey. E-mail: email@example.com P: +90 506 357 01 12 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9532-3854
Aim: Gastric adenocarcinomas take place near the top regarding mortality due to cancer. This study aims to validate IHC results with the RT-PCR method and to evaluate their contribution to confirm the absolute score of CerbB2 situation in tissues.
Material and Methods: We analyzed 80 gastric adenocarcinoma cases diagnosed in our clinic. The expression characteristics of the cases were evaluated using CerbB2 staining. Simultaneously, CerbB2 expression analyses were performed with the RT-PCR method.
Results: Positive immunoreactivity was observed in 19 of 80 cases (23,75%) in the study conducted using CerbB2 antibody. While 14 of these cases (17.5%) demonstrated weak positive (2+), 5 of them (6.25%) demonstrated strong positive (3+) immunoreactivity. With the RT-PCR method, an increase in gene expression was observed in 12 of 14 weak positive cases (75%). In all 5 strong positive cases, on the other hand, high gene expression was determined. Between CerbB2 immunohistochemical findings and gene expression, 89% compatibility and a statistically significant relationship was determined. While an increase in CerbB2 gene expression, determined by Real Tirme PCR method, was not observed in 57 of 61 cases (96.6%) without CerbB2 immunoreactivity, 4 cases had an increase in CerbB2 expression in comparison to normal.
In our study, a statistically significant relationship was determined between CerbB2 expression and Helicobacter pylori (H. pylori) that is a factor blamed for gastric cancer etiology. The relationship between CerbB2 expression and clinicopathologic prognostic factors has been statistically reviewed; no significant results have been found.
Discussion: Our study has shown that RT-PCR is a method, which might be an alternative to IHC and in ISH methods. It is concluded that a statistically significant relationship might be determined between CerbB2 expression and clinicopathologic prognostic parameters by increasing the case number.
Keywords: Gastric Adenocarcinoma, CerbB2, Immunohistochemistry, Clinicopathologic, PCR
Gastric cancer, although its prevalence and incidence in developed countries has reduced in the last 50 years, still remains the fourth most common cancer worldwide and the second leading cause of death from cancer [1,2]. Although early-diagnosed cases are common in Asian societies; in many societies, patients apply with advanced non-operable or metastatic disease . The development of gastric cancer is a multi-stage, complex process including various genetic and epigenetic changes . Human epidermal growth factor receptor 2 (HER-2/CerbB2) is a member of epidermal growth factor receptor (EGFR) family and codes a transmembrane receptor glycoprotein, which has protooncogene tyrosine kinase activity. When this gene gets phosphorylated, tyrosine kinase activity emerges, signals associated with cell proliferation and differentiation develop. As a result of the overexpression of this receptor protein or the amplification of the gene, many malignancies, particularly breast and gastric cancer emerge . According as the breast cancer, chemotherapy combined with Trastuzumab improves survival in gastric and gastroesophageal junction cancer cases .
HER-2 situation must be correctly established in order to include Trastuzumab, developed against HER-2 receptor, in treatment protocols, especially in breast cancer cases . Essential methods applied in routine practice in determining HER-2 in tumor cells are immunohistochemical studies (IHC) and in situ hybridization modalities. While currently the most commonly used in situ hybridization method is fluorescent in situ hybridization (FISH) technic, the results obtained by these modalities are not always totally compatible with each other. Gene amplification does not result in protein expression indicated as immunohistochemical all the time. Gene amplification might not be detected every time in the presence of protein expression .
Recently, it has been shown that m-RNA levels in formalin-fixed paraffin-embedded tissues might be quantified using Real-Time Polymerase Chain Reaction (RT-PCR) to determine HER-2 expression . Quantitative RT-PCR is a molecular technic allowing the quantitative assessment of mRNAs transcribed from the gene . RT-PCR is a method providing quantitative results by measuring the fluorescent signal increasing simultaneously with the nucleic acid amplification.
Literature studies on whether the HER-2 situation is a prognostic biomarker report that it is not associated with the clinicopathologic parameters such as age, gender, tumor size, histological differentiation degree; however, it is associated with prognostic parameters such as invasion depth, lymph node involvement, TNM stage [5,10].
Our study aims to validate the immunohistochemistry results based on qualitative data used to determine HER-2 activation in gastric adenocarcinomas with RT-PCR method based on quantitative data, and to evaluate the contribution of this method to confirm the results in grey-zone cases and its relationship with clinicopathologic parameters.
Material and Methods
The cases operated due to gastric tumor and diagnosed in our pathology department as primary gastric adenocarcinoma between 2011 and 2015 were included in our study. Preparations of all cases were re-evaluated by two pathologists and reviewed in regard to histological tumor type, pathologic tumor stage, tumor degree, regional lymph node involvement, histopathologic findings such as the presence of lymphovascular and perineural invasion, concomitant intestinal metaplasia, helicobacter pylori and the staging according to the American Joint Committee on Cancer (AJCC). The size, adequacy of the tissues, and the quality of fixation and processing were evaluated and reviewed. Information on age, gender and clinical data were obtained from the hospital database. Inclusion and exclusion criteria were determined.
The inclusion criteria were as follows:
a. Being diagnosed as gastric adenocarcinoma
b. Being a sporadic case
c. Having multiple paraffin-embedded blocks of tumor tissue after the resection;
The exclusion criteria were as follows:
a. Cases with types such as gastric carcinoma with mucinous/mucinous component, carcinoma with signet ring cell/signet ring cell component, undifferentiated carcinomas, mesenchymal tumors, mixed carcinomas, undifferentiated carcinomas and rare histological variants
b. The presence of cancer in family history
c. Existence of single paraffin block of tumor tissue after the resection
d. Tissues with poor quality of fixation and processing
In consideration of all these examinations, 80 cases with obtainable slides and blocks, diagnosed as gastric carcinoma in Uludağ University Faculty of Medicine, Department of Pathology between 2011-2015 were included in the study group.
The study was approved by the Uludağ University Faculty of Medicine Ethics Board of Clinical Researches dated 19.07.2017 and numbered 2017-10/24.
A single block representing the tumor morphology the best was chosen for each case from the formalin-fixed paraffin embedded preparations of 80 cases. Sections 4 micrometer-thick were cut from the blocks for immunohistochemical examination. CerbB2 clone CB11 (1:150, Novocastra, Newcastle, United Kingdom) was used in immunohistochemical examination. After leaving for 1 hour in the oven (ETUV) in immunohistochemical laboratory, blocks were processed in the automatic immunohistochemical staining device (Leica Microsystems, Berlin, Germany). Breast cancer tissue had been used as external control block for CerbB2 antibody.
According to the criteria determined in the international and randomly controlled phase 3 study participated involving 122 centers from 24 countries, Trastuzumab for Gastric Cancer (ToGA), CerbB2 antibody staining values were evaluated by scoring between 0 and +3 .
Accordingly, resection materials were reviewed as follows:
Score 0: There is no staining or there is membranous staining in less than 10% of the tumor cells
Score 1+: pale/weak; partial membranous staining in more than 10% of the tumor cells
Score 2+: weak/moderate; complete/basolateral membranous staining in more than 10% of the tumor cells
Score 3+: strong; complete/basolateral/lateral membranous staining in more than 10% of the tumor cells
Score 0-1 was considered as immunoreaction-negative, Score 2+ weak positive immunoreaction and Score 3+ strong positive immunoreaction.
All cases’ tissues, which are tumor cell-rich and compatible with normal sites were cut from the blocks in size of 0.2-0.4 cm. Materials were cleared of paraffin by being treated with BIOstic (MO BIO Laboratories, Carlsbad, CA) twice. After resolving paraffin on the tissues with BIOstic, materials were passed through stages of 100%-70% and 40% alcohol and alcohol was vaporized at room temperature. After these steps, RNA isolation from the tumorous tissue samples of 80 patients and 70 normal gastric tissue samples was performed according to the procedure using the commercial kit (Qiagen RNeasy FFPE kit) suitable for the RNA isolation from the paraffin block.
The quantity and quality of obtained RNAs were measured using a Spectrometer device (Beckman Coulter). Complementary DNA (cDNA) was obtained from 5 ng of total RNA using ProtoScript M-MuLV First Stand cDNA Synthesis Kit. The reaction mixture was prepared into a 0.2 μl PCR tube for each study specimen.
Acquired mixture was mixed by pipetting and span in a centrifuge. The mixture in PCR tube was incubated for 2 hours at 37°C. After the incubation, the obtained cDNAs were transferred in volumes of 90 μl dH2O in each PCR tube containing reaction mixture and mixed, then stored at -20°C until the following step.
Primers associated with CerbB2 determined to be used in our study were chosen from the literature. Fluorescent tagged (with Taqman probe) primers were used to determine and evaluate the specific PCR product formed during PCR cycle simultaneously.
Ct values of mRNA expressions were obtained from the Abi Step One Plus Real-Time PCR device database. In this study, by determining the Ct value of the Glyceraldehyde 3-phosphate dehydrogenase (GAPDH) gene used as a housekeeping gene, the data obtained from PCR Array were normalized. Gene expression results were given as increased/no gene expression
The compatibility of variables to normal distribution was analyzed with the Shapiro- Wilk test. Continuous variables were presented as median (minimum: maximum) values. Categorical variables were reported as n (%). According to test of normality, two independent sample Mann-Whitney test was used in comparison of two groups, independent samples the Kruskal-Wallis test was used in comparisons of three groups, the Pearson chi-square test, Fisher’s exact chi-square test and Fisher-Freeman-Halton tests were used in inter-group comparisons of categorical variables. SPSS program (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used for statistical analysis, and p-value of <0.05 was considered as statistically significant.
Demographic and Clinicopathologic Characteristics of Cases
The study included 80 gastric adenocarcinoma cases, 60 males (75%) and 20 females (25%). The age distribution of the cases was between 43 and 88 with the median of 55.2. When histological differentiation degree of tumors (grade) was reviewed, 1 case (1.3%) was well-differentiated (grade 1), 33 were (41.3%) moderate-differentiated (grade 2), 46 (57.5%) were poor differentiated (grade 3). When the cases were evaluated according to pathologic tumor stage (pT), 8 cases were (10%) pT1, 6 (7.5%) were pT2, 50 (62.5%) were pT3, 16 (20%) were pT4. While lymph node involvement was not observed in 22 of the cases (27.5%), 58 (72.5%) had lymph node involvement; 21 cases (26.3%) had lymphovascular invasion and 38 (47.5%) had perineural invasion. Intestinal metaplasia was not observed in 38 cases (47.5%). Among the remaining 42 cases, 35 (43.8%) had complete intestinal metaplasia, 1 (1.3%) had incomplete enteric intestinal metaplasia, 6 (7.5%) had incomplete colonic intestinal metaplasia. H. pylori was detected in 6 cases (7.5%).
Comparison of CerbB2 Expression Level Detected by Immunohistochemistry and RT-PCR Method
According to immunohistochemical examination results, 5 cases (6.2%) had 3+, 14 (17.5%) had 2+, 61 (76.3%) had 0/1+ (Figures 1, 2, 3). While an increase in CerbB2 gene expression determined by the Real Time PCR method was not observed in 57 of 61 cases (96.6%) without CerbB2 immunoreactivity, 4 cases had an increase in CerbB2 expression in comparison to normal. While no difference in gene expression determined by the RT-PCR was observed in 2 of 14 (25%) weak positive cases (staining score 2+), 12 cases (75%) has shown increased gene expression. High CerbB2 gene expression was determined by RT-PCR method in all 5 cases with strong CerbB2 immunoreactivity (staining score 3+). A statistically significant relationship between CerbB2 immunohistochemical findings and gene expression was observed with 89% compatibility (p<0.05) (Table 1).
CerbB2 Expression Determined by RT-PCR and Its Relationship with Clinicopathologic Parameters
What is more, when considering the effect of CerbB2 gene expression level determined by RT-PCR on demographic and clinicopathologic parameters in regard to pathologic tumor stage, a statistically significant difference is observed between groups (p<0.05). pT3 frequency is observed to be higher in the group without an increase in their CerbB2 gene expression.
No significant relationship has been demonstrated between other demographic and clinicopathologic parameters (age, gender, tumor diameter, tumor degree, regional lymph node involvement, the presence of lymphovascular and perineural invasion, concomitant intestinal metaplasia, helicobacter pylori) and CerbB2 gene expression level (Table 2).
Bosard et al.  reported that RT-PCR is an alternative method to determine HER-2 situation, by detecting 84% compatibility between HER-2 protein expression and gene amplification in their study, which examines the immunohistochemistry and PCR results of 44 breast cancer cases. Our study aims to contribute to the treatment of gastric adenocarcinoma cases, analyzing HER-2 protein expression at gene amplification level by PCR as an alternative method instead of immunohistochemistry, and revealing the expression in grey zone cases, when immunohistochemistry failed to detect. Zhu et al.  has determined CerbB2 positivity with immunohistochemistry as 13.38% (57/426) and with PCR as 11.7% (46/412) in their study on the comparison of quantitative PCR and semi-quantitative immunohistochemistry results. They have reported positive protein expression with PCR method in 4 cases, when immunohistochemistry failed to detect expression and reported 91% compatibility between immunohistochemistry and PCR. In our study, CerbB2 positivity with immunohistochemistry is 23.75% (19/80) and 26% (21/80) with PCR. The compatibility between these two methods, in accordance with the literature, is near 89% (p<0.05). Our study determined HER-2 expression with PCR in 4 immunohistochemically negative cases (3.4%). In the literature, it has been reported that HER-2 situation is not associated with clinicopathological parameters such as age, gender, tumor size, histological differentiation degree; however, it is associated with prognostic parameters such as invasion depth, lymph node involvement, tumor stage. Yan et al.  determined that HER-2 situation is associated with invasion depth, TNM stage, lymph node involvement and distant metastasis; however, it is not associated with clinicopathological parameters such as age, gender, tumor size, histological differentiation and localization. Similarly, Zhu et al.  showed that HER-2 protein expression is associated with invasion depth, lymph node involvement and TNM stage; nevertheless, it is not associated with tumor localization, age, gender, histological differentiation degree. Rajagopal et al.  determined statistically significant relationship between HER-2 expression and male gender in their study (p=0.006). They attributed this result to the greater number of male patients and the higher prevalence of gastric cancer in men. In the same study, a significant relationship has been determined between HER-2 expression and intestinal type and moderately differentiated (Grade 2) tumors. Cases without HER-2 gene expression were determined to have high pT3 frequency in our study (p<0.05). However, no statistical significance was detected in the other comparisons of the groups. No statistically significant relationship has been determined between HER-2 expression and clinicopathological parameters such as age, gender, tumor size, histological differentiation degree, the presence of lymph node involvement, distant metastasis, vascular invasion and perineural invasion. The lack of a statistically significant relationship with parameters such as lymph node involvement, TNM stage, distant metastasis might result from our small study sample. While the study by Zhu et al.  is one of the largest-scale (426 cases) studies comparing HER-2 situation with clinicopathological parameters, Yan et al.  included 476 patients from several centers.
CerbB2 is the only biomarker used to determine the indication of Trastuzumab, which is one of the standard treatment protocols in advanced stage gastric adenocarcinoma [13,14]. Currently, HER-2 activation is determined using immunohistochemical analysis and in situ hybridization tests in routine practice. Tissues removed after resection and endoscopic intervention are examined primarily with immunohistochemistry. The results are scored in four steps as 0, +1, +2 and +3 according to HER-2 protein quantity stained in tissue. Scores 0 and +1 are defined as HER-2-negative and there is no indication for Trastuzumab treatment in patients with these tumors . While ISH is recommended in cases of immunohistochemical staining score of +2, Trastuzumab treatment is applied to cases with immunohistochemical staining score of +3. However, despite the fact that immunohistochemistry and ISH are used in routine practice, considering their disadvantages such as taking long time, expensiveness and unsuitableness to analyze multiple samples, further studies still continue in an effort to determine a gold standard method . Also, both methods are based on qualitative data and vary in regards to standardization. Therefore, quantitative methods are suitable for the validation of immunohistochemistry and ISH tests.
Consequently, it has been demonstrated that RT-PCR method is an alternative to IHC and ISH methods and these modalities complement each other. Besides, in accordance with the literature, our study has shown that RT-PCR might be a method to clarify the grey zone cases, which may be missed by immunohistochemistry. Undoubtedly, a correct and reliable examination is required due to the direct relationship of HER-2 expression with treatment. In our study, it has been concluded that the relationship between HER-2 expression and clinicopathological parameters might be detected if a larger-scale study is conducted.
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Conflict of interest
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7. Kunte S, Abraham J, Montero AJ. Novel HER2-targeted therapies for HER2-positive metastatic breast cancer. Cancer. 2020; 126(19):4278-88.
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Download attachments: 10.4328.ACAM.21065
Ezgi Işıl Turhan, Seçil Ak Aksoy, Nesrin Uğraş, Berna Aytaç Vuruşkan, Berrin Tunca, Özgen Işık, Ömer Yerci. Investigation of CerbB2 at mRNA level in patients with gastric adenocarcinoma. Ann Clin Anal Med 2022;13(6):640-644
Serum Lactate as a predictor of in-hospital mortality in patients with sepsis
Ahmed Farhan, Ali Sufyan, Muhammad Awais Tahir, Arslan Ahmad, Sara Manzoor
Department of Internal Medicine, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
DOI: 10.4328/ACAM.21068 Received: 2022-01-20 Accepted: 2022-02-23 Published Online: 2022-03-02 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):645-648
Corresponding Author: Ahmed Farhan, Department of Internal Medicine, Pakistan Institute of Medical Sciences, Islamabad, Pakistan. E-mail: firstname.lastname@example.org P: +92 348 554 49 84 Corresponding Author ORCID ID: https://orcid.org/0000-0001-5068-9369
Aim: Sepsis is one of the leading causes of mortality and morbidity in health care setups. Various parameters have been investigated in sepsis. Non-invasive parameters such as serum albumin, serum lactate, and lactate to albumin ratio may be of clinical importance in predicting mortality in hospitalized patients.
Material and Methods: A descriptive prospective study was conducted at the medical wards of the Pakistan Institute of Medical Sciences. Baseline parameters including ESR, creatinine, TLC count, Percentage neutrophils, serum albumin, and lactate levels of patients who met inclusion criteria were taken and followed up until the outcome in hospital, i.e., discharge or mortality.
Results: One hundred fifty-six patients were enrolled; mortality was 24.4%. Mean TLC count and albumin levels were lower in the mortality group, while percentages of neutrophils, creatinine, lactate, and lactate to albumin ratio were higher among the mortality group. However, the difference was statistically significant only for lactate, lactate to albumin, creatinine, and percentage of neutrophils.
Discussion: High serum lactate to albumin ratio and serum lactate levels on admission in septic patients may be used as an independent predictor of in-hospital mortality.
Keywords: Lactate, Sepsis, Mortality, Prediction Models
Sepsis is a common condition characterized by the body’s overwhelming response to certain infective agents. Sepsis is a major cause of morbidity and mortality worldwide . It is associated with high in-hospital mortality in adult patients, ranging from 23% to 39% . Despite advances in its management, it is still the second most common reason for mortality in intensive care units (ICUs) .
Methods are needed to identify patients at risk of early death and to optimize management in order to improve clinical outcomes in these patients .
There are many clinical and laboratory parameters to diagnose sepsis including serum lactate levels, which are also used to guide the treatment. In critically sick patients, raised levels of serum lactate are strongly associated with significant morbidity and mortality .
Increased lactate production is caused by anaerobic metabolism due to tissue hypoxia caused by impaired circulation due to sepsis.
An elevated serum lactate level is directly proportional to the patients’ need for mechanical ventilation, ICU care and need for inotropic support . In patients presented to the emergency department with septic shock, elevated serum lactate level is associated with increased mortality, irrespective of the clinical evidence of organ dysfunction .
Therefore, it is a useful marker to identify patients at high risk for sepsis and septic shock, and hence timely intervention can decrease mortality and morbidity in these patients.
Multiple studies worldwide showed the association of serum lactate levels with the poor prognosis. Low serum lactate levels or even normal range have been shown to decrease the severity of sepsis .
Therefore, we prospectively collected clinical data on these patients to determine whether serum lactate level, independent of clinical evidence of organ dysfunction, reflects the severity of sepsis and serves as an independent predictor of the risk of death. This could help us in risk stratification of patients admitted with sepsis in developing countries where sophisticated predictors of mortality and morbidity cannot be applied.
Material and Methods
This was a prospective descriptive study conducted in the department of general medicine of Pakistan Institute of Medical Sciences, Islamabad from January 2019 to January 2020. Ethical approval was taken prior to enrollment of patients (No.F.1-1/2018/ERB/SZABMU/356). In this study, we evaluated the association of serum lactate levels and mortality in patients with sepsis. All patients between the ages of 12 and 75 years who were admitted with the provisional diagnosis of sepsis were enrolled in the study consecutively. Patients were evaluated within 24 hours and enrolled in the study if they fulfilled the inclusion and exclusion criteria and could provide written informed consent. Serum lactate levels along with baseline workup were determined within 24 hours and repeated within 7 days. All patients were given treatment as per the standard hospital protocol and were followed until discharge or death.
Data were analyzed using SPSS version 16. The association of baseline lactate and difference in lactate levels with treatment was calculated and analyzed for any association on mortality using Independent and paired T-test. A p-value of less than 0.05 was considered significant.
1. All patients with a confirmed diagnosis of infection (infective endocarditis, meningitis, encephalitis, pneumonia, cholecystitis, ascending cholangitis, hepatitis, pyelonephritis, cystitis, cellulitis or gastroenteritis etc.) for which the patient is on specific treatment
2. All patients with a temperature of >100.4F or less than 96F and bacteremia (positive blood culture)
3. All patients with no obvious source of infection but who met the following criteria and have been receiving treatment for an infective etiology
• At least three of the following
a. Temperature of > 100.4F or less than 96 F
b. TLC of >12000/ul or <4000/ul or Percentage of Neutrophils > 80%
c. ESR > 50 mm/hr or CRP: positive
d. Systolic BP <90 or MAP <70
A total of 156 patients were enrolled in the study, comprising 68 (43.6%) women and 88 (56.4%) men. The mean age of the patients in the study was 43.18 +/- 15.9 years. Death occurred in 38 (24.4%) of the study participants comprising 22 (32%) women and 16 (18.18) men. The mean TLC count of the patients was 14400/ul +/- 8.58, with a mean of 74.23% +/- 1.73 neutrophils. The mean values of ESR, albumin, creatinine, and lactate were 43.51 +/- 34.04, 3.0 +/- 0.69 gm/dl, 1.47 +/- 1.37 mg/dl, and 22.51 +/- 9.02 mmol/l respectively. The mean duration of hospital stay was 6.55 +/- 5.71 days.
The association of mortality with age, TLC count, Percent Neutrophils, ESR, Albumin, and Creatinine is summarized in Table 1. The association of mortality with serum lactate levels is summarized in Table 2.
This is a prospective study conducted on patients with sepsis at a tertiary care setup in Islamabad, Pakistan. Patients with sepsis were included, lactate levels were measured at admission within 24 hours and follow-up levels within 7 days along with other parameters. Patients were followed up until mortality or discharge. The study demonstrates significantly higher mean lactate levels in the mortality group versus the survival group. This difference was nearly similar in mean lactate levels at admission compared to follow-up levels. The study also demonstrated significantly higher mean lactate to albumin ratio in the mortality group compared to the survival group.
Higher mortality in septic patients with high lactate has been reported in multiple studies. An Australasian study has demonstrated high levels of lactate as an independent marker of severity in sepsis consistent with the current study. The study has also demonstrated an increased risk of 90-day mortality in patients with high serum lactate levels. High serum lactate levels were superior to refractory hypotension in predicting the outcome . A Massachusetts-based study has assessed mean lactate levels on day 1, Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) and compared with patient outcomes. The lactate levels were shown to determine patients’ outcomes as in the present study. However, this association was found to be associated with SOFA for outcome determination and superior to the use of qSOFA . A single centred Korean study has compared serum lactate levels and lactate clearance for predicting patient outcomes. Both were found to have prognostic potential; however, serum lactate levels were superior to lactate clearance. Serum lactate levels of 2 mmol/L or greater had maximum sensitivity . A US-based study on 3325 subjects demonstrated a greater risk of death in short run in those having high lactate levels. The study has also shown an increased risk of long-term mortality as well. However, the effect is not as pronounced as for poor outcome over a short run . Serum lactate levels in sepsis for outcome were compared among elderly (defined as age equal to or greater than 65 years) and non-elderly patients. The sensitivity of serum lactate levels of greater than 2 mmol/L was found to be higher among the elderly as a predictor of poor outcome . A US-based study over a large data has shown combination of high lactate and high glucose to be superior to either of parameters alone in predicting the outcome of septic patient .
Serum lactate to albumin ratio has also been associated with higher severity and mortality from sepsis. A US-based study retrospective single centred study over a large data has demonstrated lactate to albumin ratio to be superior to lactate alone in predicting the ICU mortality . Another study aimed at comparing lactate, albumin and lactate to albumin ratio has shown the ratio to be a stronger predictor of ICU mortality as compared to either of the parameters alone . A German single centred study followed patients and measured both in-hospital mortality as well as long-term mortality. The study showed both mortalities to be significantly higher in those showing higher lactate to albumin ratio in intensive care . A Korean multicentre retrospective study aimed to investigate 28-day mortality in the ICU setting. The study demonstrates significantly higher levels of lactate to albumin ratio in the mortality group, which is quite consistent to the present study. The study has also shown the ratio to be superior to lactate alone as a predictor of 28-day mortality . Another retrospective single centre study has demonstrated higher levels of lactate and lactate to albumin ratio in association with higher in-hospital mortality. The prognostic value of lactate to albumin ratio was better than lactate for in-hospital mortality in septic patients .
The limitations of study include the lack of evaluation of mean lactate values, peak lactate values that could have shown superiority as compared to lactate levels on admission. Mortality with different lactate levels was not studied, which could yield potentially useful information. Lactate clearance was not studied as it has been included in other studies. Risk ratio, area under the curve and sensitivity analysis with different values could be studied. Similarly, mortality was not categorized into the short and long term.
Higher levels of serum lactate and lactate to albumin ratio are linked to in-hospital mortality in the septic patient. These markers may be utilized to predict the outcome of septic patients.
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Conflict of interest
1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). Jama. 2016; 315(8):801-10.
2. Sakr Y, Rubatto Birri PN, Kotfis K, Nanchal R, Shah B, Kluge S, et al. Higher fluid balance increases the risk of death from sepsis: results from a large international audit. Crit. Care Med. 2017; 45(3):386-94.
3. Patel A, Laffan MA, Waheed U, Brett SJ. Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality. BMJ. 2014; 349:4561
4. Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009; 37(5):1670-7.
5. Chen Y, Li C. Lactate on emergency department arrival as a predictor of mortality and site-of-care in pneumonia patients: a cohort study. Thorax. 2015; 70:404-10.
6. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005; 45(5):524–8.
7. Gotmaker R, Peake SL, Forbes A, Bellomo R. Mortality is greater in septic patients with hyperlactatemia than with refractory hypotension. Shock. 2017; 48(3):294-300.
8. Liu Z, Meng Z, Li Y, Zhao J, Wu S, Gou S, et al. Prognostic accuracy of the serum lactate level, the SOFA score and the qSOFA score for mortality among adults with Sepsis. Scand J Trauma Resusc. 2019; 27(1):1-0.
9. Ryoo SM, Lee J, Lee YS, Lee JH, Lim KS, Huh JW, et al. Lactate level versus lactate clearance for predicting mortality in patients with septic shock defined by sepsis-3. Crit Care Med. 2018; 46(6):e489-95.
10. Villar J, Short JH, Lighthall G. Lactate predicts both short-and long-term mortality in patients with and without sepsis. Infect Dis. 2019; DOI: 10.1177/1178633719862776.
11. Cheng HH, Chen FC, Change MW, Kung CT, Cheng CY, Tsai TC, et al. Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department. Medicine. 2018; 97(13). DOI: 10.1097/MD.0000000000010209
12. Sotello D, Yang S, Nugent K. Glucose and lactate levels at admission as predictors of in-hospital mortality. Cureus. 2019; 11(10). e6027. doi: 10.7759/cureus.6027
13. Gharipour A, Razavi R, Gharipour M, Mukasa D. Lactate/albumin ratio: An early prognostic marker in critically ill patients. Am J Emerg Med. 2020; 38(10):2088-95.
14. Cakir E, Turan IO. Lactate/albumin ratio is more effective than lactate or albumin alone in predicting clinical outcomes in intensive care patients with sepsis. Scand J Clin. 2021; 81(3):225-9.
15. Lichtenauer M, Wernly B, Ohnewein B, Franz M, Kabisch B, Muessig J, et al. The lactate/albumin ratio: a valuable tool for risk stratification in septic patients admitted to ICU. Int J Mol Sci. 2017; 18(9):1893.
16. Shin J, Hwang SY, Jo IJ, Kim WY, Ryoo SM, Kang GH, et al. Prognostic value of the lactate/albumin ratio for predicting 28-day mortality in critically ill sepsis patients. Shock. 2018; 50(5):545-50.
17. Bou Chebl R, Jamali S, Sabra M, Safa R, Berbari I, Shami A, et al. Lactate/albumin ratio as a predictor of in-hospital mortality in septic patients presenting to the emergency department. Front Med. 2020; 7:590.
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Ahmed Farhan, Ali Sufyan, Muhammad Awais Tahir, Arslan Ahmad, Sara Manzoor. Serum Lactate as a predictor of in-hospital mortality in patients with sepsis. Ann Clin Anal Med 2022;13(6):645-648
Evaluation of COVID-19 fear and nutrition habits in healthcare workers
Muhammed Fatih Baran, Selma Pekgör
Department of Family Medicine, University of Health Sciences, Konya City Hospital, Konya, Turkey
DOI: 10.4328/ACAM.21069 Received: 2022-01-20 Accepted: 2022-03-03 Published Online: 2022-03-05 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):649-653
Corresponding Author: Muhammed Fatih Baran, Department of Family Medicine, University of Health Sciences, Konya City Hospital, Konya, Turkey. E-mail: email@example.com P: +90530 637 66 41 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1827-2317
Aim: This study aims to evaluate the COVID-19 fear level and nutrition habits of healthcare workers.
Material and Methods: This research was conducted with 208 healthcare workers in Konya City Hospital and Meram State Hospital. Participants filled out the sociodemographic information form, COVID-19 Phobia Scale and Three-Factor Eating Questionnaire. The SPSS 22,0 program was used for data analysis.
Results: Among participants between the ages of 18-65 included in the study, 59.1% (n=123) were female and 40.9% (n=85) were male. The average age of participants was found to be 29.32 ±0.43 years. In the COVID-19 Phobia Scale, scores of women in psychological (p<0.001), somatic (p=0.001), social (p=0.001), economic (p=0.001) sub-dimensions and total score (p=0.026) were found to be higher than those of men. Fear levels of married participants were higher in somatic (p=0.018) and economic (p=0.044) sub-dimensions. Scores of obese and overweight participants’ in psychological (p=0.002), somatic (p=0.017), social (p=0.028), economic (p=0.011) sub-dimensions and in total score (p=0.001) were found to be lower. The total score of the Three-Factor Nutrition Questionnaire (p=0.017) and emotional eating levels (p=0.006) of healthcare workers who had COVID-19 before were found to be higher. It was detected that there was a positive correlation between the degree of emotional eating and the social sub-dimension (p=0.048), and there was a negative relationship between the degree of consciously restricting eating and the psychological sub-dimension (p=0.009).
Discussion: Nutritional habits have changed due to isolation conditions, sedentary lifestyles and the need for supplemental food. The stressful and risky working environment of healthcare workers affected their fear levels. With the increase in the fear level, eating habits have also changed. As in all pandemics, policies should be followed to reduce the level of fear of healthcare workers, who are among risky groups, during the COVID-19 pandemic process. In this process, the importance of nutrition should be emphasized and negative habits should be avoided.
Keywords: COVID-19 Phobia, Three-Factor Eating Questionnaire, Healthcare Workers, Pandemic
At the beginning of the century, the new type of coronavirus, which also caused the deadly Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), started to spread and was declared a COVID-19 pandemic by the World Health Organization on March 11, 2020 .
As in many other natural disasters, pandemics cause societies to show different reactions. The resulting environment of uncertainty and health anxiety can cause a social trauma in a short time .
In previous pandemics, it has been demonstrated that measures such as lockdowns, temporary closures, limited personnel employment in workplaces and travel bans, apart from medical practices, have prevented the spread of the disease . It has been observed that these practices, which were implemented in the first coronavirus epidemic (SARS) in 2003, increased the level of anxiety of the public and health workers, leading to desperation and trauma . In addition, it has been found that women and people with low education levels have higher anxiety levels . In a study conducted during avian influenza, it was determined that individuals with high anxiety levels were more stressed and tended to lean more on avoidance behavior . These examples show that the perception of illness in different segments of society is related to anxiety levels.
According to a study conducted during the SARS epidemic, it was revealed that healthcare workers experienced more stress than the normal population, and this stress persisted for a long time, causing depression, anxiety and post-traumatic stress disorder . It has been stated that long-term support services should be provided against psychological distress and burnout syndrome among healthcare workers during the COVID-19 process .
In the pandemic process, isolation, stay-at-home warnings and decreasing social life have increased inactivity and reduced the need for energy. However, with the thought of leaving the house less, food was stocked and food consumption increased. Studies show that eating habits deteriorate, the need for eating increases, the feeling of self-restraint while eating decreases, and the number of meals increases . With the prolongation of the process, living at home for a long time caused boredom and stress. In such cases, people have resorted to a diet based on carbohydrates, take-home foods and sugar in order to relax emotionally. Emotional eating habits cause excessive intake of food . In this process, diseases such as diabetes and obesity have also increased [11, 12].
The importance of a healthy nutrition in increasing resistance to infections was recognized, and it was emphasized that malnutrition has caused an increase in mortality rates in previous epidemics . It is recommended to consume foods rich in vitamins such as A, B6, B12, D, E, polyunsaturated fatty acids such as omega-3, zinc, iron and selenium in viral infections . All these processes have increased the interest in nutrition in society. However, it is not clear whether this interest was in the direction of healthy nutrition.
In this study, it was aimed to determine the nutritional habits of healthcare professionals (consciously restricting eating, uncontrolled eating, emotional eating, sensitivity to hunger) and to evaluate its relationship with the COVID-19 fear level.
Material and Methods
Setting and population of the study
Healthcare workers between the ages of 18-65 who agreed to fill out the questionnaire at the Konya City Hospital and Meram State Hospital between November 2021 and December 2021 were included in this study. Pregnant and lactating women, those with endocrine disorders and those using drugs that affect appetite were not included in the study.
Approval for the study was obtained from the Selcuk University Faculty of Medicine Local Ethics Committee (2021/524). Participants were asked to fill in the sociodemographic features form. Questions like ‘Was there COVID-19 patients nearby?’, ‘Has s/he contacted with COVID-19 patients?’, ‘Did s/he get tested due to COVID-19 suspicion?’, were asked and if so, the results were recorded. The COVID-19 Phobia Scale (C19P-S) was used to measure the COVID-19 phobia of the volunteers and the Three Factor Eating Questionnaire (TFEQ) was conducted to determine the change in their eating habits.
COVID-19 Phobia Scale (C19P-S)
C19P-S was developed by Ibrahim Arpaci et al. in 2020. It was created to measure excessive and permanent fear of the new type of coronavirus disease. It is a 5-Likert-type self-assessment scale consisting of 20 items. This scale consists of 4 sub-dimensions: psychological, somatic, social and economic. High scores indicate high COVID-19 phobia .
Three Factor Eating Questionnaire (TFEQ)
TFEQ is a survey created to measure dietary habits. The 18-question format of the TFEQ was developed by Jan Karlsson et al. in 2000. It consists of 4 sub-dimensions that measure an individual’s level of consciously restricting eating, eating uncontrollably, eating emotionally, and sensitivity to hunger. Turkish validity and reliability study was conducted by Deniz Kıraç et al. as the “Three-Factor Eating Questionnaire” .
Statistical analysis of the data obtained in the study was evaluated with Statistical Packet for the Social Science for Windows Version 22.0 (SPSS) at the α=0.05 significance level. Descriptive statistics in single groups and Kolmogorov-Smirnov and Shapiro-Wilk analyses, which are among the tests of compatibility to distribution in continuous data, were used. The Mann-Whitney U test was used for the analysis of non-normally distributed data. Spearman’s correlation analyses were used in the measurement of relationship levels.
Power analysis for the study was obtained using the Epi Info 1.4.3 package program. In the power analysis, the sample number of 4015 health workers working in Konya City Hospital and Meram State Hospital was 158, with a 5% margin of error and 80% power. The study was completed with 208 people.
The study was completed with a total of 622 people between the ages of 18-65. The average age of the participants was 29.32±0.43 years, 59.1% (n=123) of the participants were women, 49.5% (n=103) were married, and 58.2% (n=121) had a high monthly income; 31.7% (n=66) of the participants were smokers. Of the participants, 60.6% (n=126) were of normal weight and 12% (n=25) were obese. There were 21 (10.1%) people with a chronic disease.
In the COVID-19 Phobia Scale, scores of women in psychological (p<0.001), somatic (p=0.001), social (p=0.001), economic (p=0.001) sub-dimensions and total score (p=0.026) were found to be higher than those of men. Married people had higher scores in the somatic and economic sub-dimension of C19P-S (p=0.018, p=0.044, respectively). Those with chronic disease had higher somatic sub-dimension scores in C19P-S (p=0.033). Total C19P-S and subgroup scores of the underweight and normal weight groups were higher than those of the overweight and obese (p=0.002, p=0.017, p=0.028, p=0.011, p=0.001, respectively). Those with a relative with COVID-19 had lower scores in the somatic sub-dimension of C19P-S (p=0.005) (Table 1).
Women’s scores were found higher in the emotional eating sub-dimension of TFEQ (p=0.026). In the level of uncontrolled eating, the degree of emotional eating, the level of sensitivity to hunger, and the total score of TFEQ, the scores of the obese and overweight were higher than those of underweight and normal weight (p<0.001, p=0.014, p<0.001, p<0.001, respectively). Emotional eating degree and total score of TFEQ were found to be higher in those with positive COVID-19 test (p=0.006, p=0.017, respectively) (Table 2).
A positive correlation was found between the degree of emotional eating and the social sub-dimension of C19P-S (p=0.048). A negative correlation was found between the degree of consciously restricting eating and the psychological sub-dimension of C19P-S (p=0.009) (Table 3).
In this study, the fear of COVID-19 and the nutritional habits of healthcare workers were evaluated. Research findings show that COVID-19 fear levels were high in women, married people, normal-weight and underweight people. In addition, it has been observed that the eating habits of overweight and obese people change.
It has been revealed that women are more affected by the process during the COVID-19 period [17, 18]. In our study, fear levels were found to be higher in the female gender. In a study measuring eating behavior during the COVID-19 period, it was revealed that women change the number of meals more than men . In this study, it was found that emotional eating levels of female health workers were higher than that of males. We think that women are affected more emotionally by this process and this also affects their eating habits.
In a study conducted in China among the normal population, it was observed that mental status was not different between married and single people during the COVID-19 period . In this study, it was found that married health workers developed more fear than singles. The reason for the high level of fear among married health workers may be due to the fact that, unlike other occupational groups, health workers are in constant contact with COVID-19 patients at work and the possibility of transmitting the disease to their spouse and children is high.
As in other infections, the risk of contracting COVID-19 is higher in those with chronic diseases and it has a more fatal course [20, 21]. In our study, it was found that healthcare workers with chronic diseases had a higher fear of COVID-19. This result was expected.
Obesity is one of the important risk factors for COVID-19. It is known that obese individuals have a lower immune response to infections, reduce respiratory capacity and pose a risk for COVID-19 infection . In this study, it was found that overweight and obese individuals have a lower incidence of COVID-19 phobia. This may be due to the low health perception of overweight and obese individuals.
With the increase in the time spent at home and online shopping, unbalanced eating habits have begun to be observed. With the decrease in physical activity, the susceptibility to obesity has increased. In this process, an increase in unbalanced eating behaviors was observed in overweight and obese individuals with impaired nutritional habits . In this study, it was determined that overweight and obese healthcare workers have high levels of uncontrolled eating, emotional eating and sensitivity to hunger.
Many studies mention that health workers develop more stress, fear, mental problems and depression due to their higher risk in the COVID-19 pandemic . It has been revealed that nurses and doctors, who are in direct contact with the patients, experience these problems more than the administrative staff . However, in this study, it was revealed that the level of fear in healthcare workers whose relatives were infected with COVID-19 was lower. The reason for this can be explained by the high level of knowledge about COVID-19 of healthcare professionals, while other professions learn about the disease when their relatives have had COVID-19.
Vitamins A, B, C, D, omega-3, selenium, and zinc supplements are generally recommended during COVID-19 disease . It has been recommended that nutritional supplements and healthy nutrition programs be continued during hospitalizations and after discharge . These recommendations have been applied more carefully by healthcare professionals who have had COVID-19. This may be the reason for the high level of emotional eating in healthcare workers in our study. It has been revealed that as the level of fear of COVID-19 increases in healthcare workers, the level of emotional eating increases, and the level of consciously restricting eating decreases.
Considering the social effects of the COVID-19 Pandemic, healthcare workers are among the risky groups. Healthcare workers were affected by the uncertainty, risky and intense working environment, and increased fear, stress and mental problems.
Nutritional habits have changed due to isolation conditions, sedentary life and the need for supplemental food. The stressful and risky working environment of healthcare workers affected their fear levels. The increase in the level of fear has also changed eating habits.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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Muhammed Fatih Baran, Selma Pekgör. Evaluation of COVID-19 fear and nutrition habits in healthcare workers.Ann Clin Anal Med 2022;13(6):649-653
Relationship between biochemical recurrence and CD47 expression after radical prostatectomy
Serkan Dogan 1, Sukran Ziysan Sakaogullari 2
1 Department of Urology, Sancaktepe Sehit Prof Dr Ilhan Varank Education and Research Hospital, Istanbul, 2 Department of Pathology, University of Health Sciences, Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.21074 Received: 2022-01-22 Accepted: 2022-03-02 Published Online: 2022-03-02 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):654-658
Corresponding Author: Serkan Dogan, Emek Mahallesi, Namık Kemal Caddesi, No: 54, 34785, Sancaktepe, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 216 606 33 00 / +90 505 729 97 29 F: +90 216 606 33 95 Corresponding Author ORCID ID: https://orcid.org/0000-0001-5215-9281
Aim: This study aimed to investigate the relationship between biochemical recurrence after radical prostatectomy and CD47 glycoprotein expression level assessed according to immunohistochemical staining pattern.
Material and Methods: Pathologic specimens of 54 patients who underwent retropubic radical prostatectomy at our clinic were stained for CD47. Staining patterns showed a level of expression. Staining patterns of patients with and without biochemical recurrence during follow-up were statistically compared.
Results: The mean age was 64.9±5.5 years, mean preoperative prostate-specific antigen (PSA) was 9.38±4.17 ng/dl, and the mean follow-up time was 45.9±6.5 months. Biochemical recurrence was identified in 15 (28%) patients. The CD47 staining pattern was significantly prevalent in the biochemical recurrence group (p=0.000). Patients with biochemical recurrence had higher Gleason scores in both biopsy specimens and surgical specimens (p=0.000, p=0.000 respectively).
Discussion: Biochemical recurrence frequently develops after radical prostatectomy. Various parameters have been investigated to predict this occurrence. Our study is the first in the literature to demonstrate increased CD47 expression as an independent predictor of biochemical recurrence following radical prostatectomy.
Keywords: Prostate Adenocarcinoma, CD47, Gleason Score, Biochemical Recurrence, Markers
Prostate adenocarcinoma (PCa) is a common malignancy in the USA and is the second most common cause of cancer-related deaths in males . There are various therapeutic options in the treatment of prostate cancer. Radical prostatectomy has been recognized as the standard treatment for localized prostate cancer [2, 3]. However, recurrence may occur in some patients after surgery and is known to be associated with a prostate-specific antigen (PSA), Gleason score (GS), and stage of the disease . Biochemical recurrence (BCR) is used as an early indicator of recurrent disease and/or metastasis. BCR is considered as a serum PSA level above 0.2 mg/dl. BCR incidence in a 5-10-year follow-up period is relatively high . Early detection of BCR and even its prediction holds great importance in the clinical prognosis of patients.
A Cluster of Differentiation 47 (CD47) is a transmembrane receptor glycoprotein for the immunoglobulin superfamily. It plays a role as a receptor for Thrombospondin-1 (TSP-1) and Signal Regulating Protein-α (SIRP-α). These two interactions of CD47 have been encountered in various pathologies, including hemostasis, ischemic damage, inflammation, radiation injury, and cancer. CD47 functions as a ligand in its relationship with SIRP-α. SIRP-α is an inhibitory transmembrane receptor and plays a role in regulating the two-way signaling pathway that permits intercellular transmission. The purpose of CD47 as a ligand for this receptor and its “don’t-eat-me” message to phagocytic cells and its increased expression in tumor cells have been demonstrated. There are also publications indicating that increased expression of CD47 is associated with decreased cancer-related survival rates .
In this study, we investigated the relationship between BCR relapse occurrence and CD47 staining pattern in pathology specimens in patients who underwent radical prostatectomy for prostate cancer. We hope that our retrospective study, as the first on this topic, will be a contribution to the literature.
Material and Methods
A total of 54 patients who underwent radical prostatectomy for prostate cancer at our clinic were included in this study. Patients with a history of any other malignancies and chemotherapy or radiotherapy were excluded from the study. Patients with primary prostate adenocarcinoma were included in the study. Ultrasound-guided prostate needle biopsy due to elevated PSA or abnormal digital rectal examination had been conducted on all patients. Demographic data, as well as biopsy and pathological assessment of surgical specimens, CD47 staining patterns, and PSA follow-up values, were recorded. Surgical specimens were stained with CD47 only. In the mean follow-up period of 4 years, the statistical relationship of CD47 staining pattern was examined in the BCR recurrence group.
All patients had nonmetastatic prostate cancer, and they underwent retropubic radical prostatectomy. Patients were followed-up every three months for clinical evaluation and PSA measurement. Beckman Coulter brand Unicel DXC 800 Synchron clinical biochemistry system was used to measure PSA with the chemiluminescence method.
CD47 immunohistochemical staining procedure
For the immunohistochemical study of all cases, 4-micron thick sections with paraffin blocks and a rotary microtome were coated with Poly-L-lysine. The avidin-biotin method was used as the immunohistochemical staining system.
Slides of the sections were kept in the incubator at 80ºC for 30 minutes, for melting the paraffin. The slides were removed from the incubator and kept in xylol for 10 minutes. They were then rehydrated by placing them in three different alcohols of densities ranging from 90% to 70% for five minutes. The rehydrated sections were incubated in hydrogen peroxide for five minutes and rinsed with distilled water. The slides were placed in a saline solution containing citrate buffer and microwaved at 850 watts for five minutes and 500 watts for five minutes. Microwaved slides were left to cool in the citrate buffer. The slides were removed and rinsed in distilled water then incubated in phosphate buffer solution (PBS) for two minutes in two batches. Margins of the tissues on the slides were marked with a PAP Pen. The vicinity was dried with blotting paper, and each slide was placed in a covered humidity chamber. CD47 (Dako EnVision Cat. No. 1046) was stained with two drops of antibodies from these dyes onto the slides. They were left covered for 30 minutes and filtered onto blotting paper. They sat for five minutes and were submerged in PBS. The slides were dried, and drops of biotinylated link for streptavidin-HRP/AP (UltraVision Large Volume Detection System of Lab Vision Corporation) were applied and left to sit for 10 minutes. After the biotinylated link for streptavidin-HRP/AP solution was drained, they were left in PBS in two batches for five minutes. The slides were dried, and Streptavidin-HRP solution drops were applied and left for 10 minutes. After draining the streptavidin-HRP solution, PBS was gone for five minutes, and then slides were removed and dried. At this stage, the DAB+ chromogen solution was prepared by dropping two drops of chromogen solution into 1cc DAB (Diamino benzene) substrate, which was dripped on slides and kept for 5-7 minutes. The chromogen slides were filtered and rinsed rapidly with distilled water.
For counterstaining, slides were kept in Mayer hematoxylin for one minute and washed with distilled water. The slides were passed through an alcohol series and dried in the incubator. The slides were removed from the incubator and kept in xylol, applied Entellan drops, and closed with a coverglass.
The slides obtained according to the method described, immunohistochemically prepared for CD47 evaluation, were examined and scored according to the following method under the Olympus brand BX51 microscope. Brown staining of tumor cell nuclei was used as a criterion for CD47 antigen positivity.
Staining assessment was conducted in four categories:
0: No staining in tumor cells
1: < 35% staining in tumor cells
2: 35-70% staining in tumor cells
3: >70% staining in tumor cells
In this evaluation, the lack of staining was considered negative (category 0), while categories 1-3 were considered positive (Figure 1).
The study obtained approval from the Turkey Yüksek Ihtisas Training and Research Hospital Education and Planning Board (No. 4312). The study was planned under the principles of the Helsinki Declaration. Informed written consent was acquired from all patients.
Data obtained in this study were statistically evaluated with SPSS version 22.0 (SPSS IBM, Statistical Package for Social Sciences, Chicago, IL, USA) statistical software. For statistical analysis, the Mann-Whitney U test was used to compare groups with and without BCR according to the categorical, ordinal variable of CD47 expression level. Student’s-t independent test was used to compare numerical data including age, preoperative and postoperative PSA, and follow-up time in groups with a normal distribution. The Mann-Whitney U test was used to compare the Gleason score of biopsies and surgical specimens between the groups. P<0.05 values were considered statistically significant.
The mean age of the 54 patients included in the study was 64.9±5.5 years, mean preoperative PSA was 9.38±4.17 ng/dl, and the mean follow-up time was 45.9±6.5 months. The mean prostate volume was 64.4±21.4 cc (Table 1).
Eight of the patients were T2a (15%), 19 were T2b (35%), and 20 were T2c (37%), and 7 were T3a (13%). T staging of the patients is shown in Figure 2.
Surgical margin positivity was detected in 4 (7.4%) patients. BCR occurred in the follow-up of 15 patients. Thirteen patients were upgraded, and two patients were downgraded according to the assessment of biopsy and surgical specimens. The Gleason score remained unchanged in 39 patients. Five of the 13 patients with the upgrade and ten of the 39 consistent patients developed BCR, while BCR was not observed in the two downgraded patients. Mean CD47 staining was 1.92 in upgraded patients, 1.44 in unchanged patients, and 0.5 in downgraded patients.
There was a statistically significant difference in CD47 staining patterns between the patients who developed BCR (Group 1) and those who did not (Group 2) (p=0.000). Comparison of the groups showed a significant difference between preop and postop PSA, while age and follow-up times were similar (Table 2).
When biopsy GS and surgical GS values were compared separately, there was also a statistically significant difference.
The mean period until patients developed BCR was 24.6 months in six patients with pattern three staining and 31.2 months in nine patients with pattern two stainings. Meantime, until BCR, occurrence was 29.3 months in all patients.
Studies in recent years have identified prostate adenocarcinoma as the most common malignancy . It accounts for 15% of all cancers, with more than 1.1 million new diagnoses per year . In autopsy studies, the incidence was 5% under the age of 30, while it was 60% over the age of 80 . Its incidence is higher in developed societies such as North America, Northern and Western Europe . The introduction of PSA’s clinical use has led to better early diagnosis rates as well as improved surgical techniques, fewer complications, and increased survival rates with advanced follow-up protocols. Radical prostatectomy remains the gold standard in the treatment of organ-localized disease . BCR rates at the end of a 10-year follow-up period ranged between 35-50% . BCR may be an early sign of recurrent primary disease or metastasis. It should also be kept in mind that BCR may not necessarily be associated with clinical recurrence, progression, or disease-specific mortality, but may result from indolent prostate cancer or postoperative benign tissue. Predicting BCR remains helpful in reducing morbidity and mortality associated with the disease.
Numerous studies have been conducted on preoperative PSA levels, histological grade, positive surgical margins, and clinical-stage to predict disease-related death . Studies show postoperative recurrence associated with prostate-specific antigen (PSA), Gleason score (GS), and disease stage . Positive surgical margins (PSM) are also an independent risk factor for recurrent disease and/or metastasis. Many studies also indicate PSM as an independent risk factor of BCR. PSM is detected in up to 30% of cases after radical prostatectomy . While PSM may not necessarily lead to clinical disease, it is a problem that must be well-managed.
CD 47 is a cell surface glycoprotein that acts as a counter receptor for SIRP-α, playing a role in the immune system’s recognition of the body’s cells. CD 47 also independently functions as a signal receptor to regulate the cell’s response to stress. CD 47, also known as integrin-related protein or Rh-related protein, was first described as a protein lacking in erythrocytes of patients with Rh (-) hemolytic anemia .
CD47 has two main functions. The first is its interaction with SIRPα on phagocytic cells resulting in the generation of a “don’t-eat-me” signal towards erythrocytes carrying CD47 at the minimum required concentration, therefore preventing their disposal from circulation. Cells carrying trace amounts or chemically modified CD47 are marked for elimination by phagocytes, while malignant cells with increased CD47 levels are resistant to elimination. The second main role of CD47 is its mechanism as a signal receptor. CD47 binds to TSP-1, generating a signal, and regulating intracellular calcium increase, cyclic nucleotide, integrin, cell status with growth factor signaling, viability, and resistance to stress .
Increased expression of CD47 occurs in many human malignancies. Some studies indicate that elevated expression can be used as a diagnostic marker and negative prognostic factor . Based on a similar elevation in hematopoietic stem cells, increased CD47 expression has been reported as a marker that protects cancer stem cells from being eliminated by phagocytes .
There are studies in which CD47 expression is associated with poor prognosis and disease progression [16, 17]. Negative effects on survival have been reported in different tumors such as lung, blood, and liver [18, 19]. In addition, there are studies in the literature in which increased CD47 expression in different tumor types was determined as an independent risk factor for recurrence [20, 21]. There is no study in the literature regarding CD47 expression in prostate cancer. This study was conducted to determine whether or not a CD47 expression level can be used as an indicator of BCR. Many studies have investigated the prediction of BCR. A portion of these studies is clinical, while a large number are also laboratory-based.
In a study by Sun et al., the predictive value of microRNA-126 towards BCR was investigated in 128 patients, in whom decreased miRNA-126 expression level was associated with an increased BCR risk . Joung et al. investigated prostate-specific membrane antigen (PSMA) in 124 patients and indicated that serum PSMA levels could be used as a BCR marker . Bauman et al. found that decreased CD147 expression was an independent risk factor for BCR . Shahait et al. conducted a study on 117 patients and reported that increased Ki-67 expression in surgical margin cells was an independent marker for BCR .
In conclusion, our study found that increased CD47 expression level after radical prostatectomy was an independent risk factor for BCR. A low number of patients and short follow-up time were limitations of our study; however, it is important to note that our study is the first topic in the literature.
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Conflict of interest
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2. Han M, Partin AW, Piantadosi S, Epstein JI, Walsh PC. Era specific biochemical recurrence-free survival following radical prostatectomy for clinically localized prostate cancer. J Urol. 2001;166(2):416-9.
3. Marra G, Valerio M, Heidegger I, Tsaur I, Mathieu R, Ceci F, et al. Management of Patients with Node-positive Prostate Cancer at Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review. Eur Urol Oncol. 2020;3(5):565-81.
4. Ishizaki F, Hara N, Koike H, Kawaguchi M, Tadokoro A, Takizawa I, et al. Prediction of pathological and oncological outcomes based on extended prostate biopsy results in patients with prostate cancer receiving radical prostatectomy: a single institution study. Diagn Pathol. 2012;7:68.
5. Freedland SJ, Humphreys EB, Mangold LA, Eisenberger M, Dorey FJ, Walsh PC, et al. Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA. 2005;294(4):433-9.
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7. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69-90
8. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-86.
9. Bell KJ, Del Mar C, Wright G, Dickinson J, Glasziou P. Prevalence of incidental prostate cancer: A systematic review of autopsy studies. Int J Cancer. 2015;137(7):1749-57.
10. Haas GP, Delongchamps N, Brawley OW, Wang CY, de la Roza G. The worldwide epidemiology of prostate cancer: perspectives from autopsy studies. Can J Urol. 2008;15(1):3866-71.
11. Roehl KA, Han M, Ramos CG, Antenor JA, Catalona WJ. Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: Long-term results. J Urol. 2004;172(3):910-4.
12. Evren I, Hacıislamoğlu A, Ekşi M, Yavuzsan AH, Baytekin F, Çolakoğlu Y, et al. The impact of single positive surgical margin features on biochemical recurrence after robotic radical prostatectomy. Int Braz J Urol. 2019;45(1):45-53.
13. Okunuki Y, Tabor SJ, Lee MY, Connor KM. CD47 Deficiency Ameliorates Ocular Autoimmune Inflammation. Front Immunol. 2021;12:680568.
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16. Tuo Hu , Huashan Liu , Zhenxing Liang , Fengwei Wang , Chi Zhou , Xiaobin Zheng , et al. Tumor-intrinsic CD47 signal regulates glycolysis and promotes colorectal cancer cell growth and metastasis. Theranostics. 2020;10(9):4056-72.
17. Kamijo H, Miyagaki T, Takahashi-Shishido N, Nakajima R, Oka T, Suga H, et al. Thrombospondin-1 promotes tumor progression in cutaneous T-cell lymphoma via CD47. Leukemia. 2020;34(3):845-56.
18. Kim H, Bang S, Jee S, Paik SS, Jang K. Clinicopathological significance of CD47 expression in hepatocellular carcinoma. J Clin Pathol. 2021;74(2):111-15.
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22. Sun X, Liu Z, Yang Z, Xiao L, Wang F, He Y, et al. Association of microRNA-126 expression with clinicopathological features and the risk of biochemical recurrence in prostate cancer patients undergoing radical prostatectomy. Diagn Pathol. 2013;8:208.
23. Joung JY, Cho KS, Chung HS, Cho IC, Kim JE, Seo HK, et al. Prostate specific membrane antigen mRNA in blood as a potential predictor of biochemical recurrence after radical prostatectomy. J Korean Med Sci 2010;25(9):1291-5.
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Serkan Dogan, Sukran Ziysan Sakaogullari. Relationship between biochemical recurrence and CD47 expression after radical prostatectomy. Ann Clin Anal Med 2022;13(6):654-658
Early warning score versus quick sequential organ failure assessment in COVID-19
Mehmet Tunç 1, Kemal Sener 2, Nurettin Yılmaz 1, Tufan Nayir 3, Sadiye Yolcu 1
1 Department of Emergency Medicine, Adana City Research and Education Hospital, Adana, 2 Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, İstanbul, 3 Ministry of Health Ankara, Turkey
DOI: 10.4328/ACAM.21080 Received: 2022-01-24 Accepted: 2022-03-05 Published Online: 2022-03-15 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):659-662
Corresponding Author: Kemal Şener, Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital İstanbul, Turkey. E-mail: email@example.com P: +90 506 915 62 12 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8579-6663
Aim: COVID-19 is a viral pandemic that has affected the whole world in 2020. Our knowledge about this infection is improving each day. The emergency department (ED) management of COVID-19 patients is still unclear. Early warning scores (EWSs) and quick sequential organ failure assessment (qSOFA) are widely used scores in the ED. In this study, we aimed to compare EWSs and qSOFA scores in COVID-19 patients.
Material and Methods: We evaluated patients diagnosed and hospitalized with COVID-19 between 10 April 2020 and 17 April 2020, including 63 COVID-19-positive patients. We calculated both EWSs and qSOFA scores for all patients and compared them by hospitalization unit (clinic or intensive care unit [ICU]), hospitalization length, and outcome.
Results: EWS was positively correlated with hospitalization length, but we could not find a relationship between qSOFA and hospitalization length. The ICU hospitalization rate increases with high EWSs AND qSOFA scores. The mean EWS of patients hospitalized in the inpatient clinic was 1.39 and that of patients hospitalized in the ICU was 5.7. These scores were significantly different (p=0.000). The mean EWS of the patients who were discharged from the hospital was 1.6, and that of the exitus patients was 11.7 (p = 0.01). These values were 0.06 and 2.25 for qSOFA, respectively.
Discussion: Both qSOFA and EWSs can predict the hospitalization unit and mortality, but EWSs are superior in determining the hospitalization length of COVID-19 patients.
Keywords: COVID-19, Early Warning Score, qSOFA
An early warning score (EWS) measures respiratory rate, oxygen saturation, heart rate, systolic blood pressure, and consciousness level according to AVPU for determining the severity of the illness in the emergency department (ED; Table 1). A score of 0 to 1 means mild conditions, and patients with a score of 2 should be observed much more carefully. Additional immediate evaluation and treatment should be provided to patients with a score of 3 to 5. Patients who score 6 to 8 points require much more extensive evaluation, and patients with an EWS ≥ 9 should consult with a senior expert physician. EWSs reflect the severity of a disease, with high scores predicting worse prognoses (Royal College of Physicians (London) Report of a working party; 2012. National Early Warning Score (NEWS). Standardising the Assessment of Acute-Illness Severity in the NHS) .
The quick sequential organ failure assessment (qSOFA) score was suggested for sepsis and septic shock in 2016. This score is used to predict the sepsis risk and in-hospital mortality (range, 0-3, receiving 1 point for each of the following criteria that are met: systolic arterial blood pressure ≤ 100 mmHg; respiratory rate > 21 breaths/min; or altered mental status) .
The development of sepsis is frequently seen in cases of pneumonia, especially in pneumonia due to COVID-19 .
In this study, we aimed to compare EWSs and qSOFA in COVID-19 patients and to determine which score better predicts the prognosis of the patients.
Material and Methods
After obtaining approval from the XXX Research and Education Hospital Ethics Committee, in this retrospective study, we evaluated patients diagnosed and hospitalized with COVID-19 between 10 April 2020 and 17 April 2020, including 63 COVID-19-positive patients. We validated the positivity via a combined oro-nasopharyngeal swab PCR test. We noted demographic data (age, gender, comorbidities), EWS, qSOFA, hospitalization unit (clinic/intensive care unit [ICU]), hospitalization length, and outcome. We calculated and compared EWSs and qSOFA for all patients.
All patients included in the study were diagnosed and hospitalized with COVID-19. The exclusion criteria were patients with missing data, patients under 18 years old, cardiopulmonary arrest in the ED, and pregnancy (Figure 1).
We performed statistical comparisons using the statistical software package SPSS 25.0 (SPSS Inc., Chicago, IL, USA) and used the Kolmogorov-Smirnov test for normal distribution. For normally distributed variables, we used an unpaired t-test, and for non-normally distributed variables, we used the Mann-Whitney U test. Categorical variables are expressed in frequencies and percentages. We used a chi-square test to compare categorical variables and a paired t-test for continuous variables. Definitive statistics were expressed as mean ± standard deviation (SD) and median (interquartile range, IQR). We used Pearson’s and Spearman’s correlation tests for correlations. A p-value < 0.05 was considered significant.
We included 34 (53.9%) men and 29 (46.1%) women for a total of 63 COVID-19 patients in our study. The mean age of our study group was 46.78 ± 18.57 years (min: 18, max: 83) (Table 1).
Fifty-four patients were hospitalized in the inpatient clinic and 9 patients in the ICU. Fifty-nine patients underwent endotracheal intubation. Fifty-nine patients were discharged, and 4 patients died. EWSs were positively correlated with hospitalization length, but we could not find a relationship between qSOFA and hospitalization length. The ICU hospitalization rate increased with high EWSs AND qSOFA scores (Table 2).
The mean EWS of patients hospitalized in the inpatient clinic was 1.39 and that of the patients hospitalized in the ICU was 5.7. These scores were significantly different (p = 0.000).
The mean EWS of the patients discharged from the hospital was 1.6 and that of the exitus patients was 11.7 (p = 0.01). These values were 0.06 and 2.25 for qSOFA, respectively.
Patients with EWS more than 5 points were hospitalized for more than five days, and when we divided the patient group according to 5 hospitalization days (1. Group: less than 5 days/31 patients, 2: more than 5 days/32 patients), age (p=0.00), and EWS (p=0.02) were significantly different in patients hospitalized more than 5 days (independent sample test). qSOFAs were not significantly different (p=0.221). Hospitalization length was positively correlated with EWS (p=0.011, r=0.317) (Figure 2).
Suspected COVID-19 patients were present in the ED first and waited for some blood tests and thorax CT to support the diagnosis. After a swab for PCR, the patients were hospitalized in the inpatient COVID clinic or COVID ICU. During this time, the ED management of these patients was not clear enough. A lack of literature means guidelines are required for the ED management of suspected COVID-19 patients. ED clinicians sometimes follow up suspected patients for many hours before hospitalization. The main complaints of these patients are respiratory distress, fever, cough, altered mental state, syncope, etc. According to one case series, hypotension occurred in 17 of 24 critically ill COVID-19 patients who required fluid and rapid vasopressor administration .
EWSs and qSOFA have recently been compared for critically ill patients in several studies. According to a large study (8,204 patients), EWSs were superior at predicting mortality. The researchers also compared these scoring systems with SIRS criteria and found that both EWSs and qSOFA were better predictors of mortality than SIRS .
Similarly, Usman et al compared qSOFA, EWSs, and SIRS for ED triage of sepsis and septic shock patients. They suggested that the EWS is simply calculated score and the best predictor for mortality and severity .
Ambulance triage and scoring systems play an important role in the emergency setting. Ambulance staff members want to know about the severity of the illness as much as an ED doctor. The researchers conducted a pre-hospital-setting study among 1,713 patients to compare EWSs and qSOFA in predicting ICU hospitalization and 30-day mortality. In this study, EWSs were much more effective at determining these parameters when compared with qSOFA .
There is a lack of data in the literature on qSOFA and EWSs for specific infections. Chang et al researched qSOFA for the in-hospital mortality of H1N1 infection in the geriatric population, enrolling 491 H1N1 patients. Patients with qSOFA ≥ 2 increased the in-hospital mortality risk .
Determining the severity of COVID-19 remains problematic. A study from China suggested that male gender, older age, and hypertension are the most important risk factors for this severity. The researchers included 487 COVID-19 patients, 49 of whom were critically ill at admission time. According to their data, severe cases mainly comprised older (> 50 years old), hypertensive, and male patients. The researchers concluded that by identifying host risk factors associated with severe COVID-19 cases, their study shed light on the underlying mechanisms of the disease progression. They reported that the host risk score provides a helpful tool to identify high-risk patients, which is useful for performing specific strategies to prevent and treat the disease .
It is very important to decide the severity of ED patients without waiting on a blood test or any other imaging studies. Simple scoring systems consisting of vital signs and a patient’s status are much more helpful for clinicians. Analyzing 108 COVID-19 patients retrospectively, Yao et al performed research to identify the clinical characteristics and risk factors associated with severe incidences of SARS-CoV-2 infection. According to their data, older age and comorbidities such as hypertension, higher blood leukocyte or neutrophil count, higher sensitive C-reactive protein level, D-dimer level, Acute Physiology and Chronic Health Evaluation ӀӀ score, and sequential organ failure assessment (SOFA) score were associated with a greater risk of developing severe COVID-19 cases, as were lower lymphocyte count and albumin level .
Rapid and early severity assessment is the main decisive factor for critically ill patients with COVID-19 in the ED. Initial evaluation and treatment strategy are planned according to these scoring systems. Hu et al compared the Modified Early Warning Score (MEWS) and the Rapid Emergency Medicine Score (REMS) according to their outcomes in 138 critically ill COVID-19 patients. They divided patients into two age subgroups (< 65 and ≥ 65years) and reported that the REMS could provide a much more effective risk stratification tool for critically ill patients with COVID-19, especially for those aged < 65 years. The effectiveness of REMS for screening these patients is attributed to its high negative predictive value .
Most members of the patient group were in good condition, and similarly most were hospitalized in the inpatient clinic rather than in the ICU. This situation made it difficult to study critically ill COVID-19 patients.
ED s are the places where the suspicious COVID-19 patients present first, and the ED physicians are responsible for providing effective care during these patients’ stay. Tools are required to predict the severity and prognosis, especially for critically ill COVID-19 patients. Both qSOFA and EWS can predict the hospitalization unit and mortality. But EWS is superior in determining the hospitalization length of COVID-19 patients. At this point, further comprehensive studies are required for the management of suspected or validated COVID-19 patients in the ED.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016;315(8): 801-10.
2. Bora ES, Çakır A, Hacar S, Arıkan C, Yurtsever G, Acar H. Nonthyroid disease syndrome: a strong prognostic predictor of death in patients with pneumonia. Signa Vitae. 2021;17(5):137-41.
3. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill Patients in the Seattle Region – Case Series. N Engl J Med. 2020;382(21): 2012-22.
4. Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, et al. Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS One. 2019;14(1):e0211133.
5. Usman OA, Usman AA, Ward MA. Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department. Am J Emerg Med. 2019; 37(8): 1490–7.
6. Silcock DJ, Corfield AR, Staines H, Rooney KD. Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting. Eur J Emerg Med. 2019;26(6):433-9.
7. Chang SH, Yeh CC, Chen YA, Hsu CC, Chen JH, Chen WL, et al. . Quick-SOFA score to predict mortality among geriatric patients with influenza in the emergency department. Medicine (Baltimore). 2019;98(23):e15966.
8. Shi Y, Yu X, Zhao H, Wang H, Zhao R, Sheng J. Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan. Crit Care. 2020;24(1):108.
9. Yao Q, Wang P, Wang X, Qie G, Meng M, Tong X, et al. . A retrospective study of risk factors for severe acute respiratory syndrome coronavirus 2 infections in hospitalized adult patients. Pol Arch Intern Med. 2020;130(5):390-9.
10. Hu H, Yao N, Qiu Y. Comparing Rapid Scoring Systems in Mortality Prediction of Critically Ill Patients With Novel Coronavirus Disease. Acad Emerg Med. 2020;27(6):461-8.
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Mehmet Tunç, Kemal Sener, Nurettin Yılmaz, Tufan Nayir, Sadiye Yolcu. Early warning score versus quick sequential organ failure assessment in COVID-19. Ann Clin Anal Med 2022;13(6):659-662
Clinical features and prognostic factors affecting survival of ambulatory followed COVID-19 patients aged over 65 years
Murat Yalcinsoy 1, Engin Burak Selcuk 2, Kadir Uckac 2, Abdullah Fahri Sahin 3, Ayse Tas 4, Umut Kasapoglu 5, Recep Bentli 6
1 Department of Chest Disease, School of Medicine, Inonu University, 2 Department of Family Medicine, School of Medicine, Inonu University, 3 Department of Pathology, School of Medicine, Turgut Ozal University, 4 Battalgazi District Health Directorate, 5 Clinic of Pulmonary and Critical Care Medicine, Malatya Training and Research Hospital, 6 Department of Internal Medicine, School of Medicine, Inonu University, Malatya, Turkey
DOI: 10.4328/ACAM.21083 Received: 2022-01-26 Accepted: 2022-03-02 Published Online: 2022-03-07 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):663-668
Corresponding Author: Engin Burak Selcuk, Turgut Ozal Medical Center, Inonu University, Elazığ Yolu 15. Km., 44280, Battalgazi, Malatya, Turkey. E-mail: firstname.lastname@example.org P: +90 532 488 20 43 / +90 422 341 08 80 F: +90 216 421 42 74 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8484-0223
Aim: The majority of the patients with COVID-19 are followed ambulatory. Determination of prognostic factors of mortality in risky groups is essential to improve patient management. The aim of this study is to describe the clinical presentation in patients over 65 years of age with COVID-19 who are followed up at home by a physician and provide insights into the initial prognostic factors in this distinctive population.
Material and Methods: This is a retrospective and observational study. Clinical records of the patients aged over 65 years who were visited by the filiation team, including a physician at home, due to the diagnosis of COVID-19 disease within 2 months were reviewed. Factors affecting mortality were examined.
Results: Our study included 51 deceased (mean age: 75,1±9,0 years, 40,2% males), and 102 patients with COVID-19 who survived (mean age: 73,0±6,9 years, 68,6% male). Platelet count ( < 150.000, OR 7,26, p=0,001), CRP level ( < 4, OR 4,55, p=0,02), albumin level ( OR 3,24, p=0,02), and Troponin I level (OR 0,03, p=0,02) were the strongest predictors for death. When propensity score matching was applied, gender (male, OR 7,14, p=0,02) and platelet count (< 150.000, OR 5,34, p=0,02) were the strongest predictors.
Discussion: Elderly COVID-19 patients have a high mortality rate. An easily measurable and accessible platelet count may be a predictor of a bad outcome. Close follow-up and timely treatment may significantly reduce mortality in high- risk elderly patients under.
Keywords: COVID-19, Frail Elderly, Ambulatory Care, Mortality
SARS-CoV-2 has caused a pandemic after detection of the first case in Wuhan city in December 2019. The spectrum of the disease ranges from pneumonia, mostly asymptomatic, to acute respiratory distress syndrome with a fatal outcome . The first case has been reported on March 10, 2020; growth in different regions within different time periods was detected despite precautions. The case fatality rate is high in elderly patients. The case fatality rate in COVID-19 patients was 2.67% as of the end of 2020 in Turkey. Although 11% of the patients were 65 years of age or older, 72% of deaths are in this age group (available at: https://covid19.saglik.gov.tr/ COVID-19 Haftalık Durum Raporu 12/10/2020 – 18/10/2020 Türkiye).
Since the majority of the patients have mild symptoms, they are followed on an outpatient basis. However, the presence of parameters to predict worsening in patients over 65 years of age, in whom most of the mortality is seen, would enable close follow-up of this group of patients and thus reduce mortality. Although there are many studies on the prediction of mortality in elderly patients, there are no studies focused on demonstrating the deterioration of the home follow-up patient group [2,3].
The aim of this study is to describe the clinical presentation in patients aged over 65 years with COVID-19 who are followed up at home by a physician and provide insights into the initial prognostic factors in this distinctive population.
Material and Methods
The present study was planned as a retrospective observational study. COVID-19 was diagnosed according to the guidelines of the World Health Organization (WHO) (available at: Organization WH. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance, 25 January 2020). Inclusion criteria were patients over 65 years of age who were visited by a filiation team with a physician at home due to the diagnosis of COVID-19 disease within 2 months (October 1-November 31, 2020). Exclusion criteria were those with deficient data.
This study was approved by the Ethical Review Committee of Inonu University (Ethical Review Committee decision date and number: 20/04/2021-2021/1888).
Principles of home attendants
The COVID-19 home follow-up team visited patients over 65 years who had no indication for hospitalization at home. Patients with “positive” PCR test for COVID-19 were identified and recorded daily. The population over the age of 65 was determined and their medicines were left in their homes. The planning was done so that the patient would be visited at home on the 3rd day of a positive PCR test result. Anamnesis Form and laboratory blood tubes for each patient were prepared before the visit. Each team consists of a physician, a nurse, and a driver. The physician obtained the patient history and examined the patient, the nurse measured the patient’s vital findings and collected blood at home. Symptoms, past medical history, co-morbidities and current drugs of the patient were recorded. The field coordinator was contacted and referred to the hospital with an ambulance for the patients for whom the physician recommended hospitalization (impaired vital values, general condition disorder, malnutrition, elderly living alone and/or difficulty in care, etc.).
Clinical, laboratory and radiological findings of the patients on the 3rd-day visit were obtained from the records. Parameters included in the analysis were as follows:
• Demographic and physical examination parameters: age, sex, temperature, heart rate, respiratory rate, blood pressure, peripheral oxygen saturation, comorbidities,
• Symptoms at home visit: fever, dyspnea, cough, chest pain, myalgia, fatigue, or other (including sore throat, headache, diarrhea, abdominal pain).
• Laboratory findings: total white cell blood count, lactate dehydrogenase, fibrinogen, prothrombin time, D-dimer, ferritin, C-reactive protein (CRP). Lymphocyte-monocyte-neutrophil count and percentage, RDW, MPV, NLR (Neutrophil/Lymphocyte Ratio), MLR (monocyte/lymphocyte ratio), PLR (platelet/lymphocyte ratio), troponin, albumin, triglyceride, CK, total protein
Platelet, lymphocyte count, CRP, D-dimer, Ferritin values were divided into groups according to poor prognosis criteria determined by WHO (available at: Organization WH. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases: interim guidance, 19 March 2020.).
The primary study end-point was the patient’s death. Survival follow-up was assessed at 30 days after admission.
The data analysis was performed using SPSS 19.0 (Statistical Package for the Social Sciences, IBM) program. Compliance with normal distribution was evaluated using the Kolmogorov-Smirnov test. Descriptive statistics were presented as mean ± standard deviation for normally distributed data, median (IQR) for non-normally distributed data, and numbers (n) and percentage (%) for countable data. The student t-test was used in the analysis of measurement data conforming to a normal distribution; the Mann-Whitney U test was used in the analysis of measurement data that did not conform to the normal distribution, and the chi-square test was used to evaluate the relationship between categorical data. Related parameters were included in the logistic regression with the “Enter” method and the estimated relative risks were calculated. D-Dimer, Lymphocyte, Platelet, Ferritin and CRP values were taken as categorical according to their prognostic cut-off for COVID-19, other continuous values were taken as categorical. To minimize the selection bias propensity, score matching applied and logistic regression was performed. The type-1 error level was accepted as 0.05.
Fifty-one patients were included in the dead group, and 102 patients were included in the survival group. The characteristics of both groups are summarized in Table 1. Among all patients enrolled, 50.3% were female and 49.7% were male; the mean age was 73.7±7.7 years. All these patients were over 65 years of age, and 5.9% (n=6) of these were over 85 years of age. The age average of dead patients was 75.1±9.0; 15.6% (n=8) of these are over 85 years. The age average of the patients who survived was 73.0±6.9.
There were more male patients in the group of died patients (68.6 % vs. 40.2%, x2 = 10.9, p < 0.001) than in the survivors group. Coronary Artery Disease (CAD) was more common in deceased patients (83.3%) than in survivors (16.7%) (p<0.001).
When the blood groups of the patients were evaluated, A (n=65), B (n=20), 0 (n=51) and AB (n=13) blood groups did not make a significant difference between groups (p=0.621). Furthermore, Rh+ (n=129) and Rh- (n=20) blood groups did not affect the outcome in the course of the disease (p= 0.921).
The median Pulse O2 saturation of all participants was 96 (94-97), and respiratory rate median was 18 (16-20). There was no significant difference in the proportion of patients with fever, dyspnea, chest pain, myalgia and GIS symptoms between the two groups (all P > 0.05). However, the proportion of patients with cough was significantly higher in the deceased group compared with the survivor group. While there was no difference in respiratory rate between the groups, oxygen saturation measured in room air was significantly lower in the deceased group than in the survivor group (95 (91-96) vs 96 (95-98), U = 1540, p < 0.001) (Table 1).
When the laboratory values of the COVID-19 patients in the study were examined, in the hemogram, leukocyte count, neutrophil count, neutrophil percentage, RDW-CV, NLR, MLR parameters were significantly higher in the deceased group compared to the survivor group (p<0.05). Lymphocyte count, lymphocyte percentage, monocyte percentage and platelet count were significantly lower in the deceased group (p<0.05). Total protein, triglyceride and albumin values among biochemistry parameters were significantly lower in the deceased group (p<0.05). Creatine Kinase (CK) and troponin levels were significantly higher in the deceased group than in the survival group (p<0.05). A review of serology and hormone parameters revealed that CRP and ferritin values were significantly higher in the deceased group than in thesurvivor group (p<0.05) (Table 2).
When assessing D-dimer level according to the poor prognostic factor cut-off point, there was no relationship between the disease outcome as survival or death. In the evaluation of platelet, lymphocyte count, CRP and ferritin values according to the bad prognostic factor cut-off point, the deceased group had significantly worse prognostic blood values than the survivors group (Table 2).
The variables were put into the logistic regression model with the ENTER method in order to evaluate the factors affecting the recovery or death from the disease. Nagelkerke R2 value was detected as 0.65. The specificity of the model was 80.4, the sensitivity of the model was 90.2, and the accuracy of the model was 86.9.
Survival was 7.3 times higher in patients with a platelet level above 150.000 than in those with a lower platelet level. Survival was 4.5 times higher in those with a CRP value below 4. As troponin I level decreased and albumin level increased, survival also increased significantly (Table 3).
Propensity Score Matching was applied to the groups. Survival was 7.14 times higher in men than in women. Survival was 5.34 times higher in patients with a platelet level above 150.000 than in those with a lower platelet level (Table 3).
In our study, we determined that a decrease in platelet count and gender are independent risk factors for mortality. We believe that thrombocytopenia detected at the beginning in outpatients should be a serious risk for mortality, and these patients should be followed carefully and closely. Since the hemogram is a simple, economical, fast and widely available laboratory test, it will ensure convenience in follow-up and applicability. According to our current knowledge, this is the first study on mortality markers in patients under outpatient follow-up.
Numerous studies have been published on mortality factors [4-7]. Age is the best known predictor of mortality, and countries with older populations have been shown to have a death-to-case ratio . Our study is already focused on this high-risk group. Another frequently reported mortality predictor is the male gender. Recent studies have shown that the male gender is a risk factor independent of age [8,9]. The effect of the male gender on mortality was shown in this study, too.
We also searched for symptoms and findings in our study. Cough, shortness of breath and fever (35-40%) have been reported as main symptoms in moderate to severe disease (Available at: Organization WH. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases: interim guidance, 19
March 2020), . However, the most common symptom (78.8-88.5%) in the early period was fever [5,8]. The most common symptoms in our patient group were myalgia, cough and fever. None of these parameters were associated with mortality. The symptoms given in the literature are usually the symptoms and signs seen in hospitalized patients. Differences from our results may be related to the fact that our patients were outpatients, the number of patients in the study and local data.
The platelet count is an ideal clinical prognostic tool because it is easy and inexpensive to perform. It is a biomarker that is independently associated with disease severity and risk of mortality in the intensive care unit . Furthermore, the lower platelet count is a biomarker for disease severity scores such as the Multiple Organ Dysfunction Score (MODS), the Simplified Acute Physiology Score (SAPS) II, and the Acute Physiology and Chronic Health Assessment (APACHE) II . A trend towards lower platelet counts in COVID-19 patients may suggest a worsening thrombotic state , lower platelet counts are associated with increased mortality. Yang et al. showed that mortality increased as the platelet count decreased (platelet counts 100–150, 50–100, and 0–50 × 109/L, respectively, and hospital mortality of 3.4 (95% confidence interval [CI] 2.4–5.0), 10.0 (95% CI), respectively) 7.2-14.0) and 13.7 (95% CI 9.9-18.9) . Moreover, there are many studies showing that thrombocytopenia is associated with mortality and disease severity in line with these findings [6,7,14]. Lippi et al. stated that thrombocytopenia increased mortality 3 times in a meta-analysis including 9 studies including 1779 patients . A study from Wuhan stated that thrombocytopenia detected at admission in COVID-19 patients increased mortality 4.24 times. There was a correlation with mortality was between thrombocytopenia in this study. On the contrary, improvement of thrombocytopenia in COVID-19 patients could mean imminent clinical improvement .
Acute phase reactants in COVID-19 infection are clinically important similar to any infection. It is also important to predict both the severity of the disease and the mortality. It may also guide the treatment decision. Several studies indicated that inflammatory markers are associated with both disease severity and mortality [17, 18]. In a meta-analysis of 64 studies on mortality and disease severity, neutrophils, lymphocytes, interleukin-6 (IL-6), ferritin, C-reactive protein (CRP), D-dimer and high sensitivity troponin I were found to be associated with mortality independent of age and gender . Bannaga et al detected in hospitalized elder patients that CRP and lower serum albumin levels were associated with mortality when the age was ignored . There are studies reporting that the CRP-albumin ratio and the neutrophil-albumin ratio are indicators of mortality [21, 22]. We found in our study that the inflammatory markers CRP, Troponin I and albumin were risk factors in logistic regression model but in matched groups, only thrombocytopenia and gender were independent risk factors. However, examination of inflammatory markers may also be important in predicting the clinical course.
Our study has some limitations. First, the present study was a retrospective study with a relatively small number of cases. The second is carrying out the study in a single center. These two limitations may reduce the overall reflection of the findings. These findings are preliminary data and we believe that they will guide our further studies and patient follow-ups. We think that the strength of our study is that all patients detected in a province are followed up by an outpatient doctor.
Our findings show that male gender and thrombocytopenia will be reliable predictors of mortality in elderly patients. Our study is the only study reporting patients followed up with an outpatient doctor without hospitalization. Since a large proportion of COVID-19 patients are followed as outpatients, our results are important in determination of follow-up parameters and predicting mortality, and may lead to larger studies.
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Animal and human rights statement
Conflict of interest
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3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.
4. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA. 2020;323(18):1775-16.
5. Li J, Huang DQ, Zou B, Yang H, Hui WZ, Rui F, et al. Epidemiology of COVID-19: A systematic review and meta-analysis of clinical characteristics, risk factors, and outcomes. J Med Virol. 2021;93(3):1449-58.
6. Merugu GP, Neishwat Z, Balla M, Patel M, Fatima R, Shiekh T, et al. Predictors of Mortality in 217 COVID-19 Patients in Northwest Ohio, United States: A Retrospective Study. J Med Virol. 2021;93(5):2875-82.
7. Lu W, Yu S, Liu H, Suo L, Tang K, Hu J, et al. Survival analysis and risk factors in COVID-19 patients. Disaster Med Public Health Prep. 2021:1-15.
8. Li Lq, Huang T, Wang Yq, Wang Zp, Liang Y, Huang Tb, et al. COVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol. 2020;92(6):577-83.
9. Jin J-M, Bai P, He W, Wu F, Liu X-F, Han D-M, et al. Gender differences in patients with COVID-19: focus on severity and mortality. Front Public Health. 2020;8:152.
10. Varol Y, Hakoglu B, Kadri Cirak A, Polat G, Komurcuoglu B, Akkol B, et al. The impact of charlson comorbidity index on mortality from SARS-CoV-2 virus infection and A novel COVID-19 mortality index: CoLACD. Int J Clin Pract. 2021;75(4):e13858.
11. Vanderschueren S, De Weerdt A, Malbrain M, Vankersschaever D, Frans E, Wilmer A, et al. Thrombocytopenia and prognosis in intensive care. Crit Care Med. 2000;28(6):1871-6.
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Download attachments: 10.4328.ACAM.21083
Murat Yalcinsoy, Engin Burak Selcuk, Kadir Uckac, Abdullah Fahri Sahin, Ayse Tas, Umut Kasapoglu, Recep Bentli. Clinical features and prognostic factors affecting survival of ambulatory followed COVID-19 patients aged over 65 years. Ann Clin Anal Med 2022;13(6):663-668
Relationship between mNUTRIC score and 28-day mortality in critical patients
Semiha Orhan 1, Kemal Yetiş Gulsoy 2
1 Department of Intensive Care Unit, Afyonkarahisar University of Health Sciences, Afyonkarahisar, 2 Department of Intensive Care Unit, Burdur Public Hospital, Burdur, Turkey
DOI: 10.4328/ACAM.21085 Received: 2022-01-27 Accepted: 2022-03-07 Published Online: 2022-04-07 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):669-673
Corresponding Author: Semiha Orhan, Department of Intensive Care Unit, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey. E-mail: email@example.com P: +90 532 728 19 79 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2617-6197
Aim: In this study, we aimed to investigate the effect of the modified NUTRIC score on 28-day mortality in critical patients in the internal medicine intensive care unit.
Material and Methods: A retrospective review of patients in the intensive care unit between 01.10.2019 and 01.03.2020 was carried out. The study included patients aged >18 years, treated for more than twenty-four hours in the Intensive Care Unit, with mechanical ventilation for more than 48 hours. Patient demographic data, length of stay in the internal medicine intensive care unit, and the modified NUTRIC score were recorded. Patients were separated into two groups according to the calorie sufficiency calculated in the first 5 days as those receiving <70% energy or >70% energy.
Results: One hundred twenty-eight patients were examined. Supportive treatment of vasopressor drugs was applied to 34 (26.6%) patients, renal replacement therapy to 35 (27.3%) and mechanical ventilation to 71.8% of the patients. The 28-day survival rate was determined to be statistically significantly low in the group with a high mNUTRIC score (p:0.044). The time spent on mechanical ventilation was determined to be statistically significantly longer in the group receiving >70% energy (p<0.05).
Discussion: The higher rate of 28-day mortality in patients in the medicine intensive care unit was determined to be related to the higher mNUTRIC score. When >70% of the daily calorie requirement was administered to patients on a mechanical ventilator, the number of days spent on mechanical ventilation was high.
Keywords: Intensive Care Units, Mortality, Nutritional Status
Adequate nutrition is very important for critical patients in the intensive care unit (ICU). However, the heterogeneity of critical patients means that not all patients will respond equally to nutritional treatment .
The provision of adequate nutrition is standard care for critical patients expected to remain in the intensive care unit for more than 48 hours .
A lengthy stay in the intensive care unit is a reason for malnutrition together with loss of skeletal muscle mass and function, and can lead to diminished the quality of life, weakness and morbidity in the long term after discharge from the intensive care unit .
Rates of inadequate nutrition have been reported to be extremely high in ICU patients compared with the general hospital population . Infectious and non-infectious complications and reduced functional strength resulting from inadequate nutrition have been reported to be associated with a longer duration of stay in hospital and increase hospital costs [5,6].
Various methods are used to assess the risk of malnutrition . The first scoring system to be used was the Nutrition Risk in the Critically Ill (NUTRIC) score, which was developed by Heyland et al for the evaluation of intensive care unit patients and includes comorbidities, reduced energy intake, body mass index, and prognosis markers. Interleukin-6, which is used as a marker of inflammation, and so it is possible to calculate the modified NUTRIC (mNUTRIC) score without using IL-6. Risk groups are defined as low (0-4) or high (5-9) according to the mNUTRIC score, and high-risk groups have been associated with poor prognosis .
In this study, we aimed to investigate the effect of mNUTRIC score on 28-day mortality in critically ill patients admitted to our intensive care unit.
Material and Methods
This retrospective study was conducted in the Internal Diseases ICU of Afyonkarahisar Health Sciences University Medical Faculty Hospital between 01.10.2019 and 01.03.2020. Approval for the study was granted by the University Clinical Research Ethics Committee (decision no:73, dated: 2020). All procedures were applied in compliance with the principles of the Helsinki Declaration.
The study included patients aged >18 years, in the intensive care unit for more than 24 hours and patients applied with a mechanical ventilator for more than 48 hours. Patients who developed mortality and those discharged from intensive care unit within 24 hours were not included in the study. At 24 hours after admission to the intensive care unit, enteral nutrition (EN) of 25 kcal (kg.d) was started. If the patient had enteral intolerance or contraindication for EN, parenteral nutrition (PN) support was given. A residual gastric volume was checked every 12 hours, and if <500mL, the nutrition was continued and if >500 mL, the nutritional support was terminated. Calorie intake was calculated for 5 days. The calorie sufficiency of patients was separated into 2 groups as those receiving <70% or >70% of the energy requirement calculated for the first 5 days. Calorie sufficiency (%) was calculated as (5-day calorie intake/ 5-day calorie requirement) x 100.
The nutritional risk status of the patients was defined using the 9-point mNUTRIC score. Those with a score of 0-4 were evaluated as low risk and those with a score of 5-9 as high risk of malnutrition, which has been associated with poor clinical results .
The conformity of continuous variables to normal distribution was assessed with the Shapiro-Wilk and Kolmogorov-Smirnov tests. Continuous variables were stated as mean±standard deviation (SD) values if showing normal distribution and as median and interquartile range values if distribution was not normal. Categorical data were stated as number (n) and percentage (%). The Chi-square test was applied in the comparisons of categorical variables. The Independent Samples t-test was used for comparisons of continuous variables with normal distribution and the Mann-Whitney U-test for those not showing normal distribution. The Kaplan-Meier method was applied in survival analysis. The factors affecting survival were examined with the Log Rank test.
The mean age of the patients evaluated was 63.4±12 years, and the mean body mass index was 25.5±4.8 kg/m2. Vasopressor drugs were used by 34 (26.6%) patients, renal replacement therapy (RRT) by 35 (27.3%), and 92 (71.8%) received mechanical ventilator (MV) support. The median length of stay in intensive care unit was 12 days (IQR: 8-20), and the mean hospital stay before admission to ICU was 6 days. APACHE II score was calculated as a mean value of 20.1±6.1. Characteristics of all the patients and of the patients with MV, are shown according to 28-day mortality in Table 1. In both groups, the mNUTRIC score of patients with mortality was found to be significantly higher than that of surviving patients (p<0.05). The rates of vasopressor use and RRT were determined to be significantly higher in the patients with mortality compared to the surviving patients in both groups (p<0.05).
The 28-day survival of patients classified according to the mNUTRIC score is represented in graph form in Figure 1. The 28-day survival rates of patients with a high mNUTRIC score
were determined to be significantly low (p:0.044).
No significant difference was determined between the groups with <70% or >70% intake of daily calorie requirement in respect of length of stay in intensive care unit, length of hospitalization before admission to intensive care unit, mNUTRIC score, and 28-day mortality (p>0.05). The median length of time on MV was determined to be significantly longer in the group receiving >70% energy (p<0.05). The comparisons of length of stay in the intensive care unit, 28-day mortality, length of hospitalization before admission to ICU, and duration of MV requirement according to energy intake are shown in Table 2.
In this study, we aimed to investigate the effect of mNUTRIC score on 28-day mortality in critically ill patients admitted to our intensive care unit. The results of the survival analysis demonstrated a relationship between mNUTRIC score, vasopressor drug use and RRT and 28-day mortality in all patients and those with MV support.
Wang et al compared a high NUTRIC score with those with a low NUTRIC score, and reported higher mortality rates in patients with high NUTRIC scores .
The mNUTRIC score may be helpful in identifying patients who will gain the most benefit from nutritional support [9,11].
It has been reported that the majority of severe COVID-19 patients with mNUTRIC scores of high nutritional risk and patients at high nutritional risk admitted to ICU have a significantly higher 28-day mortality rates compared to those at low nutritional risk .
Similarly, in the current study, 28-day mortality was determined to be significantly higher in patients with a high mNUTRIC score than in patients with a low mNUTRIC score. The optimal amount of nutritional support to obtain the maximum benefit in critical patients remains a matter of debate. Observational studies have reported a relationship between full calorie intake in critically ill patients at high nutritional risk and better outcomes [8,9].
While some studies have shown improved patient outcomes associated with optimal nutrition [13,14], others have reported no significant effect [15,16].
There are also studies reporting that critical patients with adequate nutrition did not benefit significantly from nutritional support .
As the heterogeneity of patients in ICU, and the differences in disease severity and organ failure mean that not all patients will respond equally to nutrition therapy, it can be considered that it would be most useful to provide nutritional support on an individual patient basis.
Jung et al reported that in the group with a high mNUTRIC score, 30-day mortality was higher in patients with insufficient calorie supplementation (calorie sufficiency <70%) compared to those with sufficient supplementation, but this was not observed in patients with low mNUTRIC scores .
Zusman et al stated that patients with 70% target calories had better outcomes than patients with optimal nutrition (receiving 100% target calories), and intake of >70% calories was associated with a longer stay in ICU and a longer duration of MV . In the current study, there was no statistically significant difference in 28-day mortality rates between the critical patients receiving >70% of the target calorie requirement and the patients receiving <70%, but the time on MV was significantly longer in the >70% group (p:0.04). In the INTACT study, higher calorie intake was reported to increase mortality in patients with acute liver damage . This can be explained by high calorie intake increasing the respiratory workload and therefore prolonging the time to weaning from ventilation.
There were some limitations in this study, primarily that it was retrospective and conducted in a single centre, and that the low number of patients prevents generalization of the results. Furthermore, although an indirect calorimeter is ideal for the calculation of the energy requirement of an individual, this was not available throughout the study. Therefore, as an alternative, a formula using the ideal body weight of each patient was used for the calculation of energy required. A further limitation was that protein sufficiency, which can affect clinical results, was not taken into consideration.
The results of this study demonstrated that high mNUTRIC scores in ICU patients are associated with 28-day mortality. Patients on MV receiving >70% of the calorie requirement spent more days on MV than those receiving <70%. Despite the energy target of 100% of the calculated energy requirement remaining the ideal target, further studies using an indirect calorimeter to calculate the real-time energy requirement in ICU may be useful to confirm the outcomes of this study.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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5. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2013;32(5):737-45
6. Merli M, Giusto M, Gentili F, Novelli G, Ferretti G, Riggio O, et al. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver Int. 2010;30(2):208-14.
7. Arabi YM, Aldawood AS, Al-Dorzi HM, Tamim HM, Haddad SH , Jones G et. al. Permissive underfeeding or standard enteral feeding in high and low nutritional risk critically III adults: posthoc analysis of the permit trial. Am J Respir Crit Care Med. 2017;195(5):652-62.
8. Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Critical Care. 2011;15(6):1-11.
9. Rahman A, Hasan RM, Agarwala R, Martin C, Day AG, Heyland DK. Identifying critically-ill patients who will benefit most from nutritional therapy: further validation of the “modified NUTRIC” nutritional risk assessment tool. Clin Nutr. 2015;35 (1):158-62.
10. Wang N, Wang MP, Jiang L, Du B, Zhu B, Xi XM, Association between the modified Nutrition Risk in Critically 1 Ill (mNUTRIC) score and clinical outcomes in the intensive care unit: A secondary analysis of a large prospective observational study. BMC Anesthesiol. 2021; 8;21(1): 1-9.
11. de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.
12. Zhang P, He Z, Yu G, Peng D, Feng Y, Ling J, et al. The modified NUTRIC score can be used for nutritional risk assessment as well as prognosis prediction in critically ill COVID-19 patients. Clinical Nutrition. 2021; 40(2):534-41.
13. Philipson TJ, Snider JT, Lakdawalla DN, Stryckman B, Goldman DP. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121-8.
14. Singer P, Anbar R, Cohen J, Shapiro H, Shalita-Chesner M, Lev S, et al. The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med. 2011; 37(4):601-9.
15. Chapman M, Peake SL, Bellomo R, Davies A, Deane A, Horowitz M, et al. Energy- dense versus routine enteral nutrition in the critically ill. N Engl J Med. 2018; 379(19):1823-34.
16. Chelkeba L, Mojtahedzadeh M, Mekonnen Z. Effect of calories delivered on clinical outcomes in critically ill patients: systemic review and meta-analysis. Indian J Crit Care Med. 2017; 21(6):376-90.
17. Jung YT, Park JY, Jeon J, Kim MJ, Lee SH, Lee JG. Association of Inadequate Caloric Supplementation with 30-Day Mortality in Critically Ill Postoperative Patients with High Modified NUTRIC Score. Nutrients. 2018;10(11): 1589.
18. Zusman O, Theilla M, Cohen J, Kagan I, Bendavid I, Singer P. Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study. Critical Care. 2016; 20(1):367.
19. Braunschweig CA, Sheean PM, Peterson SJ, Perez SG, Freels S, Lateef O, et al: Intensive nutrition in acute lung injury: A clinical trial (INTACT). JPEN J Parenter Enteral Nutr. 2015; 39(1):13–20
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Semiha Orhan, Kemal Yetiş Gulsoy. Relationship between mNUTRIC score and 28-day mortality in critical patients. Ann Clin Anal Med 2022;13(6):669-673
Evaluation of incidental findings in patients undergoing computed tomography (CT) due to trauma
Ayse Cetin 1, Serkan Altuntas 1, Isil Yurdaisik 2
1 Department of Emergency Medicine, Altinbas University, Bahcelievler Medical Park Hospital, 2 Department of Radiology, Istinye University, Medical Park Gaziosmanpasa Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.21086 Received: 2022-01-27 Accepted: 2022-03-09 Published Online: 2022-03-10 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):674-678
Corresponding Author: Ayse Cetin, Department of Emergency Medicine, Altinbas University, Bahcelievler Medical Park Hospital, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 212 484 14 84 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1352-0035
Aim: There are numerous studies reporting incidental findings in traumatic and non-traumatic patients undergoing imaging studies for various reasons. However, further studies are needed for the accumulation of evidence. Therefore, we conducted this retrospective study to analyse incidental findings in patients who underwent CT scans in our hospital due to trauma.
Material and Methods: This retrospective observational study included 1263 patients who were admitted to the emergency department of our hospital with the diagnosis of trauma and who underwent CT scans. Patients’ demographic data such as age, gender and body mass, past medical history, type of trauma, mechanism of trauma, involved body part, length of stay in hospital and discharge status were analyzed. The incidental findings were divided into Class I, Class II and Class III based on the previous studies in the literature.
Results: The most common cause of trauma was found as falls at 65% followed by motor vehicle accidents (21%). The type of trauma was found as blunt in 425 (93.41%), penetrating in 7 (1.54%) and other in 23 (5.05) patients with incidental findings. The mean length of stay in the hospital was 9.2 ± 11.00 days in these patients. A total of 698 incidental findings were found in 455 patients, with 310 (68.30%) having one finding and 145 (31.87%) having more than one finding.
Discussion: We found the rate of incidental findings as 36.3%, consistent with many previous studies in the literature. It is crucial to communicate and document incidental findings and to prepare a proper follow-up schedule.
Keywords: Trauma, CT Scans, Incidental Findings, Incidentaloma, Follow-Up
Trauma is among the leading causes of morbimortality worldwide. Trauma remains the leading cause of mortality among teenagers and a major reason for morbidity and mortality among elderly, and is a growing concern and important public problem . Between 2006 and 2012, there have been nearly 200 million traumatic injuries discharged from emergency departments across the USA .
Advancements in computed tomography (CT) technology provided significant improvements such as decreased scan times (less than 1 minute) and high-quality thinner slices (< 1 mm) . CT is the gold standard for the assessment of solid organ injury following trauma and is widely used as an imaging modality because of its ability to mainly demonstrate trauma-related thoracic, abdominal, cranial and cervical abnormalities in detail . CT scans provide not only information about acute trauma-induced injuries, but also reveal pathologies that are not associated with trauma and are called ‘incidental findings’ . The use of CT has improved the immediate diagnosis of injuries as well as increased detection of incidental findings .
With the widespread use of imaging modalities, the prevalence of both traumatic and non-traumatic incidental findings has increased. Therefore, detection of serious illness at an earlier asymptomatic stage, survival can be increased and mortality decreased . The frequency of incidental findings depends on the examination modality, field strength and sequence as well as a patient cohort. Studies in the literature have reported clinically significant incidental findings between 3.5-16.5% in trauma patients . In fact, because of the comprehensive nature of CT scanning, incidental findings are found on almost all CT scans performed for various reasons in a radiology department .
On the other hand, concerns have been raised about communicating incidental findings to patients and/or relevant specialties, and there is ongoing debate in the literature on this issue . Furthermore, these findings also increase patients’ anxiety and healthcare costs because of additional investigations undertaken . Since the rapidly advancing image resolution is driving a surge in incidental findings. The frequency of such findings is increasing day by day because of the rapidly advanced improvements in the duration and section thickness, i.e. resolution of CT scans.
In order to find answers to the raised concerns and questions on incidental findings, first of all, the prevalence of incidental findings should be investigated and these findings should be discussed in detail. There are numerous studies reporting incidental findings in traumatic and non-traumatic patients undergoing imaging studies for various reasons. However, further studies are needed for the accumulation of evidence on the problem to achieve national and international consensus. Therefore, we conducted this retrospective study to analyze incidental findings in patients who underwent CT scans in our hospital due to trauma.
Material and Methods
Study Design and Patients
Before beginning, the study protocol was approved by the Ethics Committee of our hospital with the 15/09/2020 dated and 77 numbered decision. Patient consent was waived since the study was retrospective. The study was performed in line with the ethical principles of the Declaration of Helsinki (DoH).
This retrospective observational study included 1263 patients who were admitted to the emergency department of our hospital with the diagnosis of trauma with various underlying mechanisms and who underwent CT scans between 2018 and 2020. Study data were collected from the patient files in the electronic medical records system. Patients who underwent CT scans of the whole body, head, cervical spine, chest, abdomen and pelvis were included in the study.
Patients’ demographic data such as age, gender and body mass, past medical history (smoking status, alcoholism, comorbidities, smoking, previous surgeries), type of trauma (blunt vs penetrating), mechanism of trauma (fall, motor vehicle accident, pedestrian injury, gunshot wound, assault, stab, other), involved body part, injury severity score, length of stay in hospital and discharge status were recorded and analyzed. Patients aged under 18 years and above 75 years, who did not undergo CT scans, those with poor scanning range and patients with missing data in the reports were excluded from the study. In addition, normal anatomic variations and artifacts were excluded. The frequency of incidental findings, length of hospital stay and subsequent interventions for the incidental findings during 1-year follow-up were also recorded. CT scans were performed by experienced radiologists.
Evaluation of Incidental Findings
The CT scans were retrospectively reviewed for the presence of reported incidental findings. A total of 1,500 patient files involving CT reports with images and other information were reviewed, and 237 reports with exclusion criteria were excluded from the analysis. The remaining 1263 reports were subjected to analysis. An incidental finding was defined as any finding not related to traumatic injury. Accordingly, 455 (36.03%) CT reports were found to have incidental findings. The incidental findings were divided into three main groups based on the previous studies in the literature [7, 12-14]:
Class I: minor degenerative, non-degenerative, congenital findings that do not require further investigation
Class II: findings do not require emergency intervention, but require follow-up within 3 months to 1 year
Class III: findings that require urgent investigation before discharge from hospital or soon after discharge
Data obtained in this study were statistically analyzed using SPSS version 26.0 (SPSS, Statistical Package for Social Sciences, IBM Inc., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables as frequency counts and percentages. The relationship between the incidental findings and the age and gender of the patients was evaluated using the independent sample t-test. P- values <0.05 were considered statistically significant.
A total of 1500 patient files were reviewed and 1263 reports who met the inclusion criteria were selected for further analysis. Two hundred and thirty-seventh reports were excluded because of the exclusion criteria. Out of those 1263 patients, 455 (36.03%) were found to have incidental findings on CT, with about 1/3 of them having more than one incidental finding (145, 31.87%).
The mean age of the patients was 56.5±23.07 years in all patients and 64.01±25.2 years for the patients with incidental findings. Incidental findings were further analyzed in patients aged >65 years to determine the effect of age on the frequency of incidental findings. Of the patients, 525 (41.57%) were aged over 65 years. The frequency of incidental findings was not statistically different between the genders (p>0.05). But it was statistically significantly higher in patients aged ≥ 65 years compared to younger patients (for both, p<0.001). Demographic characteristics of the patients with incidental findings on CT scans are given in Table 1.
When baseline clinical characteristics of the patients were examined, 160 (35.16%) of the patients were active smokers and 15 (3.27%) were alcohol abusers. The distribution of the comorbidities in the patients with incidental findings is shown in Figure 1.
The most common cause of trauma was found as falls at 65%, followed by motor vehicle accidents at 21%. The distribution of the mechanisms underlying trauma in patients with incidental CT findings is presented in Figure 2.
The type of trauma was found as blunt in 425 (93.41%), penetrating in 7 (1.54%) and other in 23 (5.05) patients with incidental findings. Injury severity score (ISS) was found as 14.5±6.7 in all patients and 13.2±6.6 in patients with incidental findings. The number of CT scans was found as 433 (95.16%) of the head, 270 (59.34%) of the chest, 402 (88.35%) of the abdomen/pelvis and 214 (47.03%) of the whole body. A total of 173 (38.02%) patients with incidental findings required ICU admission due to trauma. The mean length of stay in the hospital was found as 9.2 ± 11.00 days in these patients. Whereas 15 (3.30%) patients died in the hospital, 238 (52.31%) patients were discharged home, and the other 202 (44.40%) patients were referred to other services. Only 67 (14.73%) of the patients with incidental findings continued to follow-up visits. A total of 698 incidental findings were found in 455 patients with 310 (68.30%) having one finding and 145 (31.87%) more than one finding. The distribution of the incidental findings according to the classes is given in Table 2.
Patients being evaluated for traumatic injury often undergo CT scans performed in the head, cervical spine, chest, abdomen, pelvis or whole body. CT scans are an excellent imaging modality to identify traumatic injuries as well as to detect other pathologic conditions that are not related to trauma, which are called “incidental findings” or with a novel term “incidentalomas”. This, of course, raises the question of how best to handle the additional information obtained.
In the present study, we investigated the incidence and characteristics of incidental findings in patients undergoing CT scans due to trauma. We found the incidence of these findings as 36.3%. In other words, approximately 1.8 of each 5 CT scans revealed incidental findings. This finding is similar to the results of previous studies. In their study on incidental findings on CT scans in the emergency department, Thompson et al. reported the incidence of incidental CT findings as 33.4%. This rate was reported as 40% in a study by Andrawes et al., examining a total of 1000 CT scans . Other studies in the literature also reported similar results [6, 12].
As expected, the most common CT incidental findings were detected in abdomen/pelvis region, while the least common findings were in the head region despite the highest rate of CT scans of the head. In our study, incidental findings were defined as Class I in 105, Class II in 468 and Class III in 125 scans. The highest rate was found in Class II findings that required follow-up visits within 3 months to 1 year. However, when these findings were further investigated, it was found that there was no need for urgent diagnostic or therapeutic studies before discharge. On the other hand, as many authors report in the literature, we also think that incidental findings should be communicated to the patient or their families and documented [14, 15]. Studies have shown that proper follow-up visit planning at the initial visit decreased the number of patients lost to follow-up .
In our study, we did not find a significant difference between the two sexes in terms of the rate of incidental findings (p>0.043). Likewise, Barboza et al. did not find an association between gender and incidental findings, while some studies reported female dominance . The difference might be resulted from the study populations included.
It is obvious that incidental findings are associated with aging, namely a higher rate of these findings are expected to be detected in older patients. In the present study, patients aged ≥ 65 years had a much higher rate of incidental findings compared to the younger patients. In this age group, 54.51% of all incidental findings were detected. Barboza et al. reported a higher rate of incidental findings at cervical spinal CT of traumatically injured patients, especially among older patients .
We also found insufficient follow-up documentation of the patients with incidental findings, and could not include assessment of the follow-up documentation in our study due to missing data. In a study by Munk et al., 43% of trauma patients had incidental findings on CT scans of the abdomen and pelvis, and only 27% of those had documentation of the findings . It would be more reasonable to closely follow up these patients not to miss the opportunity of early diagnosis and therapy and increasing the chance of survival. In our study, only 14.73% of the patients visited our hospital for follow-up. This rate is similarly low in previous studies with Andrawes et al. reporting this rate as 10% .
This study has several limitations. Major limitations of the study include its retrospective design and being conducted in an emergency department of a single center. Thus, the results cannot be generalized. In addition, incidental findings could not be analyzed according to the body regions in more detail. Variables could be compared with the trauma patients without incidental findings. Furthermore, we could not evaluate the follow-up process of the patients with incidental findings due to missing documentation. We believe that our findings will contribute to the accumulation of evidence for incidental findings. Further prospective multicenter studies with long-term follow-up of the patients with incidental findings are urgently needed.
Incidental findings are common on CT scans performed to evaluate injuries in trauma patients because almost all patients with a traumatic accident undergo CT examination. We found the rate of incidental findings as 36.3%, consistent with many previous studies in the literature. It is crucial to communicate and document incidental findings and to prepare a proper follow-up schedule.
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Animal and human rights statement
Conflict of interest
1. DeGrauw X, Annest JL, Stevens JA, Xu L, Coronado V. Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006-2011. J Safety Res. 2016;56:105–9.
2. DiMaggio CJ, Avraham JB, Lee DC, Frangos SG, Wall SP. The Epidemiology of Emergency Department Trauma Discharges in the United States. Acad Emerg Med. 2017;24(10):1244-56.
3. Lee JY, Jung MJ, Lee JG, Lee SH. Prevalences of Incidental Findings in Trauma Patients by Abdominal and Pelvic Computed Tomography. J Trauma Inj. 2016;29(3):61-7.
4. Ergun T, Lakadamyali H. The prevalence and clinical importance of incidental soft-tissue findings in cervical CT scans of trauma population. Dentomaxillofac Radiol. 2013;42(10):20130216.
5. You JS, Lee HJ, Chung YE, Lee HS, Kim MJ, Chung SP, et al. Diagnostic radiation exposure of injury patients in the emergency department: a cross-sectional large scaled study. PLoS One. 2013;8(12):e84870.
6. Ekeh AP, Walusimbi M, Brigham E, Woods RJ, McCarthy MC. The prevalence of incidental findings on abdominal computed tomography scans of trauma patients. J Emerg Med. 2010;38(4):484-9.
7. Sierink JC, Saltzherr TP, Russchen MJ, de Castro SM, Beenen LF, Schep NW, et al. Incidental findings on total-body CT scans in trauma patients. Injury. 2014;45(5):840-4.
8. James MK, Francois MP, Yoeli G, Doughlin GK, Lee SW. Incidental findings in blunt trauma patients: prevalence, follow-up documentation, and risk factors. Emerg Radiol. 2017;24(4):347-353.
9. Bluemke DA. Coronary computed tomographic angiography and incidental pulmonary nodules. Circulation. 2014;130(8):634-7.
10. Baugh KA, Weireter LJ, Collins JN. The trauma pan scan: what else do you find? Am Surg. 2014;80(9):855-9.
11. Onwubiko C, Mooney DP. The prevalence of incidental findings on computed tomography of the abdomen/pelvis in pediatric trauma patients. Eur J Trauma Emerg Surg. 2018;44(1):15-18.
12. Klein RP, Velan G, Young N, Shetty A, Moscova M. Quality use of diagnostic imaging in trauma, and the impact on emergency medical practice-a retrospective clinical audit [published correction appears in Emerg Radiol. 2021 Mar 19;]. Emerg Radiol. 2021;28(4):761-70.
13. Munk MD, Peitzman AB, Hostler DP, Wolfson AB. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med. 2010;38(3):346-50.
14. Andrawes P, Picon AI, Shariff MA, Azab B, von Waagner W, Demissie S, et al. CT scan incidental findings in trauma patients: does it impact hospital length of stay? Trauma Surg Acute Care Open. 2017;2(1):e000101.
15. Seah MK, Murphy CG, McDonald S, Carrothers A. Incidental findings on wholebody trauma computed tomography: Experience at a major trauma centre. Injury. 2016;47(3):691-4.
16. Meyering SH, Schrader CD, Kumar D, Zhou Y, Alanis N, Shaikh S, et al. Role of HEART score in evaluating clinical outcomes among emergency department patients with different ethnicities. J Int Med Res. 2021;49(4):3000605211010638.
17. Barboza R, Fox JH, Shaffer LE, Opalek JM, Farooki S. Incidental findings in the cervical spine at CT for trauma evaluation. AJR Am J Roentgenol. 2009;192(3):725-9.
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Ayse Cetin, Serkan Altuntas, Isil Yurdaisik. Evaluation of incidental findings in patients undergoing computed tomography (CT) due to trauma. Ann Clin Anal Med 2022;13(6):674-678
A corroborative study of effects of body mass index on the anatomical region of hindfoot
Wajid Ali Chatha
Department of Anatomy, College of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
DOI: 10.4328/ACAM.21088 Received: 2022-01-27 Accepted: 2022-03-10 Published Online: 2022-03-29 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):679-682
Corresponding Author: Wajid Ali Chatha, Department of Anatomy, College of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia. E-mail: email@example.com P: +966 53 352 85 31 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1740-555X
Aim: An experimental study was designed to find an anatomical correlation between the area of the hindfoot, height and weight of an individual.
Material and Methods: Medical students of preclinical years were recruited into the study and their footprints were taken on a predesigned A4-sized paper. The foot was divided by geometrical tools into three regions: forefoot, midfoot and hindfoot area. The area of the hindfoot was calculated using the specific image-J software after standardizing the metric units into pixels.
Result: Analysis through SPSS showed a strong relationship between the studied parameters.
Discussion: As per our knowledge, this is the first study defining the hindfoot surface area and correlating it with the height and weight of the individual. A strong association was found between the studies parameters that may be useful in predicting complications related to obesity in near future.
Keywords: Area, Body Mass Index, BMI; Hindfoot, Foot Arch, Obesity
Foot and ankle injuries are among the most severe in daily life and sports . The complicated foot-ankle complex consists of 26 bones moving ground reaction forces to the lower extremity. The rear-foot is often subjected to injury and deformity due to its role in receiving and transmitting such forces to and from the rest of the body.
One of the seven articulating bones that make up the tarsus is calcaneus. The calcaneus along with the talus forms the skeleton called the hindfoot bone. The part of calcaneus that is in contact with the ground is commonly called “Heel” that articulates mainly with the talus and cuboid bones. Numerous ligaments and muscles bind themselves to the calcaneus and aid with its role in biomechanics of human bipedals. The calcaneus acts as an attachment point for a powerful tendon (Achilles tendon), which aids in standing, walking, running and jumping and the plantar flexion of the foot. The calcaneus also serves as a point of attachment for the muscles, which move the toes.
In a simplified fashion, the subtalar joint can be divided into two parts: anterior and posterior. However, it is important to note that not only the articulating surfaces of the calcaneus and the navicular bone support the talar head, but also the ‘spring’ ligament. This network of ligaments plays an important role in stabilizing the talar head. The insufficiency of this structure can lead to deformity of the acquired flat foot.
The size and shape of the three facets of the calcaneus differ among individuals. Both the anterior and middle facets are concave, while the posterior facets are convex . The posterior facets are larger than the middle and anterior facets and are separated by the interosseous calcaneal ligament from the other two facets .
In the past, several studies were conducted to search for the relation between the foot structure and the body mass index (BMI). Though those researching a relationship between the individual foot areas and the index of body mass were scanty. Many of those researches indicated a certain relationship between the arches of the foot and the BMI .
The current paper evaluates another hypothesis that an individual’s hindfoot area is directly proportional to one’s body mass index in the given context information.
Material and Methods
A theoretical, quantitative and experimental analysis was planned to verify the hypothesis. The scientific proposal was submitted for approval to the Ethics Committee. The data collection began after the approval of the study. The subjects’ confidentiality was thoroughly protected in the report.
The data collection included documenting the individual’s weight, height and foot imprint. Any individual with any foot infection, deformity and foot injury was excluded. The rationale of the research, to investigate the relationship between the foot pattern and the structure of the body, was clarified to the volunteers. The procedure obtained verbal consent and the intention was thoroughly explained to the subjects, beforehand.
An A4-sized paper with fixed measured calibrations printed was used to take the ink embossed footprints of the subjects. In addition to a space for writing the weight and height of the person, the paper had numbered square boxes of 1cm2. For recording the weight and height, respectively, an electronic weighing scale was used with the embedded stadiometer.
A customized thick foam pad was used as a stamping pad. This pad was pasted into a tray with a pasting solution and soaked with office stamp ink that is used for normal thumb impressions.
Weight was measured in kilograms at the beginning of the experiment, while height was noted in centimeters for each person. The subject’s body mass index (BMI) was then measured and noted using the standard formula as shown below:
BMI = Weight (in kilograms) / Height (in square centimeters).
The subjects were asked to better soak the sole of their feet in the ink by pressing and standing barefoot on the ink-soaked foot-pad; they were then asked to step out of the foam pad and emboss their foot on the A4 size paper mentioned above. The foot ink prints thus taken, were then let to air dry on the paper.
Next, the exact outline of the footprint was then delicately drawn by hand with a dark marker in the dried footprint. The long axis of each sample was drawn to standardize the alignment. The middle of the middle finger was used as a guide for this purpose. The extent of the foot area that needed to be measured has been marked using the mathematical square package. The long axis of the foot was then split into three equal regions; the perpendiculars were drawn using the same square set to outline the three regions of the foot, namely: fore-foot (F), mid-foot (M) and rear or hind-foot (R) (Figure 1).
Next, at a high resolution, these papers were scanned in color and saved as JPEG files. In the “FIJI” image software, which is an advanced version of the “ImageJ2” software, these files were opened. A fixed unit of length (3 cm) was standardized into the pixels on the opened images. The area for each divided region of the foot was measured using the free hand drawing tool of the image-J program, and the mean reading in square centimeters was registered.
Using SPSS tools, reported data were analyzed and p-values were determined by applying a single sample t-test for the variables. A p-value ≤ 0.05 was taken as a significant level of difference in the calculated results.
Extrapolation of the data using SPSS showed a strong correlation between the two parameters. The calculated p -value came out to be 0.00 showing the highly significant difference between the means of the two calculated parameters. The mean BMI was closer to, but slightly above normal. The hindfoot area was found to have a low deviation from the mean and hence significant.
Foot pain is a common complaint which affects nearly one in four adults after the age of 45 . Obesity is a contributing factor in foot pain development , and elevated body mass index (BMI) is closely correlated with both chronic plantar heel pain and non-specific foot pain . In addition, the feet of obese people are structurally and physically different from their non-obese counterparts, manifesting as thicker, broader and heavier, along with flatter-foot postures, reduced joint motion range and increased plantar peak pressures [9, 10].
This study investigated associations between weight status and normal plantar surface area among youth and specially calculated the heel region. The limitation of this study was that the number of participants was not enough.
Prosperity with the mechanization of nations brings with it a sedentary lifestyle in which the morbid person enters a cascade of obesity, contributing to, but not limited to hypertension, diabetes, etc., and many related diseases. A new class of patients has emerged in the recent past that can be termed as suffering from lifestyle diseases.
In our study, we have attempted to equate body size of the individuals with an important anatomical region of the foot skeleton. We hope that this simplest data can be converted into useful predictors of the imminent risk factors for obesity-related diseases using basic calculations. Furthermore, in this study, hindfoot surface area is investigated according to BMI to obtain data for future use in the fields of physiotherapy intervention, assistive devices, and shoes that address foot diseases.
Studies have shown that people with obesity show an increase in non-uniform plantar pressures, with midfoot and forefoot areas of highest pressure relative to non-obese people [10–12]. Provided that obesity is strongly associated with plantar heel pain [13, 14], increased plantar pressure became discordant where the pain was strongly associated with unnecessary pressure. Paradoxically, as opposed to monitors, people with chronic heel pain show reduced load under the heel .
Musculoskeletal pain has a bidirectional relationship with both obesity  and depression , whereas depression and obesity frequently intensify each other . Such associations, however, are not restricted to weight-bearing joints with a reported association between elevated BMI and symptomatic hand osteoarthritis , indicating that metabolic mechanisms, including systemic inflammation , can underpin the relationship between obesity and joint pain .
The Western Pacific Regional Committee of the WHO on a new BMI for Asians identified 23kg/m2 or higher as overweight, and 25 kg/m2 or higher as obesity . It is associated with increased body fat, BMI, and waist measurements, which adversely affect daily and physical activity activities . The incidence of degenerative foot diseases is also growing with rising life expectancy, and diabetic foot disease is also growing with increasing numbers of patients with diabetes . Plantar pressure is also assessed in patients with pain, diabetes or rheumatism to overcome foot problems .
In addition, several comparative studies have been performed on plantar pressure and balance in patients suffering from different diseases, but not many of them have been on foot changes in the general population. One of the drawbacks of this analysis is its modest sample size. Further future research involving more cohorts of different ages may improve reliability with a variety of outcomes.
The findings of this study can be used as basic evidence for exercise programs in order to increase the level of spontaneity in the obesity community by increasing the hindfoot level, or for studies on reducing foot swaying.
Clinically, our findings imply that barring progressive metabolic changes that may precipitate type II diabetes and associated neuropathy, youth with obesity. Further clinical studies on patient populations are needed to validate these conclusions, as well as to determine whether and how they can be precisely applied to different populations. Our findings could prove valuable in various areas of application. However, despite limitations, the results of this study provided preliminary information for future prospective, randomized clinical trials with larger samples. In addition, to the best of our knowledge, this is the first study defining the hindfoot surface area and correlating it with the height and weight of the individual.
The author acknowledges the efforts of Mr. Hassan Mohammad Iqbal, lecturer of the anatomy, college of medicine, Northern Border University for all his extended help during this project.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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Wajid Ali Chatha. A corroborative study of effects of body mass index on the anatomical region of hindfoot. Ann Clin Anal Med 2022;13(6):679-682
Diagnostic value of the APRI score in pregnant women infected with COVID-19
Sezin Erturk Aksakal, Caner Kose, Yaprak Engin Ustun
Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.21093 Received: 2022-02-01 Accepted: 2022-03-08 Published Online: 2022-03-15 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):683-687
Corresponding Author: Sezin Erturk Aksakal, Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Ankara, Turkey. E-mail: firstname.lastname@example.org P: +90 505 387 65 50 F: +90 312 323 81 91 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4418-7319
Aim: There are several methods to diagnose COVID-19. Early diagnosis and treatment are important in pregnant women with COVID-19. This study aims to investigate whether the APRI score is a method that can be used in the diagnosis of COVID-19 in pregnancy.
Material and Methods: A cross-sectional retrospective study was conducted between March 2020 and November 2020. Pregnant women who were found to be COVID-19 positive by the RT-PCR test were included in the study. The same number of healthy pregnant women who were matched for age, BMI, and gestational week without any systemic disease were included as a control group. Age, gravida, parity, gestational week, BMI, mode of delivery, complete blood count, liver function tests, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and APRI scores were evaluated. The sensitivity and specificity of NLR, PLR, and APRI score in the diagnosis of COVID-19 were investigated.
Results: Gravida, parity, gestational week, body mass index, and rate of previous vaginal delivery were similar between PCR-positive and negative patients. PCR-positive patients had significantly higher APRI scores (0.4±0.3 vs 0.2±0.0), NLR scores (7.7±5.3 vs 4.2±1.9) and PLR scores (217.3±105.7 vs 140.8±57.6) than PCR negative patients. The sensitivity of the NLR to detect COVID-19 was 69.44%, the specificity was 77.5%, the sensitivity of the PLR to detect COVID-19 was 58.33% (CI = 40.8–74.5), and the specificity was 87.5%. The APRI score sensitivity was 80.56%, and specificity was 80.0%.
Discussion: The APRI score can be useful in predicting COVID-19 infection in pregnant women.
Keywords: COVID-19 Disease, Pregnancy, Neutrophil-Lymphocyte Ratio, Platelet-Lymphocyte Ratio, APRI Score
Coronaviruses (CoV) are a large family of viruses that can cause mild infections such as the common cold or more severe illnesses such as Severe Acute Respiratory Syndrome (SARS) . “COVID-19” (2019-nCoV Disease) started in Wuhan, China, for the first time in December, spread worldwide, and began to be seen in our country since March 2020 [Available at: https://covid19bilgi.saglik.gov.tr/tr/.]. The clinical picture due to COVID-19 virus could be asymptomatic, carriage may be in the form of mild upper respiratory tract infection or severe pneumonia resulting in mortality [Available at: https://www.cdc.gov/coronavirus/2019-ncov/index.html]. According to the WHO’s COVID-19 report, the fatality rate of the People’s Republic of China was reported as 3.8% and 2.6% in our country [Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019].
Pregnancy is a condition that predisposes women to viral infections and respiratory complications. Studies conducted at the beginning of the pandemic did not report increased susceptibility to COVID-19 infection in pregnant women than in the general population [2,3]. However, the meta-analysis showed that pregnancy is an increased risk factor for severe disease [4,5].
The diagnosis of COVID-19 infection is made by detecting specific sequences of virus RNA with a NAAT (nucleic acid amplification test) such as real-time reverse transcription-polymerase chain reaction (rRT-PCR) [Available at: https://www.quidel.com/immunoassays/rapid-sars-tests/sofia-sars-antigen-fia,]. Besides, other methods such as serological tests (antigen, antibody detection), computerized tomography are also used for diagnosis . However, PCR testing is an expensive method, requiring equipment and time-consuming results .
Aspartate aminotransferase to Platelet Ratio Index (APRI) is a calculation method that is frequently used in clinical practice, can be calculated easily, and can detect inflammation and significant fibrosis in liver diseases at a considerable rate .
The study aims to investigate whether there is a difference between pregnant women diagnosed with COVID-19 and healthy pregnant women in terms of whole blood parameters and APRI score and to investigate whether the APRI score is a method that can be used in the diagnosis of COVID-19 in pregnancy.
Material and Methods
This cross-sectional retrospective study included pregnant women admitted to our hospital between March 2020 and November 2020 and were found to be COVID- 19 positive by RT-PCR test. The same number of healthy pregnant women who were matched for age, Body mass index (BMI), and gestational age without any systemic disease were included in the study as a control group.
Ethical Approval: The study was approved by the Institutional Review Board (IRB) of Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Ankara, Turkey (02.2021/02-04).
Nasopharyngeal swab samples of patients who applied to the COVID service of our hospital were detected in the Microbiology Reference Laboratory by the General Directorate of Public Health of the Ministry of Health, according to the epidemiology and diagnostic guide of COVID-19 infection, and a diagnosis was made by detecting rRT-PCR positivity [Available at:https://covid19.saglik.gov.tr/Eklenti/39551/0/covid19rehberigenelbilgilerepidemiyolojivetanipdf.pdf]. All diagnosed patients were referred to the pandemic hospital for follow-up and treatment after their condition had stabilized.
NLR was calculated as the ratios of the absolute neutrophil count to the absolute lymphocyte count. PLR was calculated as the ratios of the absolute platelet count to the absolute lymphocyte count. The APRI score was defined as the AST/upper limit of normal range/platelet count (109/L)×100. The upper limit of normal for AST was accepted as 40 U/L.
Age, gravida, parity, gestational week, BMI, previous delivery type, symptoms, complete blood count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, creatinine, D-dimer, activated partial thromboplastin time (aPTT), prothrombin time (PT), Sodium (Na), Potassium (K), Chloride (Cl), total bilirubin, lactate dehydrogenase (LDH), creatine kinase-MB (CK-MB), c-reactive protein (CRP), troponin, ferritin, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and APRI score were evaluated retrospectively from PCR-positive patients records. Age, gravida, parity, gestational week, BMI, previous delivery type, complete blood count, AST, ALT, NLR, PLR, and APRI score of the control group were also recorded.
It was aimed to determine whether there was any difference in APRI score, NLR, PLR between pregnant women with COVID-19 positive and the control group, and the sensitivity and specificity of APRI score in detecting COVID-19.
Statistical evaluation was performed using the Statistical Package for Social Sciences version 23 software (SPSS Inc., Chicago, IL, USA) and MedCalc. The visual (Q-Q plots and histograms) and analytical methods (Kolmogorov–Smirnov/Shapiro–Wilk test) were used to assess the normality of variables. Continuous variables were stated as mean ± standard deviation (SD), median (Md), and minimum-maximum values. Categorical variables were indicated as frequency (n) and percentage (%). The Mann-Whitney U test was used to compare continuous variables with non-normal distribution. The receiver operating characteristic curve (ROC curve) was drawn for the two groups with differences. Area under the curve (AUC) was calculated to estimate the predictive power of the APRI, NLR, and PLR score for predicting RNA RT-PCR results. The sensitivity, specificity, positive predictive values, and negative predictive values of the statistically significant cut-off values were calculated. Statistical significance level was accepted as p<0.05.
Descriptive and Preliminary Statistics
The most common symptom in PCR positive patients cough (n = 19, 52.8%), and more than half of the patients had these complaints (n = 20, 55.5%). The cesarean section (CS) births in PCR positive patients (Md = 1.0) were significantly higher than in PCR-negative patients (Md = 0.0) (p=0.001). However, no significant differences were found between PCR negative and positive patients in gravida, parity, gestational week, body mass index, and rate of vaginal delivery (p > 0.05 for all) (Table 1).
The AST value was significantly higher in PCR-positive patients (24.3±7.2) than in PCR-negative patients (18.0±3.4) (p < 0.001). However, the creatinine value was significantly higher in PCR-negative patients (0.6 ± 0.5) than in PCR-positive patients (0.5 ± 0.1) (p=0.002). There were no significant differences between PCR-negative and positive patients in ALT and BUN levels (p > 0.05 for both) (Table 2).
PCR-positive patients had significantly higher APRI scores (0.4±0.3) than the PCR-negative patients (0.2±0.0) (p < 0.001). Similarly, PCR-positive patients had significantly higher NLR scores (7.7±5.3) than PCR-negative patients (4.2±1.9) (p = 0.001). Lastly, PCR-positive patients have significantly higher PLR score (217.3±105.7) than PCR-negative patients (140.8±57.6) (p < 0.001) (Table 3).
ROC analysis for NLR, PLR, and APRI Indexes
According to ROC analysis, AUC values of APRI score were .860 (SE = 0.043) (CI = 0.761– 0.929) p < 0.001, and were considered acceptable in the diagnosis of SARS-CoV-2. Diagnostic sensitivity was 80.56 (CI = 64.0–91.8) and the 1-specificity was 0.200 (i.e., the true negative rate indexing the specificity of the model was 80.0 CI = 64.4–90.9). The optimal cut-off value for APRI is >0.202 based on these criteria (Figure 1).
To find the cutoff point of NLR, the ROC analysis was conducted and AUC value was 0.731 (SE = 0.060) (CI = 0.616– 0.826) p < 0.001. The true positive rate indexing the sensitivity of the model was 69.44 (CI = 51.9–83.7), and the false positive rate (1-specificity) was 0.225 (i.e., the true negative rate indexing the specificity of the model was 77.5. (CI = 61.5–89.2). ROC curve analysis suggested the optimum NLR cutoff value >4.8 as seen in Figure 2.
ROC analysis revealed that the AUC values of PLR were statistically significant, AUC = 0.742 (SE = 0.060) (CI = 0.629– 0.836) p < 0.001. With a PLR optimal cut-off value of >181.33, the true positive rate indexing the sensitivity of the model was 58.33 (CI = 40.8–74.5), and the false positive rate (1-specificity) was 0.125 (i.e., the true negative rate indexing the specificity of the model was 87.5 (CI = 73.2–95.8) (Figure 3).
In this study, sensitivity and specificity of NLR, PLR, and APRI score in the diagnosis of COVID-19 were investigated in pregnant women. The sensitivity of the NLR to detect COVID-19 was 69.44%, the specificity was 77.5%, the sensitivity of the PLR to detect COVID-19 was 58.33% (CI = 40.8–74.5), and the specificity was 87.5%. APRI score sensitivity was 80.56%, and specificity was 80.0%.
Information about the 2019-nCoV disease is gradually increasing, and more information can be obtained with the publication of reviews and meta-analyzes in recent months. In the literature, symptoms of COVID-19 in pregnant women were similar to the non-pregnant patients and the general population, however, pregnancy is a risk factor for severe disease . In the review by Islam et al., including 235 COVID-positive pregnant women, fever (58.72%), cough (47.23%), and sore throat (8.93%) were the most common symptoms, besides, neutrophil count, serum levels of CRP, ALT, and AST were high, and lymphocyte count and albumin levels were low . In the meta-analysis published by Khalil et al., the most common symptoms in pregnant women positive for COVID-19 are fever (63.3%), cough (71.4%), and dyspnea (34.4%). The most common laboratory findings are increased CRP, transaminases, and lymphopenia . The most common symptoms were cough, weakness, and fever in our study, following the literature. According to the normal reference values, serum CRP and D-dimer levels were found to be elevated in COVID- positive pregnants.
The diagnosis and general management of COVID-19 in pregnant women are similar to that in the general population. Several methods are recommended to diagnose the disease, such as RT-PCR test, computed tomography, antigen testing, and viral culture, etc. . Despite there is still no gold standard test for diagnosis, the most commonly preferred test around the world and also recommended by WHO, is the RT-PCR test [Available at: https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2]. The sensitivity of the RT-PCR was reported as 85.7% for inpatients, 95.5% outpatients, and 89.9% for all patients by Kortela et al . In a systematic review and meta-analysis, for RT-PCR test, nasopharyngeal swab sensitivity was 85%, the nasal swap was 86%, throat swabs 68%, the specificity ranged from 97% to 99% . Compared to CT scan and RT -PCR testing, the sensitivity of CT scan was 95%, which is higher than RT-PCR (91%). The specificity of CT and RT-PCR was 31% and 100% . Despite its high sensitivity and specificity, RT-PCR test has disadvantages in terms of expensiveness, time-consuming results, and required experts.
NLR, PLR, and APRI score indices are parameters obtained from hemogram parameters and correlated with inflammation. The frequency of usage of these parameters has been increasing in the obstetrics practice in recent days [15,16]. Ming-Zhu Yin et al. evaluated 31 pregnant and 30 non-pregnant women infected with COVID-19 in comparison of NLR, PLR and APRI scores, they found NLR, PLR and APRI scores were higher in pregnant women than in non-pregnant women . Additionally, they found that NLR and Systematic immune-inflammation-based prognostic index (SII) were higher in patients with severe pneumonia. Our study revealed that APRI score with a sensitivity of 80.56 % and specificity of 80.0% could be a diagnostic marker of the COVID-19 infection in pregnancy.
Pregnancy can compromise the immune system, and potentially, COVID-19 infection can increase the risk of pulmonary infection in pregnant patients compared to non-pregnant patients. Evaluation of the elevated risk for COVID-19 infection is very important for taking precautions in pregnancy . Increased inflammatory index scores in the routine hemogram parameters could give clinicians tricks for making early diagnosis and appropriate management.
Some limitations should be considered in results of this study. First, there are data with a small number of patients. Secondly, since we do not have intensive care conditions, the patients’ follow-up and treatment are not performed in our hospital, so maternal and neonatal outcomes could not be evaluated. Third, we only include hospitalized pregnant patients with laboratory confirmed COVID-19.
Inflammatory index scores, including NLR PLR and APRI score, are non-invasive diagnosis tools. To make a diagnosis, the availability of a rapid, cost-effective, simple, and easy test is essential. These inflammatory index scores, especially the APRI score, can be useful in recognizing and predicting COVID-19 infection in pregnant women.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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4. Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis. BMJ. 2020;370: m3320
5. Di Toro F, Gjoka M, Di Lorenzo G, De Santo D, De Seta F, Maso G, et al. Impact of COVID-19 on maternal and neonatal outcomes: a systematic review and meta-analysis. Clin Microbiol Infect. 2021;27(1):36-46.
6. Taleghani A, Taghipour F. Diagnosis of COVID-19 for controlling the pandemic: A review of the state-of-the-art. Biosens Bioelectron. 2021;174:112830
7. Wai CT, Greenson JK, Fontana RJ, Kalbfleisch JD, Marrero JA, Conjeevaram HS et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38(2):518-26
8. Ryan GA, Purandare NC, McAuliffe FM, Hod M, Purandare CN. Clinical update on COVID-19 in pregnancy: A review article. J Obstet Gynaecol Res. 2020; 46(8):1235–45.
9. Islam MM, Poly TN, Walther BA, Yang HC, Wang CW, Hsieh WS, et al. Clinical Characteristics and Neonatal Outcomes of Pregnant Patients With COVID-19: A Systematic Review. Front Med (Lausanne) 2020;7:573468.
10. Khalil A, Kalafat E, Benlioglu C, O’Brien P, Morris E, Draycott T, et al. SARS-Cov-2 Infection in Pregnancy: A Systematic Review And Meta-Analysis Of Clinical Features And Pregnancy Outcomes. E Clinical Medicine 2020; 25: 100446
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Download attachments: 10.4328.ACAM.21093
Sezin Erturk Aksakal, Caner Kose, Yaprak Engin Ustun. Diagnostic value of the APRI score in pregnant women infected with COVID-19. Ann Clin Anal Med 2022;13(6):683-687
Can endometrial injury increase the success of clomiphene citrate in achieving pregnancy?
Gamze Nur Cimilli Senocak, Emsal Pınar Topdagi Yılmaz
Department of Obstetrics and Gynaecology, Ataturk University, Erzurum, Turkey
DOI: 10.4328/ACAM.21094 Received: 2022-02-02 Accepted: 2022-03-10 Published Online: 2022-03-29 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):688-692
Corresponding Author: Gamze Nur Cimilli Senocak, Department of Obstetrics and Gynaecology, Ataturk University, Erzurum, Turkey.
E-mail: email@example.com P: +90 530 588 00 25 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6750-9210
Aim: The aim of the study is to observe whether endometrial injury has an effect on pregnancy success in patients who are scheduled for timed intercourse after ovulation induction with the use of clomiphene citrate in patients with unexplained infertility.
Material and Methods: The study was planned as a prospective randomized controlled trial with 215 patients, 105 patients in the injury group and 110 patients in the control group. All patients had unexplained infertility. In the injury group, endometrial injury was performed, before the ovulation induction cycle, in the mid-luteal phase. No intervention was performed on the patients in the study group before the treatment cycle. Ovulation induction was initiated by administering 100 mg/day clomiphene citrate and after follicle development, human chorionic gonadotropin (hCG) was administered to the patients in both groups and timed intercourse (36 hours after hCG) was planned for all patients.
Results: It was observed that 27 (25.7%) patients in the injury group and 19 (17.3%) patients in the control group could achieve pregnancy, 21 (20%) of these patients in the injury group and 14 (12.7%) patients in the control group were able to achieve clinical pregnancy. As a result, although both pregnancy and clinical pregnancy rates were found to be increased in the injury group, this increase was not statistically significant.
Discussion: Much larger and more comprehensive studies are needed to show that adding endometrial injury to treatment with clomiphene citrate, which is an extremely cost-effective and easy procedure, can actually increase pregnancy rates.
Keywords: Ovulation, Induction, Clomiphene, Injury
Infertility is still an important health concern in women nowadays. Clomiphene citrate is one of the first-line drugs that are used, especially in the treatment of unexplained infertility, because it is cheap, easy to use, and has few side effects [1, 2]. Clomiphene citrate is an estrogen receptor antagonist that increases follicular growth by increasing follicle-stimulating hormone release, as well as triggering luteinizing hormone (LH) peak by creating a negative feedback effect in the estrogen signaling pathway and thus triggering ovulation . Although it is generally successful in triggering ovulation, pregnancy rates achieved with clomiphene citrate are less due to its anti-estrogenic effects on the endometrium . Hence, scientists are looking for ways in which the anti-estrogenic effect of clomiphene citrate use can be prevented.
According to the literature, endometrial injury emerges as a new method that facilitates the attachment and implantation of the embryo to the endometrium, and it is seen that majority of the studies on endometrial injury are aimed at increasing the success of implantation in patients with repeated unsuccessful in vitro fertilization (IVF) cycles [4-7]. Local endometrial injury (i.e., mechanical trauma to the endometrium) causes the secretion of various cytokines and adhesion molecules that are thought to facilitate implantation and embryo adhesion by increasing endometrial receptivity [4, 8]. However, many recent studies have demonstrated that adding injury to every IVF cycle in routine practice does not provide any benefit to pregnancy rates, and recommends limiting the injury procedure only to patients with implantation failure [9, 10]. Considering the use of clomiphene citrate, despite the high ovulation rates, it is noteworthy that the pregnancy rates and the implantation success are low due to the effects of clomiphene citrate on the endometrium [11, 12]. Based on this, it can be thought that adding endometrial injury to the clomiphene citrate treatment, which is cost-effective and easy to use, will overcome the endometrial adverse effects caused by clomiphene citrate, increase the effectiveness, and facilitate embryo implantation. The aim of the study is to observe whether endometrial injury has an effect on pregnancy success in patients who are scheduled for timed intercourse after ovulation induction with the use of clomiphene citrate in patients with unexplained infertility.
Material and Methods
The study was planned after the permission of our University Medical Faculty Ethics Committee. We evaluated 230 patients who were admitted to our gynecology and obstetrics outpatient clinic with unexplained infertility. Six patients were excluded because they did not agree to participate in the study or did not fully meet the inclusion criteria. The remaining patients were randomized into two groups (injury group and control group), including 112 participants each. We excluded 6 patients from the injury group and 2 patients from the control group from the study because they did not complete their follow-up or because they were resistant to clomiphene citrate (follicle did not develop with the use of clomiphene citrate). Also, one patient grew 3 follicles in the injury group and was excluded from the study. Thus, the study was performed on a total of 215 patients, 105 patients in the injury groupб and 110 patients in the control group.
The study was planned as a prospective randomized controlled trial. Informed consent was obtained from all participants included in the study. The inclusion criteria for the study were determined as follows: Age group between 18 and 38 years, no chronic comorbidities, no pathological findings on ultrasonography, no basal hormone level disturbances on the third day of menstruation, no previous infertility treatment, body mass index value between 18.5-24.9, normal findings on hysterosalpingography, and the partner having normal spermiogram values according to the WHO criteria . The patients who did not develop follicles after treatment or who developed more than two follicles were excluded from the study. All patients included in the study were divided into two groups, i.e., study and control groups.
The patients were randomized into two groups, namely the injury group and the control group. In the injury group, the same researcher performed the endometrial injury procedure on the posterior wall of the uterine cavity, by moving the curette back and forth for one time, in a sterile manner using a Novak curette before the treatment cycle of the patients, in the mid-luteal phase (between the 21st and 24th days of the cycle). In order not to disrupt the implantation by causing excessive damage to the endometrium, the injury procedure was preferred to be performed in the cycle before ovulation induction. No intervention was performed on the patients in the control group before the treatment cycle. Ovulation induction was initiated by administering 100 mg/day clomiphene citrate (Klomen 50 mg tablet, Kocak Farma Pharmaceutical and Chemical Industry Co., Ltd., two doses per day, orally) for 5 days starting on the 3rd, 4th, or 5th day of the treatment cycle. A successful ovarian response was considered as the formation of one or two follicles of size 18 mm or more, 3–5 days after the completion of clomiphene citrate and was evaluated by transvaginal ultrasonography. After proper follicle development, human chorionic gonadotropin (hCG) (Ovitrelle 250 mcg / 0.5 mL, Merck Pharmaceutical and Chemical Industry Co., Ltd., single-dose, 6500 IU hCG, subcutaneous) was administered to the patients in both groups and timed intercourse was planned for all patients 36 hours after hCG for ovulation. Patients who did not develop follicles or developed more than two follicles after clomiphene citrate were excluded from the study.
On the 14th day after coitus, the serum beta-hCG values of the patients were measured for determination of pregnancy. Transvaginal ultrasound was performed on pregnant patients at the 5th and 7th weeks to identify gestational sac and fetal heart activity, and upon confirmation of this, the patient was thought to have clinical pregnancy.
The 20th version of the licensed SPSS (Statistical Package for the Social Sciences) program (SPPS Inc. Chicago, USA) was used for statistical analysis. The suitability of the parameters to the normal distribution was evaluated using the Kolmogorov–Smirnov test. The sample t-test (student t-test) was used for the comparison of normally distributed data. The Mann–Whitney U test was used to compare data that did not show normal distribution. The Chi-square test was used for the comparison of categorical data. P < 0.05 was found to be statistically significant.
A total of 215 patients, 105 patients in the injury group and 110 patients in the control group were included in our study (Figure 1).
Both groups (injury and control groups) had similar characteristics in terms of age, duration of infertility, primary or secondary infertility, endometrial thickness on hCG administration day, and number and size of mature follicles (Tables 1 and 2). Both groups consisted of patients with infertility due to unknown cause, normal basal hormone levels, and with partners having normal spermiogram results according to the WHO criteria.
According to the results of the study, it was observed that 27 (25.7%) patients in the injury group and 19 (17.3%) patients in the control group could achieve pregnancy, 21 (20%) of these patients in the injury group and 14 (12.7%) patients in the control group were able to achieve clinical pregnancy (Table 3). As a result, although both pregnancy and clinical pregnancy rates were found to be increased in the injury group, this increase was not statistically significant (p = 0.131 for pregnancy rate; p = 0.545 for clinical pregnancy rate).
This study demonstrated that performing local endometrial injury in the luteal phase of the cycle before ovulation induction with clomiphene citrate and timed intercourse 36 hours after hCG administration, increased the rate of pregnancy and clinical pregnancy, but this increase was not statistically significant.
In the literature, it is seen that various procedures have been attempted to induce endometrial injury in infertility treatment using clomiphene citrate. It is seen that many different procedures, such as selected patient groups, method of injury and time of injury, timed intercourse after injury, or trial of intrauterine insemination (IUI) have been tried, different results have been obtained, and there is no clear consensus on these issues. We used a Novak curette for injury, because it is easy to use it and it can make enough injury even for one time.
In the study of Helmy et al., timed intercourse was planned by administering human chorionic gonadotropin (hCG) after ovulation induction with clomiphene citrate to patients with unexplained infertility similar to our study . The endometrial injury was applied to the patients in the study group (n: 52) using a Pipelle catheter during the luteal phase of the previous cycle (between days 15 and 24), and a sham procedure was applied to the control group (n: 53) on the same days. Evaluation of the results showed that the rate of total pregnancy and clinical pregnancy were statistically significantly higher in the injury group . When our results are compared with this study, which was planned with a similar method and the number of patients was much less than our study, we can say that although pregnancy rates are higher in the injury group numerically, our results are not statistically significant. Also, Helmy et al. found endometrial thickness on follicular maturation days similar in both groups like our study. Although there was no statistically significant difference in endometrial thickness between the two groups, we attributed the increase in pregnancy rates in the study group to the increase in endometrial receptivity.
In the study conducted by Ghuman et al., intrauterine insemination (IUI) was planned in a heterogeneous group (first, 2nd, 3rd and overall cycles included, n: 150) requiring IUI after ovulation induction with clomiphene citrate; however, unlike our study, 75 of them were examined in the same cycle using a Pipelle endometrium sampling catheter during the proliferative phase and injury was applied, and IUI was administered with human chorionic gonadotropin (hCG) after ovulation . On evaluation of the results, it was seen that the rates of pregnancy and clinical pregnancy increased in the study group, just like our results, but the results were not statistically significant . They found endometrial thickness on hCG trigger day was significantly greater in the intervention group compared to control group, only in the first cycle ovulation induction, unlike our study.
In a randomized controlled study conducted by Maged et al., a total of 154 patients with unexplained infertility were subjected to IUI procedure following ovulation induction with clomiphene citrate and administration of human chorionic gonadotropin (hCG) for ovulation . These patients were divided into two groups and one group underwent endometrial injury with a number 8 neonatal feeding tube, 24–36 hours before the IUI procedure. No additional intervention was made in the control group. When evaluating the results, it was seen that pregnancy rates were statistically significantly higher in the injury group. They were not investigated endometrial thickness and injury procedure relationship . In our study, we preferred to apply the injury procedure during the luteal phase of the previous cycle so as to not damage the endometrium. Also, we used the Novac curette for injury. We can say that different types of injury procedures can make enough effect for endometrial injury like feeding tube, pipelle or curette.
On the other hand, in a randomized controlled study performed on 217 patients with unexplained infertility, Parsanezhad et al. added human menopausal gonadotropin with clomiphene citrate on the 6th–8th days of the cycle and spontaneously planned timed intercourse after ovulation . After a spontaneous urinary LH peak was detected using a urinary kit, endometrial biopsy was performed with an endometrial Pipelle catheter or mock pipette in the pre-ovulation period, and endometrial injury was induced. When evaluating the results, it was observed that there was a statistically significant increase in pregnancy rates in the injury group when compared with the control group  . In many studies, especially in IVF patients, because the injury procedure performed on the day of oocyte collection traumatized the endometrium very much and there was no time for adequate repair, researchers prefer the injury procedure over the previous cycle [16-18]. Therefore, like Persanezhad et al. we preferred to make injury process in the cycle before ovulation induction. Also, they found endometrial thickness similar in both injury and not injury group, while pregnancy rates are increased in injury group, like our study. They attributed these results of endometrial injury to positive effects such as increased endometrial receptivity, increased decidualization, cytokine production, and gene expression.
As seen in the study, endometrial injury can increase the success of pregnancy after using clomiphene citrate in patients with unexplained infertility and timed intercourse after ovulation induction. Perhaps, this study will show that the negative effect of clomiphene citrate on the endometrium can be prevented through endometrial injury. Thus, clomiphene citrate, which is a very easy to use ovulation induction agent, can be made a preferred method in the treatment of infertility thanks to endometrial injury.
Considering all these studies, our study seems sufficient and comprehensive in terms of the number of patients when compared with other studies. However, when evaluating our results, it is seen that while there is an increase in the rate of pregnancy due to endometrial injury procedures, no statistically significant result was obtained. It seems that much larger and more comprehensive studies are needed to show that adding endometrial injury to treatment with clomiphene citrate, which is an extremely cost-effective and easy procedure, can actually increase pregnancy rates.
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Conflict of interest
1. Jie L, Li D, Yang C, Haiying Z. Tamoxifen versus clomiphene citrate for ovulation induction in infertile women. Eur J Obstet Gynecol Reprod Biol. 2018;228:57-64.
2. Helmy MEE, Maher MA, Elkhouly NI, Ramzy M. A randomized trial of local endometrial injury during ovulation induction cycles. Int J Gynaecol Obstet. 2017;138(1):47-52.
3. Homburg R. Clomiphene citrate–end of an era? A mini-review. Hum Reprod. 2005;20(8):2043-51.
4. Sar-Shalom Nahshon C, Sagi-Dain L, Wiener-Megnazi Z, Dirnfeld M. The impact of intentional endometrial injury on reproductive outcomes: a systematic review and meta-analysis. Hum Reprod Update. 2019;25(1):95-113.
5. Gui J, Xu W, Yang J, Feng L, Jia J. Impact of local endometrial injury on in vitro fertilization/intracytoplasmic sperm injection outcomes: A systematic review and meta-analysis. J Obstet Gynaecol Res. 2019;45(1):57-68.
6. Gürgan T, Kalem Z, Kalem MN, Ruso H, Benkhalifa M, Makrigiannakis A. Systematic and standardized hysteroscopic endometrial injury for treatment of recurrent implantation failure. Reprod Biomed Online. 2019;39(3):477-83.
7. van Hoogenhuijze NE, Torrance HL, Mol F, Laven JSE, Scheenjes E, Traas MAF, et al. Endometrial scratching in women with implantation failure after a first IVF/ICSI cycle; does it lead to a higher live birth rate? The SCRaTCH study: a randomized controlled trial (NTR 5342). BMC Womens Health. 2017;17(1):47.
8. Senocak GC, Yapca OE, Borekci B. Comparison of pregnancy rates between patients with and without local endometrial scratching before intrauterine insemination. J Gynecol Obstet Hum Reprod. 2017;46(9):687-90.
9. Olesen MS, Hauge B, Ohrt L, Olesen TN, Loskaer J, Baek V, et al. Therapeutic endometrial scratching and implantation after in vitro fertilization: a multicenter randomized controlled trial. Fertil Steril. 2019;112(6):1015-21.
10. Liu W, Tal R, Chao H, Liu M, Liu Y. Effect of local endometrial injury in proliferative vs. luteal phase on IVF outcomes in unselected subfertile women undergoing in vitro fertilization. Reprod Biol Endocrinol. 2017;15(1):75.
11. Wang L, Lv S, Li F, Bai E, Yang X. Letrozole Versus Clomiphene Citrate and Natural Cycle: Endometrial Receptivity During Implantation Window in Women With Polycystic Ovary Syndrome. Front Endocrinol (Lausanne). 2020;11:532692.
12. Lisonkova S, Joseph KS. Temporal trends in clomiphene citrate use: a population-based study. Fertil Steril. 2012;97(3):639-44.
13. Laboratory manual of the WHO for the examination of human semen and sperm-cervical mucus interaction. Ann Ist Super Sanita. 2001;37(1):I-xii, 1-123.
14. Ghuman NK, Raikar S, Singh P, Gothwal M, Yadav G. Improving reproductive outcomes of intrauterine insemination: Does endometrial scratch injury help? A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2020;253:225-31.
15. Maged AM, Al-Inany H, Salama KM, Souidan, II, Abo Ragab HM, Elnassery N. Endometrial Scratch Injury Induces Higher Pregnancy Rate for Women With Unexplained Infertility Undergoing IUI With Ovarian Stimulation: A Randomized Controlled Trial. Reprod Sci. 2016;23(2):239-43.
16. Parsanezhad ME, Dadras N, Maharlouei N, Neghahban L, Keramati P, Amini M. Pregnancy rate after endometrial injury in couples with unexplained infertility: A randomized clinical trial. Iran J Reprod Med. 2013;11(11):869-74.
17. Karimzade MA, Oskouian H, Ahmadi S, Oskouian L. Local injury to the endometrium on the day of oocyte retrieval has a negative impact on implantation in assisted reproductive cycles: a randomized controlled trial. Arch Gynecol Obstet. 2010;281(3):499-503.
18. Nastri CO, Gibreel A, Raine-Fenning N, Maheshwari A, Ferriani RA, Bhattacharya S, et al. Endometrial injury in women undergoing assisted reproductive techniques. Cochrane Database Syst Rev. 2012;(7):Cd009517.
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Gamze Nur Cimilli Senocak, Emsal Pınar Topdagi Yılmaz. Can endometrial injury increase the success of clomiphene citrate in achieving pregnancy? Ann Clin Anal Med 2022;13(6):688-692
Impact of maternal education on the comprehension of effective home management of pediatric diarrhea in Arar, Saudi Arabia
Shahab Ahmed Alanazi 1, Ekramy Elmorsy 2,3, Taif Shayish N Alanazi 4, Talal Shayish N Alanazi 5, Ghadah khalid Alanazi 5, Maram Mohammed Alenezi 5
1 Department of Pediatrics, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia, 2 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Mansoura University, Egypt, 3 Department of Pathology, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia, 4 General Practitioner, Arar Maternity and Pediatric Hospital, Arar, Saudi Arabia, 5 Medical Student, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
DOI: 10.4328/ACAM.21097 Received: 2022-02-05 Accepted: 2022-03-07 Published Online:2022-03-08 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):693-697
Corresponding Author: Ekramy Elmorsy, Department of Pathology, Faculty of Medicine, Northern Border University, 1321, Arar, Kingdom of Saudi Arabia. E-mail: firstname.lastname@example.org P: +966 50 127 58 35 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7444-2499
Aim: The current study evaluated the effect of education on maternal awareness of home management of pediatric diarrhea in Arar city, Saudi Arabia.
Material and Methods: It is a preformed-electronic questionnaire-based survey among mothers. The questionnaire was divided into 3 sections to collect participants’ personal data and their level of awareness about pediatric diarrhea predisposing factors (PPF) (12 questions) as well as common home management methods (18 questions).
Results: Responses were received from 367 mothers after their informed consent was taken (mean age 27.4 years (range 21-39 years)). The participants’ average scores of awareness about the PPF and home management methods were 8.1±3.9/12 (range 5-11) and 13.5±6.5/18 (range 8-19), respectively. Bad hand hygiene as a risk factor for diarrhea was widely known to the participants. However, 98.2% of the participants were aware of the role of oral rehydration solution. There was a significant difference among the participants’ awareness scores in relation to their educational levels (p<0.0001). Interestingly, there was an inverse correlation (p=0.002, r =-0.83) between the mothers’ scores and the duration of diarrhea in their children.
Discussion: Awareness among mothers in Arar is reasonable about pediatric diarrhea. Education level markedly affects the awareness level. Awareness campaigns should be conducted targeting uneducated mothers.
Keywords: Maternal Education, Home Management, Pediatric Diarrhea
Diarrheal diseases are quite prevalent all over the world and these are an important cause of morbidity and mortality in the pediatric age group . More than a billion persons are affected by diarrhea around the globe. More than a million deaths are caused by diarrhea, which included approximately half-million deaths of children aged less than 5 years .
Diarrhea is characterized by the passage of three or more loose stools per day. Diarrhea causes loss of body fluid and leads to dehydration, hypotension, hypovolemic shock and even death in a significant number of cases. Diarrhea can also adversely affect the growth and cognitive development of children . In the majority of pediatric patients suffering from diarrhea, diarrhea is caused by infections, which are transmitted due to hand, water and food contamination. A large number of children are hospitalized because of diarrhea that is caused by Rotavirus. Mortality and morbidity associated with diarrheal diseases are preventable and treatable with the help of simple and cost- effective measures .
Many research projects worldwide revealed that diarrheal morbidity in children is associated with poor sanitation such as improper hand washing, improper personal and food hygiene. Other causes were also reported as lack of breastfeeding, delay in the initiation of breastfeeding, lack of nutrient-rich foods, lack of rotavirus vaccination. Additionally, a lack of awareness of home management of diarrhea such as oral rehydration therapy with oral rehydration salt solutions and a lower level of education of mothers regarding the care of sick children were also reported as contributing factors in diarrheal morbidity among children [5-8].
Various studies from different communities raised the issue of the presence of harmful practices for the management of pediatric diarrhea, which further enhance diarrhea-related morbidity and mortality among children. Important and common harmful practices in pediatric patients suffering from diarrhea include restriction of food, limitation on fluid intake, curtailment of breastfeeding and inappropriate use of medications .
Awareness of mothers regarding preventable factors and proper measures for home management of diarrhea in children plays a vital role in the reduction of morbidity and mortality in children. Hence, the current study was conducted to study mothers’ awareness level of diarrhea prevention measures and to assess the knowledge of mothers about home management of diarrhea in children. In addition, the level of awareness regarding pediatric diarrhea and various measures for home management among mothers was compared with respect to age and the educational levels of mothers.
Material and Methods
The local Bioethics Committee of Northern Border University, Arar, Saudi Arabia approved the study plan. The study was conducted as questionnaire-based survey. The questionnaire was composed of 3 sections. The first section questions were directed to the personal data of the participants including their age, children, breastfed children, level of education, and their previous experience with home management of their children’s diarrhea. The second part contained 12 questions to assess the participant’s awareness about the predisposing factors to diarrhea among children. While the 3rd section contained 18 questions and was designed to assess the participants’ knowledge about the methods of home management of pediatrics diarrhea. The questionnaire was revised and evaluated by the staff members, of the pediatric department, Northern Border University.
The data were analyzed using Graph-Pad Prism 5 (GraphPad Software Inc., San Diego, CA). The participants’ answers were given a score of 1 for right answers and a score of zero for false answers to both the second and third sections questions. One-way ANOVA and Tukey post-test were used to study the differences between the different groups. Pearson’s correlation was used to correlate the mothers’ awareness scores and the duration of their children’s diarrhea. Significance was considered with a p-value <0.05.
Three hundred eighty-seven mothers participated after giving their informed consent with the mean age of 27.4 years (range 21-39 years). Data regarding participants’ ages, number of children, educational level and history of their children’s diarrhea are shown in Table 1.
Regarding the knowledge of the participants about the predisposing factors for pediatrics diarrhea, the participants’ overall average score was 8.1±3.9/12 (range 5-11). Awareness was high regarding the effect of bad hand hygiene as a risk factor for diarrhea, while low levels of awareness were shown regarding the role of lead in diarrhea among children (Table 2). There was a significant difference among the participants in the scores for knowledge regarding the predisposing factors in relation to their ages (p<0.0001) and educational levels (p<0.0001) (Figure 1A, 1B).
The questions investigated the awareness of the participants about household methods for management of pediatrics diarrhea. The participants showed an overall average score of 13.5±6.5/18 (range 8-19). About 98.2% of the participants were aware of the role of oral rehydration solution, while only 78.3, 75.5, and 69.8 % were oriented by the value of black tea, curd and green tea, respectively. Around 30% of the mothers chose not to take any action and just to wait for spontaneous improvement (Table 3). There was a significant difference among the participants in the scores for knowledge household methods for management of pediatrics diarrhea in relation to their ages (p<0.0001) and educational levels (p<0.0001) (Figure 1C, 1D). Interestingly, there was an inverse correlation (p=0.002, r =-0.83) between the mothers’ scores and the duration of their children’s diarrhea.
The study was conducted to evaluate the effect of maternal education on household management of pediatrics diarrhea in Arar. Three hundred eighty-seven mothers participated after obtaining their informed consent with mean age of 27.4 years (range 21-39 years). Regarding the knowledge of the participants about the predisposing factors for pediatrics diarrhea, the participants showed an overall average score of 8.1±3.9/12 (range 5-11). The questions, which investigated the awareness of the participants about household methods for management of pediatrics diarrhea showed an overall mean score of 13.5±6.5/19 (range 8-19). Interestingly, 98.2% of the participants were aware of the role of oral rehydration solution, while only 78.3, 75.5, and 69.8 % were focused on the value of black tea, curd and green tea, respectively. Around 30% of the mothers had chosen not to take any action and just to wait for spontaneous improvement.
Respondents also showed that ages and levels of education significantly affect the awareness related to the predisposing factors to pediatrics diarrhea and home-hold management; poor knowledge in home management was among the uneducated and the elderly. Educational level has been shown to affect the awareness of mothers related to pediatric diarrhea in previously published data, including predisposing factors, management, as well as signs of dehydration [10-14].
The study showed high levels of awareness about ORS among all participants and the importance of all household fluids in the management of diarrhea. This is in agreement with other studies showing a high level of awareness about the importance of proper hydration in the management of diarrhea [15-17].
The current data also showed that awareness to ask for medical advice in severe cases was reported among about 70% of participants, which is mainly due to easy access to the healthcare services in Arar with large numbers of primary healthcare centers and specialized hospitals for pediatric disease with totally unpaid medical service.
The current data showed accepted levels of awareness among mothers in Arar about the predisposing factors and household management methods for pediatric diarrhea. However, more training and awareness programs should be directed to the mothers, especially the uneducated mothers, about pediatric diarrhea. This training is expected to improve the outcome and reduce pediatric diarrhea hospital visits and admission. This training can be conducted through the media or specialized awareness programs, which may be conducted in healthcare facilities, especially in primary healthcare centers, especially for mothers coming for the compulsory vaccination of their kids.
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Animal and human rights statement
Conflict of interest
1. Young MF, Mehta RV, Gosdin L, Kekre P, Verma P, Larson LM, et al. Home fortification of complementary foods reduces anemia and diarrhea among children aged 6–18 months in Bihar, India: A large-scale effectiveness trial. J Nut. 2021;151(7):1983-92.
2. Keykhaei M, Masinaei M, Mohammadi E, Azadnajafabad S, Rezaei N, Saeedi Moghaddam S, et al. A global, regional, and national survey on burden and Quality of Care Index (QCI) of hematologic malignancies; global burden of disease systematic analysis 1990–2017. Exp Hematol Oncol 2021;10(1):1-5.
3. Florez ID, Niño-Serna LF, Beltrán-Arroyave CP. Acute infectious diarrhea and gastroenteritis in children. Curr Infect Dis Rep. 2020;22(2):1-2.
4. Olesen B, Neimann J, Bottiger B, Ethelberg S, Schiellerup P, Jensen C, et al. Etiology of diarrhea in young children in Denmark: a case-control study. J Clin Microbiol. 2005;43(8):3636-41.
5. Bizuneh H, Getnet F, Meressa B, Tegene Y, Worku G. Factors associated with diarrheal morbidity among under-five children in Jigjiga town, Somali regional state, eastern Ethiopia: a cross-sectional study. BMC Pediatr. 2017;17(1). DOI:10.1186/s12887-017-0934-5
6. Rohmawati N, Panza A, Lertmaharit S. Factors associated with diarrhea among children under five years of age in Banten province. Indonesia J Health Res. 2012;26(1):31–4.
7. Mamo A, Hailu A. Assessment of prevalence and related factors of diarrheal diseases among under-five year’s children in Debrebirehan Referral Hospital, Debrebirehan town, north Shoa zone, Amhara region, Ethiopia. jourlib org J. 2014;1(1):1-14.
8. Gizaw Z, Woldu W, Bitew BD. Child feeding practices and diarrheal disease among children less than two years of age of the nomadic people in Hadaleala district, afar region, northeast Ethiopia. Int Breastfeed J. 2017;12(1):24.
9. Carter E, Bryce J, Perin J, Newby H. Harmful practices in the management of childhood diarrhea in low-and middle-income countries: a systematic review. BMC Public Health. 2015;15(1):1-34.
10. Gathogo LW. Determinants of Home Management of Diarrhea among Care Givers of Children Below 5 Years in Ngandu Location, Nyeri County. Int J Community Med Public Health. 2020;7(7):2450-4.
11. Aftab W, Shipton L, Rabbani F, Sangrasi K, Perveen S, Zahidie A, et al. Exploring health care seeking knowledge, perceptions and practices for childhood diarrhea and pneumonia and their context in a rural Pakistani community. BMC Health Serv Res. 2018;18(1):1-0.
12. Workie HM, Sharifabdilahi AS, Addis EM. Mothers’ knowledge, attitude and practice towards the prevention and home-based management of diarrheal disease among under-five children in Diredawa, Eastern Ethiopia, 2016: a cross-sectional study. BMC Pediatr. 2018;18(1):1-9.
13. Ogunrinde OG, Raji T, Owolabi OA, Anigo KM. Knowledge, attitude and practice of home management of childhood diarrhoea among caregivers of under-5 children with diarrhoeal disease in Northwestern Nigeria. J Trop Pediatr. 2012;58(2):143-6.
14. Abdinia B. Knowledge and practice of mothers in the management of children’s Diarrhea, in Northwest, Iran. Arch Pediatr. 2014;2(4):e17581.
15. Gazi E, Chowdhury A, Kumar R, Sarkar AP, Basu SS, Saha S. Can mothers care for acute diarrhoeal disease of their under five children effectively at home? a cross sectional study in slum community in bankura. J Evid Based Med Heal. 2015;2(36):5575-84.
16. Saurabh S, Shidam UG, Sinnakirouchenan M, Subair M, Hou LG, Roy G. Knowledge and practice regarding oral rehydration therapy for acute diarrhoea among mothers of under-five children in an urban area of Puducherry India. Natl J Community Med. 2014;5(1):100-4.
17. Sumathi WS, Balasubramanian S, Pradeebaa T, Sumathi B. A study on knowledge, attitude and practices of mothers about acute diarrhea and its management with oral rehydration therapy and zinc in children under 5 years. Int. Arch. Integr. Med. 2020;7:1-10.
Download attachments: 10.4328.ACAM.21097
Shahab Ahmed Alanazi, Ekramy Elmorsy, Taif Shayish N Alanazi, Talal Shayish N Alanazi, Ghadah khalid Alanazi, Maram Mohammed Alenezi. Impact of maternal education on the comprehension of effective home management of pediatric diarrhea in Arar, Saudi Arabia. Ann Clin Anal Med 2022;13(6):693-697
Investigation of the effectiveness of granulocyte colony-stimulating factor (G-CSF) in the treatment of atrophic rhinitis
Muhammet Pamukcu 1, Mehmet Ada 2, Gul Ozbilen 3
1 Department of Otorhinolaryngology, Altinbas University, Bahcelievler Medical Park Hospital, 2 Department of Otorhinolaryngology, Cerrahpasa Medical Faculty, Istanbul University, 3 Department of Otorhinolaryngology, Istanbul Medeniyet University, Istanbul, Turkey
DOI: 10.4328/ACAM.21102 Received: 2022-02-09 Accepted: 2022-03-11 Published Online: 2022-03-18 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):698-702
Corresponding Author: Muhammet Pamukcu, Department of Otorhinolaryngology, Altinbas University, Bahcelievler Medical Park Hospital, 34160, Istanbul, Turkey. E-mail: email@example.com P: +90 212 484 14 84 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9021-3194
Aim: Primary acute rhinitis (AR) remains a clinical problem in developing countries. The objective of this study was to investigate the effectiveness of granulocyte colony-stimulating factor (G-CSF) administration as an alternative to current treatment methods.
Material and Methods: Eighteen rabbits were divided into three groups with six rabbits in each. Group 1 consisted of the rabbits followed up without any treatment as healthy animal group. Pasteurella multocida solution was inoculated into the noses of 12 rabbits in Groups 2 and 3 with a micropipette in order to induce atrophic rhinitis. After three weeks of inoculation, rabbits in Group 1 and Group 2 were sacrificed. Group 3 was administered 5 microgram/kg G-CSF and sacrificed after four weeks. Total turbinate thickness, turbinate bone thickness, turbinate mucosal thickness, degree of cilia loss in epithelial cells, amount of submucosal gland, inflammatory cell infiltration, and changes in the turbinate bones and mucosa were examined.
Results: Total turbinate thickness, turbinate bone thickness and mucosal thickness were statistically significantly lower in Group 2 compared to Group 1 (for all, p<0.01). There was a statistically significant increase in the total turbinate thickness, turbinate bone thickness and turbinate mucosa thickness of the rabbits that we treated with G-CSF (Group 3), compared to the rabbits that we created an atrophic rhinitis model and did not give treatment (Group 2) (for all, p<0.01).
Discussion: We obtained findings supporting the use of G-CSF as an easy-to-apply treatment method in the medical treatment of atrophic rhinitis.
Keywords: Atrophic Rhinitis, Pasteurella Multocida, Turbinate, Mucosa, Nasal Cavity
Atrophic rhinitis is a chronic disorder characterized by progressive atrophy of nasal and underlying bones of the turbinates with the presence of dried crusts and a foul odor called ozaena. Specific infections, especially those caused by K. ozaenae, Proteus vulgaris, Escherichia coli, Pasteurella Multocida, chronic sinus infection, hormonal imbalance, iron deficiency anemia, malnutrition, autoimmunity and heredity are the blamed factors for the etiology of AR, although the exact cause is unclear . Its incidence in western countries has decreased owing to improved socioeconomic conditions, while it remains an important public health problem in Asia and Africa continents.
AR is divided into primary atrophic rhinitis and secondary atrophic rhinitis. Primary AR is seen in people without any previous nasal disorder and is characterized by sclerotic transformation of the mucous membrane and increased patency of the nasal passage due to atrophic changes . This form of AR accounts for the majority of cases . Secondary AR is less common and may occur after total turbinectomy, septoplasty, endoscopic sinus surgery, and tumor surgery . The diagnosis of AR is clinical and the marked findings on examination include nasal crusts filling the cavity, foul odor and increased volume of the nasal cavity because of the shrinkage of the turbinates .
For many years, several medical and surgical methods have been attempted for the treatment of AR. The main goals of the treatment are to reduce secondary bacterial infections and to clean the crusts. Medical treatment of AR includes treatment of injection with antibiotics, regular nasal douching with a solution of dilute sodium chloride, sodium bicarbonate and sodium borate, iron and vitamin supplementation . Surgical treatment methods include complete closure of anterior nares by surgical intervention, also known as Young’s operation, partial closure of anterior nares, implantation and denervation operations and turbinate reconstruction .
Granulocyte colony-stimulating factor (G-CSF) is a large family of polypeptide molecules that regulate cell division in various tissues by autocrine or paracrine mechanisms. G-CSF plays an important role not only in embryonic development, but also in adult tissue homeostasis, and especially in processes such as wound healing and tumorigenesis . G-CSF is involved in the mobilization of neutrophils from the bone marrow into circulation and is successfully used in the treatment of neutropenia .
Understanding the effect of G-CSF on the mobilization of stem cells, which is its natural function, and the idea that mobilized stem cells are directed to damaged tissues and accelerate healing, attracted the attention of many researchers and prompted them to conduct experimental studies on different issues. Studies on G-CSF are continuing in the field of otorhinolaryngology, especially in otology, wound healing, oncology and rhinology . The objective of this study was to investigate the effectiveness of granulocyte colony stimulating factor (G-CSF) administration as an alternative to current treatment methods.
Material and Methods
This experimental study was conducted in the Istanbul University Cerrahpasa Medical Faculty Experimental Animal Production and Research Laboratory after receiving approval from the Istanbul University Cerrahpasa Medical Faculty Experimental Animals Ethics Committee. The study was performed following the Declaration of Helsinki, institutional and national animal rights.
Eighteen white young adult male New Zealand rabbits aged 14-16 weeks and weighing 2.3-3.6 kg were used. The rabbits were fed with the same foods under the same laboratory conditions during the study. The animals were divided into three groups with six rabbits in each. Group 1 consisted of the rabbits followed-up without any treatment as the healthy animal group. Pasteurella multocida solution was inoculated into the noses of 12 rabbits in Groups 2 and 3 with a micropipette in order to induce atrophic rhinitis. After three weeks of the inoculation, rabbits in Group 1 and Group 2 were sacrificed with euthanasia using i.v Xylazin 20 mg/kg. The nasal cavity, nasal septum, paranasal sinus and turbinates in the nasal cavity of the rabbits in these groups were removed as a block and sent for pathological examination in 10% formaldehyde.
After the occurrence of atrophic rhinitis was confirmed in Group 2 by histopathological examination, the rabbits in Group 3 were administered 5 microgram/kg G-CSF (Neupogen®, Filgrastim [G-CSF] Recombinant – methionyl human granulocyte colony- stimulating factor [r-metHuG-CSF]) subcutaneously with an insulin injector to the neck. After the end of four weeks, the rabbits were sacrificed with the same method, the nasal cavity, nasal septum, paranasal sinus and turbinates in the nasal cavity were removed as a block and sent for pathological examination in 10% formaldehyde.
Induction of atrophic rhinitis with Pasteurella Multocida
Passages of Pasteurella Multocida were taken to the bloody nutrient broths. Colonies in the bloody plate medium, which grew in an oven at 37oC for 24 hours, were taken into physiological saline and homogenized by vortexing. It was adjusted to 1010/1 mL of bacteria in the homogeneous suspension by measuring with the DENSIMAT device (Bio Merieux sa France).
The samples were fixed in buffered 10% formalin overnight and were then decalcified in a strong acid solution. Five micron-thick sections were taken from the tissues embedded in the paraffin blocks and stained with Hematoxylin & Eosin (HE) and periodic acid schiff (PAS). The sections were evaluated under a light microscope by the same pathologist. In sections of each rabbit, total turbinate thickness, turbinate bone thickness, turbinate mucosal thickness, degree of cilia loss in the epithelial cells, amount of submucosal gland, inflammatory cell infiltration, and changes in the turbinate bones and mucosa were examined.
In the histopathological examination, each parameter was divided into classes among themselves. Scoring was done semi-quantitatively for each parameter using a score of “0” if there was no congestion, “1” if there was, and “0” if there was no submucosal gland, and “1” if there was.
Statistical analysis of the data obtained was carried out using SPSS version 25.0 (SPSS, Statistical Package for Social Sciences, IBM Inc., Armonk, NY, USA) software. As the variables were skewed, the Mann-Whitney U test was used for the comparison of continuous variables between the groups. Qualitative data were compared with Fisher’s Exact Chi-square test. Continuous variables were expressed as mean ± standard deviation and median values, while categorical variables were given as numbers and percentages. The results were evaluated at a 95% confidence interval and p<0.05 statistical significance level.
All of the rabbits (Group 2) infected with Pasteurella multocida developed atrophy in both the bone structure and mucosa of their turbinates compared to the healthy control group (Group 1). Total turbinate thickness, turbinate bone thickness and mucosal thickness were statistically significantly lower in Group 2 compared to Group 1 (for all, p<0.01). In addition, loss of submucosal glands, non-specific inflammatory cells in the lamina propria and epithelium, loss of bone trabeculae, and irregularities on the bone surface were found in Group 2 (Table 1). Figure 1 shows the turbinate bone and mucosa of the control group (Group 1), while Figure 2 shows the turbinate bone and mucosa of Group 2, which was infected by Pasteurella multocida.
It was seen that there was a statistically significant increase in the total turbinate thickness, turbinate bone thickness and turbinate mucosa thickness of the rabbits that we treated with G-CSF, compared to the rabbits in which we created an atrophic rhinitis model and did not give treatment (Table 2). In the histopathological examinations of the treatment group, a significant increase in the number of submucosal glands was also observed. Both the thickness of the turbinate bones increased and the irregularities on the bone surface decreased (Figure 3).
Atrophic rhinitis (AR) is a well-known disease, which dates back to the medical papyri of the Egyptian era. AR was described for the first time by Fraenkel in 1876 as a distinct clinical entity of the nose. Histopathological studies show that AR is a progressive inflammatory process with atrophy and fibrosis, and atrophic changes occur in all parts of the nose . In the present study, we observed histopathological atrophic changes in the Group 2, in which we induced rhinitis with the inoculation of Pasteurella multocida, which is among the causative agents of primary AR . We found that in all rabbits infected with Pasteurella Multocida, the turbinates were significantly thinned in total, mucosal and bone thickness, nonspecific inflammatory cell infiltration occurred in the mucosa and submucosa, and the submucosal glands were atrophied.
Primary AR is less common in developed countries, while it remains a clinical problem in developing and underdeveloped countries . Whereas, secondary atrophic rhinitis tends to increase in developed countries due to the increase in intranasal surgeries and related complications . There are several treatment methods in both forms of AR, with the first- line treatment being conservative.
The goal of conservative treatment is to reduce secondary bacterial infections and clear up crusts. A variety of medical treatments have been suggested for the treatment of primary AR, including nasal wash with anhydrous glucose in glycerin or chloromycetin in the nasal drop and systemic administration of streptomycin, vitamins, minerals, hormones and placental extract . Mechanical crust removal and nasal irrigation under the guidance of endoscopy are an important part of the treatment.
Surgical procedures are performed in severe cases or when medical treatment fails . Numerous surgical treatment methods have been attempted, including reduction of nasal cavity size, increasing the regeneration of the nasal mucosa, increasing the moistening of the nasal mucosa, and increasing the vascularity of the nasal cavity . However, despite all these surgical methods, the results have not been completely satisfactory, some techniques have failed or the disease has recurred. In addition, almost all of these procedures change the normal nasal anatomy even more.
Patients with AR must maintain nasal hygiene regularly with various solutions. Many solutions have been recommended to maintain nasal hygiene. No superiority of one solution over the other has been reported [16, 17]. The most common form of systemic treatment is antibiotics. Rifampicin and quinolones have the broadest spectrum of action covering the wide spectrum of microorganisms extracted from patients with AR . Placental extract for the treatment of AR was first described in 1971 by Sinha et al., initiating increased host deficiency, vascularization, vasodilatation and cellular immunomodulation . However, the first improvement after starting treatment either worsened at the end of treatment or did not continue after the end of treatment in all patients who received placental extract therapy . The first approach is to treat its symptoms in the treatment of AR . But this approach is often disappointing because most patients are dissatisfied with medical treatment. Medical treatment of AR is limited to palliation, it can relieve but is far from curative.
In this study, for the first time in the literature, we investigated the effectiveness of G-CSF therapy, which has been experimentally studied in many different areas, in the medical treatment of AR, the cause of which is still unknown and the treatment of which is the subject of research. Hematopoietic cytokines such as G-CSF and erythropoietin mobilize bone marrow stem cells, enabling differentiation and development of hematopoietic progenitor cells . Stimulation of G-CSF increases granulocytic phagocytosis, chemotaxis, and microbicide activities in infection in response to inflammatory disorders . Bone marrow stromal cells, monocytes, endothelial cells, mesothelial cells, and platelets can produce G-CSF. Understanding the effect of G-CSF on the mobilization of stem cells, which is its natural function, and the idea that mobilized stem cells are directed to damaged tissues and accelerate healing, attracted the attention of many researchers and prompted them to conduct experimental studies on different issues. In an experimental study, Schabitz et al. showed that G-CSF reduced the infarct area by 47% when given within the first 30 minutes in rats with stroke due to middle cerebral artery occlusion . Kawada et al. demonstrated that G-CSF increased the cytokines and provided the regeneration of neuronal cells in rats . G-CSF has been successfully used in the treatment of neutropenia. Furthermore, G-CSF has been studied in numerous medical disorders, including oncology, encephalopathy, heart failure and cerebral ischemia .
In the present study, we found that the rabbits in Group 3, in which we created an atrophic rhinitis model and treated with G-CSF, had a significant thickening in both the total turbinate thickness, the turbinate mucosal thickness, and the turbinate bone thickness, compared to the rabbits in Group 2, in which atrophic rhinitis was induced with the inoculation of Pasteurella multocida, but no treatment was administered. In addition, histopathological examinations revealed that the submucous glands lost in the subjects with AR in Group 3 regenerated, the smooth structure of the turbinate bone surface was re-formed, and the ciliary structure was closer to normal.
An ideal method to physiologically correct the impaired intranasal anatomy due to various reasons should be a simple and easily applicable treatment instead of surgical treatments that can make this situation worse. In our experimental study, we obtained findings supporting the use of G-CSF as an easy to apply treatment method in the medical treatment of atrophic rhinitis. However, further studies are needed to use this treatment method in routine ENT practice. We think that our study will become a guide for future studies on this issue.
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Animal and human rights statement
Conflict of interest
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2. Bist SS, Bisht M, Purohit JP. Primary atrophic rhinitis: a clinical profile, microbiological and radiological study. ISRN Otolaryngol. 2012;2012:404075.
3. Bakshi SS. Atrophic Rhinitis. J Allergy Clin Immunol Pract. 2019;7(8):2850.
4. Kamedien MS, Din TF, Lubbe D. Incidence of secondary atrophic rhinitis following endoscopic sinonasal tumour surgery: a retrospective review. Rhinology Online. 2020;3:100-5.
5. Hildenbrand T, Weber RK, Brehmer D. Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature. Eur Arch Otorhinolaryngol. 2011;268(1):17-26.
6. Kumar NS, Chandra TS. Prosthetic management of atrophic rhinitis. Indian J Otolaryngol Head Neck Surg. 2008;60(4):379-81.
7. Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using autologous costal cartilage. Auris Nasus Larynx. 2018;45(3):613-16.
8. Huang H, Zhang Q, Liu J, Hao H, Jiang C, Han W. Granulocyte-Colony Stimulating Factor (G-CSF) Accelerates Wound Healing in Hemorrhagic Shock Rats by Enhancing Angiogenesis and Attenuating Apoptosis. Med Sci Monit. 2017;23:2644-53.
9. Strauss RG. Neutrophil/granulocyte transfusions collected from G-CSF + dexamethasone-stimulated donors. Curr Opin Hematol. 2015;22(6):565-7.
10. Peric A, Spadijer-Mirkovic C, Matkovic-Jozin S, Jovancevic L, Vojvodic D. Granulocyte-Macrophage Colony-Stimulating Factor Production and Tissue Eosinophilia in Chronic Rhinitis. Int Arch Otorhinolaryngol. 2016;20(4):364-9.
11. Furian TQ, Borges KA, Laviniki V, Rocha SL, de Almeida CN, do Nascimento VP, et al. Virulence genes and antimicrobial resistance of Pasteurella multocida isolated from poultry and swine. Braz J Microbiol. 2016;47(1):210-6.
12. Mishra A, Mishra Shukla N, Verma V, Mishra SC. Olfaction in Primary Atrophic Rhinitis and Effect of Treatment. OTO Open. 2020;4(3). DOI: 10.1177/2473974X20949503
13. Somani SB, Wachasundar A, Somani S, Patil S. A study of Prevalence of primary and secondary atrophic rhinitis at tertiary health care centre. MedPulse International Journal of ENT. 2017;3(1):1-4.
14. Abdel-Naby Awad OG, Hasan MM. Topical Mitomycin-C can help as an adjunct to alkaline nasal wash and rifampicin in primary atrophic rhinitis. Am J Otolaryngol. 2019;40(2):137-42.
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17. Dutt SN, Kameswaran M. The aetiology and management of atrophic rhinitis. J Laryngol Otol. 2005;119(11):843-52.
18. Pattanaik S. Interesting observations on Primary Atrophic Rhinitis. Indian J Otolaryngol Head Neck Surg. 2006;58(3):264-7.
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20. Liva GA, Karatzanis AD, Prokopakis EP. Review of Rhinitis: Classification, Types, Pathophysiology. J Clin Med. 2021;10(14):3183.
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22. Fang H, Hua C, Weiss S, Liu A, Cheng W, Claus R, et al. Modulation of innate immunity by G-CSF and inflammatory response by LBPK95A improves the outcome of sepsis in a rat model. J Immunol Res. 2018; DOI: 10.1155/2018/6085095
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24. Kawada H, Takizawa S, Takanashi T, Morita Y, Fujita J, Fukuda K, et al. Administration of hematopoietic cytokines in the subacute phase after cerebral infarction is effective for functional recovery facilitating proliferation of intrinsic neural stem/progenitor cells and transition of bone marrow-derived neuronal cells. Circulation. 2006;113(5):701-10.
25. Dumbuya JS, Chen L, Wu JY, Wang B. The role of G-CSF neuroprotective effects in neonatal hypoxic-ischemic encephalopathy (HIE): current status. J Neuroinflammation. 2021;18(1):55.
Download attachments: 10.4328.ACAM.21102
Muhammet Pamukcu, Mehmet Ada, Gul Ozbilen. Investigation of the effectiveness of granulocyte colony-stimulating factor (G-CSF) in the treatment of atrophic rhinitis. Ann Clin Anal Med 2022;13(6):698-702
Oxidative stress and matrix metalloproteinases in primary pterygium
Cenk Zeki Fikret 1, Zuhal Yildirim 2, Nil Irem Ucgun 3, Ozlem Evren Kemer 3, Aysegul Koksal Kayik 4
1 Department of Ophthalmology, Ankara City Hospital, Ankara, 2 Department of Medical Biochemistry, Etimesgut Public Health Laboratory, Ankara, 3 Department of Ophthalmology, University of Health Sciences, Ankara City Hospital, Ankara, 4 Department of Ophthalmology, Isparta City Hospital, Isparta, Turkey
DOI: 10.4328/ACAM.21103 Received: 2022-02-10 Accepted: 2022-03-11 Published Online: 2022-04-05 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):703-705
Corresponding Author: Zuhal Yildirim, Etimesgut Public Health Laboratory, 06770, Ankara, Turkey. E-mail: firstname.lastname@example.org P: +90 312 243 10 12 F: +90 544 411 15 94 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2808-7860
Aim: Pterygia are common conjunctival degenerations with well-documented risk factors but unclear pathogenesis. A better understanding of the pathogenesis of pterygium could lead to improved surgical outcomes and decreased postoperative recurrence. Oxidative stress is considered a key factor involved in the pathology of many chronic diseases, including ophthalmic complications and inflammatory processes.
We aimed to assess the role of oxidative stress and matrix metalloproteinases (MMPs) in the etiopathogenesis of primary pterygium.
Material and Methods: We prospectively examined 26 eyes of 26 patients (mean age 52.76±14.92 (31-77) years) who underwent pterygium excision surgery with conjunctival autograft (CA) transplantation. Pterygium tissue samples were stored after excision. During the operation, conjunctival autograft tissue samples were obtained from the intact conjunctival tissue at the upper temporal quadrant. Part of the conjunctival autograft tissue was kept for the control group. All conjunctival samples were kept at -80°C until biochemical analysis. Total antioxidant status (TAS), malondialdehyde (MDA), matrix metalloproteinase (MMP)-2, and MMP-9 levels were examined in all samples.
Results: In the pterygium group, mean TAS, MDA, and MMP-9 levels were significantly increased when compared to those of the control group (p<0.05). In the pterygium group, mean MMP-2 levels were increased when compared to the control group. However, this was not a significant difference (p>0.05).
Discussion: These findings indicate that oxidative stress and MMPs may be effective in the etiopathogenesis of pterygium. As a result of this information, it should be considered that local antioxidant treatments may be effective in preventing pterygium progression or recurrence.
Keywords: Pterygium, MMP-2, MMP-9, MDA, TAS
Pterygium is an ocular surface disease caused by chronic ultraviolet-B (UV-B) radiation exposure. UV-B exposure leads to pterygium growth by increasing oxidative stress and a lot of mediators. Oxidative stress causes structural tissue changes by damaging DNA. Inflammation and neovascularization are effective in the formation of pterygium .
Recent studies implicate growth factors, apoptotic mechanisms, extracellular matrix modulators, cytokines, immunological mechanisms, genetic factors and viral infections. UV-B exposure and incidental oxidative stress induce pterygium pathogenesis. Pterygium development occurs due to cell migration and angiogenesis. UV-B and inflammatory mediators upregulate the expression of matrix metalloproteinases (MMPs), which engenders extracellular matrix (ECM) remodeling. ECM remodeling may provide limbal degeneration and pterygium formation. Some MMPs, for example, MMP-1, MMP-2, MMP-3, MMP-7, and MMP-9 increased in pterygium body. ECM remodeling may be a common cause of the invasive mechanism of pterygium [2, 3].
We attempt to investigate the pathogenesis of primary pterygium. The motivation of our article was to explore the relationship between the MMP-2, 9 and total antioxidant status (TAS), malondialdehyde (MDA) amounts in the pathogenesis of primary pterygium.
Material and Methods
This study was approved by the Ethics Committee of Ankara Numune Education and Research Hospital (Number: E-18-2443), the tenets of the Declaration of Helsinki were observed.
We included our prospective study of 26 eyes of 26 consecutive patients (age range 31-77 years, mean age: 52.76±14.92 years) who need surgical pterygium excision. Seventeen patients were female and nine were male. Healthy conjunctival tissue samples were obtained from those 26 eyes of superotemporal conjunctival autograft tissue. Pterygium tissue samples were also derived from those eyes.
Recurrent pterygium, glaucoma, history of previous ocular surgery or trauma.
Pterygium excision was performed under local anesthesia. Peribulbar 2% lidocaine was injected preoperatively for anesthesia. Pterygium was dissected from the cornea using a 45 degrees knife. The pterygium was dissected up to 4 mm from the limbus. Dissection was done in this region until bare sclera was seen below. All pterygium tissue was removed. Haemorrhages were tamponade with compression. Cautery was denied.
The graft was taken from superotemporal region. The conjunctival graft was dissected using Westcott tenotomy scissors. The graft was superimposed on the bare sclera and was placed in the limbus-limbus position. Each graft was sutured with 8/0 Vicryl sutures. Dexamethasone ophthalmic suspension, ofloxacin 0.3% ophthalmic suspension and preservative-free artificial tears were applied four times daily for 1 month after surgery.
Intraoperatively, pterygium tissue (2mm x 2mm) was excised and collected as pterygium samples. Autograft tissue samples (2mm x 2mm) were obtained from the superotemporal bulbar conjunctiva of the same eyes for the control group. All conjunctival samples were kept at -80 oC until biochemical analysis.
MDA, TAS, MMP-2, and MMP-9 levels were analyzed in all samples. The TAS measurements were made using Rel Assay Diagnostics commercial kit. The basis of the assay is to incubate 2,2’-azinobis (3-ethylbenzothiazoline 6-sulfonate) (ABTS), with the ferryl myoglobin radical formed by the activation of a peroxidase (metmyoglobin) with H2O2 to produce the radical cation ABTS+. It has an approximately balanced blue-green color, measured at 600 nm. Antioxidants in the affixed sample cause suppression of this color reproduction are comparative to its concentration.
MDA (the lipid peroxidation end product) levels were determined using the thiobarbituric acid (TBA) test based on the spectrophotometric measurement of the concentration obtained from the end product of the reaction between lipid peroxides and TBA. MMP-2 and MMP-9 concentrations in the samples were analyzed using commercial 96-well enzyme-linked immunosorbent assay (ELISA) kits.
Statistical analyses were completed using the statistical package SPSS for Windows, version 22.0 (SPSS, Chicago, Illinois, USA). The nonparametric Wilcoxon signed test was used in the statistical analysis. p<0.05 was considered statistically significant. Data were introduced as the mean±SD.
The mean TAS, MDA, and MMP-9 levels were significantly higher in the pterygium group when compared to the control group (p<0.05). The mean MMP-2 levels were increased in the pterygium group when compared to the control group. However, this was not a significant difference (p>0.05) (Table 1).
The etiopathogenesis of pterygium is controversial. UV is an effective factor in pterygium formation. However, causes such as immune-inflammatory reactions, oxidative stress, virus infections and genetic factors have also been reported to be associated with pterygium. Environmental stimuli trigger the secretion of proinflammatory cytokines like interleukin (IL)-1, IL-6, IL-8, IL-17, IL-23, and tumor necrosis factor (TNF)-α from the ocular surface epithelium and inflammatory cells. These cytokines promote extracellular matrix remodeling, fibroblast proliferation and angiogenesis in pterygium body. TNF-α and IL-1β increase the mRNA and protein expression of MMP-1 and MMP-3 in cultured pterygium fibroblast cells. Additionally, MMP-2, MMP-3, MMP-8, MMP-9, MMP-10, and MMP-13 have also recently been shown to be overexpressed in pterygium tissue [4-8].
Our present results showed that MMP-2 and MMP-9 levels increased in pterygium tissue but only MMP-9 levels were statistically significant. Contrary to our study, there are also studies where MMP-9 could not be detected in primary and recurrent pterygium tissues. However, they reported an increase in MMP-1 and MMP-3 . Yang et al. reported that the expression of MMP-2 and MMP-9 by pterygium fibroblasts increased after the progression of pterygium .
We also measured the TAS and MDA levels in pterygial and normal conjunctival tissues. We found that the mean TAS and MDA levels were significantly higher in pterygium tissues. These increased levels were attributed to local oxidative stress.
Some authors investigated that in the pterygium group, MDA level and catalase (CAT) activity were higher, whereas superoxide dismutase (SOD) activity was lower when compared to control groups. In the face of the significant increment in CAT activity, the MDA level was still superior in the pterygium group, demonstrating an outward growing oxidative damage .
Kormanovski and coworkers investigated decreased TAS in recurrent pterygium tissue. They attributed to the decreased antioxidant defense playing role in the recurrence of pterygium. They also showed that TAS levels were significantly increased in the primary pterygium group . We think that the increased TAS in pterygium tissue indicates the antioxidant defense mechanisms of the primary pterygium from increased oxidative stress.
Kau et al. demonstrated abundant immunoreactivity of 8-hydroxy-2’-deoxyguanosine (8-OHdG) in pterygium tissues and elevated levels of 8-OHdG in the DNA of pterygium tissues compared to normal conjunctiva. We understand from these findings that when DNA is oxidatively damaged, it may cause pterygium development . These findings show new horizons of the pathogenesis of pterygium. We must consider this in the avoidance and treatment of pterygium.
Maxia and colleagues have proven oxidative stress may be associated with activation of survivin expression, this may play an important role in the development of pterygium by inducing hyperproliferation in tissue .
Pterygium is a benign ocular surface disease that often tends to progress and recur. Myofibroblasts in pterygium tissue are resistant to cell death and are responsible for extracellular matrix synthesis through tissue remodeling. Although many surgical methods have been tried to prevent pterygium recurrence, it may be more effective to eliminate the factors in the etiology .
Increased levels of antioxidant potential and MDA in the primary pterygium confirm that oxidative stress plays an important role in the pathogenesis of pterygium. In this study, we demonstrated that MMP-2 and MMP-9 may be causative factors in formation and invasion of pterygium. Oxidative stress and MMPs may be the leading causes in the formation and progression of pterygium.
In our study, the pterygium tissue of the patients was compared with the conjunctival tissue in the same eye that was not exposed to ultraviolet light and external factors. In this respect, we think that the results we obtained provide important data for pterygium. These results should provide ideas to find new treatments to prevent pterygium formation and progression.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Funding: Our study was supported by the Turkish Ophthalmological Association.
Conflict of interest
1. Van Acker SI, Van den Bogerd B, Haagdorens M, Siozopoulou V, Ní Dhubhghaill S, Pintelon I, et al. Pterygium-the good, the bad, and the ugly. Cells. 2021; 10(7): 1567.
2. Liu T, Liu Y, Xie L, He X, Bai J. Progress in the pathogenesis of pterygium. Curr Eye Res. 2013; 38(12): 1191-7.
3. Bradley JC, Yang W, Bradley RH, Reid TW, Schwab IR. The science of pterygia. Br J Ophthalmol. 2010; 94(7): 815-20.
4. Tiong KI, Mohd Zahidin AZ, Sumugam SKA, Uchang J, Mohd Isa HD. Evaluation of interleukin-17 and interleukin-23 in pterygium: Immunohistochemistry study. Asia Pac J Ophthalmol (Philia). 2017; 6(5): 403-6.
5. Seet LF, Tong L, Su R, Wong TT. Involvement of SPARC and MMP-3 in the pathogenesis of human pterygium. Invest Ophthalmol Vis Sci. 2012; 53(2): 587-95.
6. Martín-López J, Pérez-Rico C, Benito-Martínez S, Pérez-Köhler B, Buján J, Pascual G. The role of the stromal extracellular matrix in the development of pterygium pathology: An update. J Clin Med. 2021; 10(24): 5930.
7. Tsai YY, Chiang CC, Yeh KT, Lee H, Cheng YW. Effect of TIMP-1 and MMP in pterygium invasion. Invest Ophthalmol Vis Sci. 2010; 51(7): 3462-7.
8. Feng QY, Hu ZX, Song XL, Pan HW. Aberrant expression of genes and proteins in pterygium and their implications in the pathogenesis. Int J Ophthalmol. 2017; 10(6): 973-81.
9. An MX, Wu KL, Lin SC. Detection and comparison of matrix metalloproteinase in primary and recurrent pterygium fibroblasts. Int J Ophthalmol. 2011; 4(4): 353-6.
10. Yang SF, Lin CY, Yang PY, Chao SC, Ye YZ, Hu DN. Increased expression of gelatinase (MMP-2 and MMP-9) in pterygia and pterygium fibroblasts with disease progression and activation of protein kinase C. Invest Ophthalmol Vis Sci. 2009; 50(10): 4588-96.
11. Kormanovski A, Parra F, Jarillo-Luna A, Lara-Padilla E, Pacheco-Yépez J, Campos-Rodriguez R. Oxidant/antioxidant state in tissue of prymary and recurrent pterygium. BMC Ophthalmol. 2014; 14: 149.
12. Kau HC, Tsai CC, Lee CF, Kao SC, Hsu WM, Liu JH, et al. Increased oxidative DNA damage, 8-hydroxydeoxy- guanosine, in human pterygium. Eye (Lond). 2006; 20(7): 826-31.
13. Maxia C, Perra MT, Demurtas P, Minerba L, Murtas D, Piras F, et al. Expression of survivin protein in pterygium and relationship with oxidative DNA damage. J Cell Mol Med. 2008; 12(6A): 2372-80.
14. Kim KW, Kim JC. Current approaches and future directions in the management of pterygium. Int J Ophthalmol. 2018; 11(5): 709-11.
Download attachments: 10.4328.ACAM.21103
Cenk Zeki Fikret, Zuhal Yildirim, Nil Irem Ucgun, Ozlem Evren Kemer, Aysegul Koksal Kayık. Oxidative stress and matrix metalloproteinases in primary pterygium. Ann Clin Anal Med 2022;13(6):703-705
Measuring level of knowledge about zoonoses: A scale development study
Osman Kurt 1, Ayşe Ferdane Oğuzöncül 2
1 Department of of Public Health, Adıyaman Provincial Health Directorate, Adıyaman, 2 Department of Public Health, Faculty of Medicine, University of Firat, Elazig, Turkey
DOI: 10.4328/ACAM.21163 Received: 2022-03-24 Accepted: 2022-05-23 Published Online: 2022-05-27 Printed: 2022-06-01 Ann Clin Anal Med 2022;13(6):706-711
Corresponding Author: Osman Kurt, Adıyaman provincial health directorate, Adıyaman, Turkey. E-mail: email@example.com P: +90 416 225 10 21 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4164-3611
Aim: The scope validity was provided as the first step in the development of the scale in this methodological and cross-sectional study.
Material and Methods: Item difficulty and discriminatory power index were calculated for each item. Exploratory factor analysis was used to determine the construct validity. The Cronbach alpha internal consistency coefficient was calculated to determine the reliability of the scale. The number of public health professionals working in the field, of which 403 (participation rate of 82%) could be reached, was 491.
Results: The mean difficulty levelof the Zoonotic Knowledge Level Scale (ZKLS) , with a Cronbach alpha value of 0.910, in which item-removed values varied between 0,903-0,908, was found as 0.68. Besides, it was observed that knowledge scores increased as the duration of public health professionals’ expertise and their working time in the infectious diseases branch increased. The knowledge level of those who worked in the infectious diseases branch was significantly higher than those who did not.
Discussion: As a result, this scale, developed on zoonoses, was found to be valid and reliable. However, its reliability in particular groups needs to be tested with more extensive studies to elucidate and prove its impact further and apply it to society’s other fields.
Keywords: Zoonoses, Level of Knowledge, Scale Development, ZKLS, Reliability
Zoonoses, constituting the 75% of diseases considered a public health concern, continue their evolution in nature by passing from animals to humans and from humans to animals [1-3]. Most importantly, these diseases, which have caused significant human losses in history, remain a major global health threat. Nowadays, some zoonotic infections such as swine flu, Crimean-Congo hemorrhagic fever disease, Ebola hemorrhagic fever, West Nile virus, SARS have been noticed to reach levels that commonly threaten public health in a short time. Hence, in recent years, the subject of zoonotic diseases has become much more critical nationally and especially internationally .
According to their etiologies, zoonoses are divided into eight groups: bacterial, viral, parasitic, fungal, rickettsial, protozoal, helminthic, and arthropod-borne zoonoses .
It is imperative to know how and under what conditions it is transmitted, what prevention measures, and which treatment options should be applied to avoid zoonoses. To do this, as a next step, it is also necessary to determine people’s knowledge levels and organize training accordingly. Public health professionals have been trained on zoonoses in the process of both medical school education and specialty training. They are more likely to be exposed to zoonoses since they frequently work in public health-related areas in the field. Therefore, their level of knowledge is expected to be sufficient for quality and proper health management. Many studies in the literature have measured the level of knowledge of different society segments, though not public health professionals [1,5,6]. However, in these studies, literature-based questions have been asked, and the level of knowledge tried to be measured. We suggest that common question patterns in studies will be useful for standardization. To achieve this, in the present study, we aimed to develop a scale related to zoonoses.
Material and Methods
This methodologically planned research was conducted on public health professionals working in the field.
To provide scope validity of a draft question pool, created after the literature review, a total of 13 expert opinions, including six public health specialists, two microbiologists, an infectious diseases specialist, three veterinarians who were experts in microbiology fields, and a measurement/assessment specialist, were consulted. Scope Validity Index (SVI), desired to be greater than 0.67 for the validation, is the mean of the remaining questions’ scope validity rates in the assessment tool . The Turkish linguist checked the questions that constitute ZKLS, where SVI was calculated as 0.89, whether they were correctly expressed and distorted, and made corrections. The data collection phase was started to make the 56-item ZKLS question pool validity-reliability study prepared due to the scope validity.
The approval dated 06 May 2019 and numbered 326712 from the Non-Interventional Clinical Research Ethics Committee of Firat University Faculty of Medicine and written permission dated 15 Nov 2019 and numbered 49654233-604.02 from the Ministry of Health Public Health Directorate was obtained to carry out the study.
In developing a new assessment tool, the recommended sample size is 5-10 times as much as the number of questions . Our study’s sample size should be between 280-560 since the number of questions of ZKLS is 56. Of the 491 public health professionals working in the field, 403 were reached (participation rate of 82%).
Considering that public health professionals work scattered in almost all Turkey cities, the questionnaire form was sent to them via e-mail.
SPSS (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL) 22 package program was used for statistical analysis. The study’s descriptive data were denoted by n, % values in categorical data and mean ± standard deviation (Mean ± SD) and median and interquartile range (25th 75th percentiles) values in continuous data. The Chi-square analysis was applied to compare categorical variables between groups. Conformity of the measurement data to normal distribution was tested with the Kolmogorov-Smirnov test. The Mann-Whitney U test was applied to compare variables not normally distributed between the two groups, and the Kruskal Wallis test was used between more than two groups. The Spearman correlation test was utilized to examine the relationship of continuous variables with each other. The statistical significance level in the analyses was considered p<0.05.
56.8 % of the study group were women, and the mean age was 37.8 ± 7.5 (min=25-max=67). 63.3% of the participants were married, 36.7% of the participants were single, 38.5% lived in a metropolitan city, 26.1% in the city, and 26.1% in the county. Again, 46.7% worked or were working in the infectious diseases branch.
The mean difficulty level of ZKLS was found as 0.68, and difficulty levels ranged from 32% to 98%, with no item excluded according to the item difficulty index. Twenty-three questions whose coefficients were less than 0.20, ranged between 0,21-0,83 were removed from the ZKLS ‘s item discrimination coefficient (Mean 0.56).
The mean of remaining items, excluding those removed due to their item discrimination power, were compared between the lower-upper 27%. As a result, a significant difference was observed in all items between the upper and lower 27% groups (p<0,001).
In EFA, KMO was found as 0.829, and the Barlett test results as p <0.001. While the KMO-MSA value of an item was determined to be 0.479, another item’s common factor variance value was 0.452. On the other hand, both KMO-MSA and common factor variance values of other items were calculated to be greater than 0,50.
After excluding 12 items with a factor load below 0.50, those above 0.50 remained on the scale. Based on the factor analysis, the one-dimensional scale explained 36.1% of the total variance.
The percentage of items’ correct answers with loads between 0.521 and 0.740 varied between 47.9% and 74.2% (Table 1).
Whereas the item-total correlation values of items with an in-test consistency coefficient (Cronbach alpha) of 0.910 ranged between 0,533-0,722, item-excluded Cronbach alpha values were 0,903-0,908 (Table 1).
The mean score obtained by the public health professionals included in the study from the scale was 27.8 ± 10.7, and the median was 29.0 (IQR = 21-37). There was a significant difference between the age groups in terms of scale total scores (p=0,001). This difference resulted from the difference between the <35 age group and 35-45 age group and the <35 age group and >45 age group. The score of those with more than one year of expertise duration was significantly higher than those with less than one year, those who worked in the infectious diseases branch than those who did not, and those with more than one year of working duration in the infectious diseases branch than less than one year (p <0.001, p = 0.008 and p = 0.003, respectively) (Figure 1). The answers given about thinking that they have enough knowledge about zoonoses differed significantly in terms of the total scale scores (p<0,001), with this difference being due to the difference between all answers. No statistically significant difference was observed in terms of scale score between age, marital status, living place, and the perceived level of the economic status (p>0,05) (Table 2).
A positive significant relationship was found between the scale total score and age (r=0,183, p<0,001), expertise duration (r=0,280, p<0,001), and working duration in the infectious diseases branch (r=0,253, p<0,001) (Figure 2).
When developing a new assessment tool, the items to be found in this tool should not be too easy or too difficult. If the simplicity or complexity of the assessment tool is important rather than each item, then the mean difficulty level must be considered, which has been desired to be around 0.50 so that it is not too easy or too difficult . Additionally, each item has been accepted as difficult if the difficulty level is less than 30% . Our study found the item difficulty index of all items greater than 0.30, while the mean difficulty level of ZKLS was 0.68 with no item exclusion according to the item difficulty index.
The items of measurement tools, evaluating traits such as talent and achievement, which require people to show their maximum performance, should distinguish between persons who know and who do not. While developing a new assessment tool, it is desirable that the item discrimination coefficient should be at least 0.19 and below so that items can be distinctive and fit for purpose [9,11]. In the present study, 23 items with an item discrimination power of 0.19 or less were excluded. The item discrimination coefficient of ZKLS has been observed to range from 0,21 to 0,83 in several previous studies (mean 0.56). In our study, item distinctiveness was also evaluated by comparing the lower-upper 27% groups’ scores, and all items in ZKLS were determined to be discriminatory. As a result, ZKLS is composed of items, which are relatively easy (0,68) but highly discriminating. Many published studies have been reported in the literature, where item distinctiveness was prioritized in item selection, stating that items are not removed from the scale if their distinctiveness is sufficient, even if they are too easy or difficult [11-14].
Barlett’s test of sphericity, where a p-value less than 0.05 means that the correlation matrix is suitable for factor analysis, has been used to evaluate the correlation matrix’s overall significance detected by exploratory factor analysis . Therefore, the Keiser-Meyer-Olkin (KMO) number has been calculated to decide whether the sample size is suitable for factor analysis. The KMO number usually ranges between 0-1 and must be close to 1 to perform factor analysis. Although the KMO coefficient above 0.60 has been considered sufficient, it is desired to be above 0.80 . KMO was found to be 0.829 and determined using the Barlett test as p <0.001 in the current study. This shows that the prepared scale items are suitable for EFA.
The anti image correlation matrix shows the effectiveness of the scale items on the scale. Major axis elements of the anti image correlation matrix show the ability of each item to be in the scale (KMO-MSA). The KMO-MSA value must be greater than 0.5 for each item; when it is lower than 0.5, this means that the relevant item does not contribute adequately to the scale. Another issue related to factor extraction is calculating the variance explained by the factors, called the communality, which is the sum of the squares of the factor loads of all factors. It gives the percentage variance of the variables that explain the factors and explains each item’s contribution to its factor variance. Besides, with this analysis, a common factor variance value is created, and this value means the measurement value of the variables. The higher the values, the better the variables are measured, with low ones that are excluded from factor analysis.
Meanwhile, the common factor variance value should be at least 0.50 . In our study, the KMO-MSA value of one item was 0.479, and the common factor variance value of another item was 0.452. These values were below 0.50 but close to 0.50, so we did not remove them from the scale. In contrast, both KMO-MSA and common factor variance values of other items were greater than 0.50.
In the exploratory factor analysis, each item’s factor load has been calculated in many different trials. According to Hair et al. , each item’s factor load value, which was considered to be included in the scale above 0.50 was a suitable criterion. Büyüköztürk et al.  stated that this value should be at least 0.45. However, for a small number of practice items, this limit has been lowered to 0.30 [18,19]. In our study, we obtained factor loads above 0.50. Despite the distribution of items to 10 different factors resulting from the EFA, the scale was forced into a single factor due to the number of items in these factors was below three, and the items in the factors that occurred are not logically fit into a common heading. In this case, 12 items (2 were KMO-MSA with a common factor variance value below 0.50) with a factor load below 0.50 were excluded from the scale. Other items remained on the scale as their factor loads were above 0,50. As a result of the factor analysis, the scale consisting of one dimension explained 36.1% of the total variance. It, moreover, seems sufficient for the variance explained in social sciences to be at least 40% . Our study also revealed that forcing the scale to a single factor caused a decrease in the total variance explained.
Nevertheless, since the result we found was very close to 40%, it was considered sufficient. In scales that are forced to a single factor in this way, a low total variance is the expected result. Indeed, in the study by Demirtaş et al. , it was found that the single-item scale explained 21.6% of the total variance.
Internal consistency, expressed by an internal consistency coefficient, denotes the consistency of items on a scale with each other and whether they form integrity to explain the same conceptual structure. Whereas Cronbach’s alpha coefficient was calculated to determine the scale’s internal consistency, Cronbach’s alpha reliability coefficient was defined as a weighted standard mean of change obtained by dividing the sum of all items’ variances in the scale by general variance. Cronbach’s alpha coefficient, which in our study was found to be 0.915, was accepted as “acceptable” between 0.70-0.80, “well reliable” between 0,80-0,90, “highly reliable” above 0,90 (Gliem JA, Gliem RR. Calculating, interpreting, and reporting Cronbach’s alpha reliability coefficient for Likert-type scales. Midwest Research to Practice Conference in Adult, Continuing, and Community Education; 2003). On the other hand, its item extracted values vary between 0,909-0,915.
One of the methods used for the developed scale’s construct validity is “separation between groups. It is primarily based on the hypothesis that it is different concerning the to-be-measured area. The proper analysis method should be selected according to the data’s characteristics obtained from the scale to prove this difference . For this, those who were in our study group but worked in the infectious diseases branch were presumably considered more knowledgeable. Besides, it was hypothesized that zoonotic knowledge would increase with raising expertise duration. Our results showed that the knowledge level of those who worked in the infectious diseases branch was significantly higher than those who did not. Also, it was observed that the higher the expertise duration and the higher the working duration in the infectious diseases branch, the higher the knowledge score. This situation indicates that construct validity is ensured for the segregation between groups.
Based on our study findings, 23 of 56 items were applied as questionnaires after the expert opinion was removed due to their low discrimination power and 12 due to insufficient factor loading. The reliability coefficient of the remaining 21 items was found to be 0.910, and the scale was considered easy to apply, valid and reliable in its current form. Correct answers to scale questions “2 points”, wrong answers, “0 points,” and answers of I do not know were evaluated as “1 point,” and the scores that can be obtained from the scale ranged from 0 to 42 points. These results should moreover be interpreted with caution and supported by further studies on this topic. Most importantly, we consider that testing the scale’s reliability in special groups is paramount in its application to society’s other spheres.
We thank the public health professionals working in the field who agreed to participate in the study.
Scientiﬁc Responsibility Statement
Animal and human rights statement
Conflict of interest
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Osman Kurt, Ayşe Ferdane Oğuzöncül. Measuring level of knowledge about zoonoses: A scale development study. Ann Clin Anal Med 2022;13(6):706-711