January 2024
Does the Bobath approach improve trunk control in acute stroke patients?
Ayla Fil Balkan 1, Ceren Saban 2, Yeliz Salcı 1, Ali Naim Ceren 1, Kadriye Armutlu 1
1 Department of Neurological Physiotherapy and Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, 2 Department of Physical Therapy and Rehabilitation, Eskisehir Osmangazi University, Health Application and Research Hospital, Eskisehir, Turkey
DOI: 10.4328/ACAM.21484 Received: 2022-11-06 Accepted: 2022-12-10 Published Online: 2022-12-11 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):1-6
Corresponding Author: Ayla Fil Balkan, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Adnan Saygun Street, 06100, Samanpazari, Ankara, Turkey. E-mail: aylafil@gmail.com P: +90 312 305 15 72 / +90 535 454 90 27 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2721-0222
This study was approved by the Ethics Committee of Hacettepe University (Date: 2017-04-16, No: KA-16073)
Aim: In this study, we aimed to examine the effect of Bobath-based trunk training on improving trunk control in acute stroke patients.
Material and Methods: A total of 81 stroke patients were randomized to the control (n=41) or experimental group (n=40). Then, the groups were divided into two subgroups, moderate and severe, according to disease severity using the Modified Rankin Scale (mRS). Experimental subgroups received Bobath-based trunk training 5 days a week for 1 hour a day during hospitalization. Control subgroups received a conventional physiotherapy program 5 days a week for 1 hour a day during hospitalization. Sitting ability was evaluated as independent or dependent according to sitting time. Trunk control was assessed with the Trunk Impairment Scale (TIS) and the trunk subscale of Motor Assessment Scale (MAS-T). Balance was assessed with Berg Balance Scale (BBS). Functional activity level was assessed with the motor subscale of Functional Independence Measurement (FIM-M). Comparisons between groups were made according to the severity of the disease, and the moderate subgroups were compared with each other, and the severe subgroups with each other.
Results: Trunk control, sitting ability and balance improved significantly more in the experimental moderate and severe subgroups than in the control subgroups according to TIS (p<0.05), MAS-T (p<0.05), BBS (p<0.05) and FIM-M scores (p<0.05).
Discussion: Bobath-based trunk training improved sitting ability, trunk control, balance and functional independence in acute stroke patients regardless of initial disease severity.
Keywords: Stroke, Rehabilitation, Bobath Approach, Trunk
Introduction
After a stroke, trunk impairment is prevalent and causes various difficulties in activities such as speaking, breathing, and lower and upper extremity functions [1]. It is also one of the important indicators of recovery and is associated with length of hospital stay, balance, walking, functional mobility, and activities of daily living (ADL) [2].
Stroke affects trunk muscles multidirectionally, unlike extremity muscles [3]. Moreover, altered trunk position sense also affects trunk control after stroke [4]. Trunk exercises are used to improve trunk control in stroke patients. Previous studies [5,6] demonstrated that sitting training, trunk-oriented exercises, core stabilization exercises, and balance exercises increase trunk control in subacute and chronic stroke patients.
Another method used in trunk training is the Bobath approach, which is widely used in stroke rehabilitation worldwide. Despite its widespread use, this approach appears to be utilized as an experimental or conventional method for improving trunk control in chronic stroke patients in a few studies [7-9].
The extremities and trunk recovered after the stroke with a similar time course. Verheyden et al. [10] investigated the recovery process in the trunk and extremities and indicated that the improvements were at the highest level in the first month. Although the first one-month acute period seems to be a very appropriate period to develop trunk control, studies on improving trunk control in this period are very limited. Karthikbabu et al. [11] examined the effects of physio ball and plinth trunk exercise regimens on trunk control in acute stroke patients and determined that trunk control increased in both groups, but training on the ball was more effective. Although Bobath is the most common stroke management approach, it has been used in very few studies, especially in the acute period. As a result of these studies, different results have been obtained regarding the effectiveness of this approach [12]. In the literature, although there is no consensus on the effectiveness of the Bobath approach, it is the most used stroke treatment approach in clinics. In addition, in the acute stroke phase, the improvement of the trunk positively affects various functions in the chronic stroke phase. Therefore, our study was planned to examine the effect of Bobath-based trunk training on improving trunk control in acute stroke patients with different disease severity.
Material and Methods
Design and Patients
This study was an assessor-blinded, randomized controlled trial performed at the neurology inpatient service at Hacettepe University Hospital, Turkey. The study was approved by the local ethical committee of Hacettepe University (KA-16073) and was registered in the Clinical Trials Registry (CTR number: NCT03429855). Patient recruitment started in March 2018 and ended in October 2019.
Inclusion criteria were having first stroke attack, age over 18 years, Glasgow coma scale (GCS)≥14, absence of cognitive impairment, that is, Mini-Mental State Examination >24, being within the first week after stroke onset and at stage ≥2 according to the Modified Rankin Scale (mRS). Exclusion criteria comprised recurrent strokes, other neurologic diseases, severe orthopedic problems or communication disorders that may affect the results. Patients with posterior circulation stroke were also excluded.
The patients were randomly divided into the experimental and control subgroups. The randomization was performed using a random number table. To allocate patients to one of these groups, physical therapists who were blinded to the research performed assignments based on a computer-generated random number. Then, the experimental group was divided into two subgroups according to mRS. The Severe Disability subgroup (S-EG) included patients with severe deficiency (mRS score ≥4) and the Moderate Disability subgroup (M-EG) included patients with moderate deficiency (mRS score ≤3). Similarly, the control group was divided into the Severe Disability subgroup (S-CG) and the Moderate Disability subgroup (M-CG).
Interventions
Patients in the control group (M–CG and S–CG) received the conventional physiotherapy program, which was tailored to the individual needs of patients 5 days a week for 1 hour a day during hospitalization. The program included a range of motion exercises, general strengthening and stretching exercises, balance and gait training. In the experimental group (M–EG and S–EG), the Bobath based physical therapy program was tailored to the individual needs of patients 5 days a week for 1 hour a day during hospitalization [9]. Trunk control training comprised approximately 50-60% of each session. Experienced physiotherapists took part in the identification of functional limitations and in stroke rehabilitation during the development and validation of the hypotheses. The treatment program intensively concentrated on trunk control in all directions. Treatment programs for both groups are summarized in Table 1.
Outcome Measurements
The patients were assessed on the first day when their medical condition was stable after hospitalization. Disease severity was assessed with mRS. The Trunk Impairment Scale (TIS) and trunk part of the Motor Assessment Scale (MAS-T) were used to determine the trunk control of all patients. The balance was evaluated using the Berg Balance Scale (BBS), functional activity level with a motor section of the Functional Independence Measurement (FIM-M) and sitting time without support was recorded. The tests were repeated on the day of discharge by the same physiotherapist who performed the initial assessment and was blinded to the groups.
To evaluate sitting ability, the patients were asked to sit with back unsupported, without using hands on the edge of a bed. The thighs made full contact with the bed, the hip and knees flexed ninety degrees, the feet were hip width apart and placed flat on the floor. The arms were crossed over the chest. The head and trunk were in a midline position. The sitting time was recorded during the standard sitting position. If the position changed or patients maintained their position for more than two minutes, the test was ended. Patients who were able to maintain the standard sitting position for two minutes or more were classified as independent and others as a dependent.
Trunk control was evaluated with TIS and MAS-T. TIS consists of 3 subscales: static and dynamic sitting balance and trunk coordination, scored up to 7, 10, and 6 points, respectively. The total scores range between 0 and 23 points, where a higher score indicates better trunk function. MAS-T contains rolling, lie to sit, and sitting balance. Each item is scored on a 7-point ordinal scale from 0 to 6, a higher score indicating a better performance [13].
BBS is a functional balance test. It includes 14 items and all of them are scored on a 5-point ordinal scale from 0 to 4, with a maximum score of 56 points. A higher score indicates better balance ability [14].
The degree of disability or dependence in daily activities was evaluated using mRS. It describes “global disability” with a focus on mobility. The mRS is an ordered scale coded from 0 (no symptoms at all) to 5 (severe disability) and 6 (death). Level 3 and lower values indicate moderate and less disability, while Levels 4 and 5 indicate severe disability [15]. For this reason, these values were considered when structuring the subgroups.
FIM-M was used to evaluate the ability to perform ADL. The FIM-M item scores range from 1 (total assistance required) to 7 (complete independence). A higher score indicates a greater degree of independence with regard to ADL [16].
Data analysis
Analyzes were performed separately for subgroups. Descriptive measures were summarized as mean±standard deviation or percentage. The Chi-square test was used for categorical variables. The Shapiro-Wilk test was used to determine the distribution of variables. Wilcoxon’s signed ranks tests were used for group analyses, and the Mann–Whitney U test was used to compare different groups according to distribution. The initial disability level scores of the patients in the subgroups and any potential differences in recovery rates were considered. For this reason, severe subgroups were compared to one another, while moderate subgroups were compared to one another. All statistical analyses were performed using the SPSS v.18 with a significance level of p<0.05.
The sample size calculation was based on the study of Karthikbabu et al. [11] (the post-hoc TIS scores of the plinth and control group) for our primary outcome and was conducted using G-power 3.1 (Heinrich Heine University, Dusseldorf, Germany). To determine the appropriate sample size, the effect size was set to 0.852 with 95% power to identify between-group differences in before–after intervention changes, with an α error of 0.05. The calculation indicated that 39 participants were required per group; 44 participants per group were recruited to allow for dropouts.
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
A total of 108 patients were screened for study eligibility and 88 patients met the inclusion criteria. The patients were randomly allocated to groups. The study was completed with 81 patients. Figure 1 shows a CONSORT flowchart stating the steps of the study. In the analyzes, it was seen that the experimental and the control group were homogenous in terms of demographic and clinical characteristics (Table 2).
Treatment processes of all patients were completed without any side effects. The scores of TIS, MAS-T, BBS and FIM-M increased significantly in all subgroups after interventions compared to pretreatment except for value of TIS static part for M-CG and TIS dynamic part for S-CG (p<0.001 for all comparisons). Sitting ability developed in both S-EG and S-CG (respectively p<0.001 and 0.008). In addition, the scores of TIS, MAS-T, BBS and FIM-M improved significantly in Bobath subgroups compared to control subgroups (p<0.05 for all comparisons) (Table 3).
Discussion
Our study showed that Bobath-based trunk training applied to stroke patients in the acute phase improves sitting ability, trunk control and balance more effectively than conventional physiotherapy regardless of the severity of the disability. Although the systematic reviews reported that the Bobath approach had no superiority over other methods used in stroke patients regaining mobility, motor control, gait, sitting and standing balance [12,17-19], our results did not support the literature findings. There may be some possible reasons for this discrepancy. Firstly, our study was intended to directly improve trunk control, while the reviews included a very limited number of studies focusing on the trunk, and secondly, the chosen by reviews trunk control measurement tools varied. Lastly, it may be due to the inclusion of patients in the acute phase in our study.
The sitting ability and trunk control were evaluated within the scope of our study. The number of patients who could sit independently increased significantly in the experimental group compared to the control group. In the literature, core stability training, which includes exercises such as bridge building, upper and lower trunk flexion, extension and rotation, and various weight bearing trainings are used to increase trunk control. These practices were also effective in improving sitting balance [1]. Although the training provided to the experimental group did not follow all the principles of core stability training with a specific protocol, it seems to include similar exercise practices. Considering that the role of sensorimotor control is much more important than that of strength or endurance of the trunk muscles for balance [20], the Bobath approach may have contributed to trunk control by improving sensorimotor control as well.
Turning in the bed, evaluated by using MAS-T in our study, is one of the milestones of normal development and basic ADL. In stroke patients, turning towards the unaffected side is impaired [21]. Kafri and Dickstein [21] showed in their study that the relationship between the pectoralis major and the rectus femoris, external obliques is impaired due to decreased activation on the hemiplegic side in stroke patients.
The treatment applied to the experimental subgroups may have contributed to the higher scores of these subgroups on MAS-T by providing the correct sensory input and adjusting the movement sequence.
In our study, it was observed that TIS scores increased in all sub-parameters and total scores in the study group. Unlike other studies conducted to improve trunk control [7, 22], there was also an increase in the static balance score of the TIS.
This may be due to the fact that the studies generally specified the ability to sit independently for more than 10 seconds, which is sufficient to receive a full score on the static balance section of the scale, as an inclusion criterion, and included chronic stroke patients who are likely to sit already. The inclusion of acute patients in our study may have allowed the scale to show the post-treatment change in this population.
Previous studies show that trunk training improves BBS scores [7,23]. Similarly, the scale’s scores increased in our study. The increase in transfer activities and the improvement in sitting and standing activities together with the increase in sitting balance of our patients in the study group may have improved the scores.
The FIM-M scores in the study subgroups improved more than in the control subgroups in our study. Likhi et al. [24] reported that the overall functional independence in acute stroke patients is most closely correlated with trunk function, followed by upper limb impairments.
Considering the relationship between independence in ADL and trunk control in stroke patients, it could be said that the improvement in ADL in our study is due to the recovery in trunk control.
The study has some limitations. There was no follow-up after discharge within the scope of the study. For this reason, it cannot be commented on how long the obtained treatment effects will last. In addition, the effect of improvement in trunk control on other functions has not been examined and since inpatients were included in the study, the level of independence of the patients in their daily living activities may not have been fully demonstrated. Therefore, FIM values should be interpreted with caution.
Conclusion
In conclusion, the Bobath approach may be a viable treatment option for the development of trunk control regardless of the disability level of the patients in the acute period after stroke. The effectiveness of the Bobath-based trunk training in the severely affected group is one of our most important study findings. Since most of the studies on practices that have been shown to be effective in the literature preferred to include individuals who have reached a good level in their studies rather than individuals with serious disabilities. In our study, on the other hand, individuals with severe effects were not excluded, and as a result of our study, satisfactory results were obtained in this group as well. Our study suggested that perhaps the Bobath approach is not as ineffective as reported by systematic reviews in regaining mobility, balance, and ADL. It may still be an appropriate approach that could be prioritized for patients with at least some disability levels. In further studies, the long-term effects of Bobath-based trunk training may be examined. In addition, the effects of improvement in trunk control on other functions may be examined.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Funding: None
Conflict of interest
The authors declare no conflict of interest.
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Ayla Fil Balkan, Ceren Saban, Yeliz Salcı, Ali Naim Ceren, Kadriye Armutlu. Does the Bobath approach improve trunk control in acute stroke patients? Ann Clin Anal 2024;15(1):1-6
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Evaluation of COVID-19 antibody levels in emergency department healthcare workers
Selin Celik 1, Ertugrul Altinbilek 1, Ozgur Cevrim 1, Nesrin Gareayaghi 2
1 Department of Emergency Medicine, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hopital, 2 Department of Clinical Microbiology, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hopital, İstanbul, Turkey
DOI: 10.4328/ACAM.21575 Received: 2023-01-03 Accepted: 2023-03-02 Published Online: 2023-11-19 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):7-10
Corresponding Author: Ertugrul Altinbilek, Department of Emergency Medicine, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hopital, 34371, Sisli, Istanbul, Turkey. E-mail: ertugrulaltinbilek@gmail.com P: +90 505 904 68 33 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4201-8850
This study was approved by the Ethics Committee of Sisli Hamidiye Etfal Training and Research Hospital (Date: 2021-02-03, No: 3167)
Aim: In this study, we aimed to evaluate the contact status of emergency department healthcare workers of a tertiary health center by investigating their antibody levels against COVID-19.
Materials and Methods: COVID-19 transmission status and SARS-CoV-2 IgG levels of 24 doctors and 55 nurses working at the emergency department and a control group of 73 non-healthcare workers were included in the study.
Results: PCR testing was positive for COVID-19 in 39.2%, only CT in 7.6%, both PCR and CT were positive in 10.1%, while both PCR and CT results were negative in 43%. PCR testing was positive in 13.7% of the control group. Compared to the control group, symptomatic frequency of COVID-19 infection (57% vs 14%, p<0.001), COVID-19 antibody positivity, RT-PCR positivity, and COVID-19 IgG levels were statistically significantly higher. In both groups, the SARS-CoV-2 IgG level of those with positive RT-PCR in any test was higher than those with negative RT-PCR (p<0.001). There was a negative (p = 0.001) correlation between SARS-CoV-2 antibody level and the time elapsed after detection of positivity, and a positive correlation with ferritin levels (p = 0.027) among Emergency Department workers (p< 0.05).
Discussion: The frequency of COVID-19 and antibody levels were significantly higher in emergency department workers who were diagnosed and treated COVID-19 patients than in the non-healthcare worker group. There are asymptomatic carriers in the community, hence protective equipment use, social distance and cleaning rules should be meticulously followed.
Keywords: COVID-19, Emergency Medicine, Healthcare Personnel, COVID-19 Serological Testing
Introduction
In December 2019, a novel virus called SARS-COV-2 from the Coronavirus family was introduced. This virus is transmitted between humans and tends to affect the human respiratory system. Due to the growing number of people infected with the virus, the World Health Organization announced the COVID-19 pandemic on March 11, 2020. The pandemic resulted in death of more than 200,000 people, and an effective management protocol has not yet been reported [1, 2]. In treatment of COVID-19, antivirals, immunomodulators, anticoagulants, immune plasma therapies and other supplemental treatments are used [1, 3].
Patients with COVID-19 present with non-specific symptoms including fever, cough, myalgia, loss of taste and smelling functions. Admission to the wards was most commonly indicated due to respiratory dysfunction secondary to viral pneumonia [4, 5]. In addition to the respiratory involvement, renal and less commonly cardiac systems are frequently affected as well [6, 7].
While trying to control the infection rate, it is also important to determine patients who have the disease and healthy people at risk to decrease the number of people who necessarily have to be followed in quarantine. Reverse transcriptase polymerase chain reaction (RT-PCR) was carefully investigated to determine the symptomatic infection period and was found to be successful [8]. The number and results of methods to detect previous infection, however, are limited. The presence of antibodies, as with other infectious diseases, can be a guide to detect patients with a previous infection status and therefore can be used to evaluate whether or when patients are able to return back to their daily living. However, in order to make such decisions affecting people in large scales, the results of antibody testing should be accurate and precise [9].
A specific test should detect the antibodies against SARS-CoV-2 and a sensitive one should not give similar results with other antibodies. Thinking practically, a perfect test is not possible, especially in infectious diseases, where the timing of the test during a variable symptomatic period is also critical. Moreover, seroconversion also takes a considerable amount of time. Frequently, the initial IgM surge is followed by IgG and then IgA, but this may change depending on the severity of the disease, on the immune system of the patient. For instance, Roche and Abbott both reported a sensitivity of around 100% for their tests when they are performed after 14 days or more of the appearance of the symptoms in contrast to the other studies where reported sensitivities of the same kits were 87% and 93,4%, respectively [9, 10].
Being a healthcare professional is commonly a risk factor for not only other infectious diseases, but also COVID-19. In such a population, determination of the disease status and epidemiological investigation are important for public health purposes. In this study, we aimed to present the infection status, characteristics of infected patients and antibody levels among the healthcare professionals working at a tertiary center.
Material and Methods
This cross-sectional study was performed among healthcare professionals who were not vaccinated against SARS-CoV-2. Informed approval was obtained from every participant in the study. All procedures performed in studies 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. Only doctors and nurses who worked solely in the emergency department were included irrespective of a previous history of COVID-19. Patients over 18 years of age, who presented to the emergency department without symptoms of COVID-19 and who were not healthcare professionals were included in the study as a control group. Patient characteristics were recorded, including a previous history of COVID-19. Blood samples were obtained from the study and control groups and isolated at -40ºC after centrifugation. An ELISA kit (DiaPro, Milano, Italy) was used to determine the antibody titer.
Statistical analysis
Statistical analysis was performed using the Number Cruncher Statistical System 2007 (NCSS, Kaysville, Utah, USA). This study was approved by the Ethics Committee of Sisli Hamidiye Etfal Training and Research Hospital (Date: 2021-02-03, No: 3167)
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
A total of 79 healthcare workers, 45 females (57%), including 24 (30.4%) doctors and 55 (69.6%) nurses were included. The control group included 73 patients; 21 females (28.8%) admitted to the emergency department with a similar range of age during the study period. Among healthcare workers, a retrospective investigation demonstrated that during diagnosis, PCR was positive in 39.2%, only computerized tomography was positive in 7.6%, and both were positive for COVID-19 in 43% of patients, with 2.5% requiring admission (Table 1). Antibody testing for COVID-19 yielded positive results in 55.7% of healthcare providers. Compared to the control group, a number of tests with positive results was significantly higher (p=0.002). PCR tests were positive in 49.4% of the healthcare workers compared to 13.7% in the control group (p<0.001). The frequency of asymptomatic COVID-19 infection was significantly higher among healthcare workers. IgG levels were significantly higher in the healthcare worker group (p=0.027) (Table 2). Patients testing negative for COVID-19 with computerized tomography and PCR tests had significantly lower IgG levels compared to patients testing positive for either CT or PCR or both (Figure 1). IgG levels were also significantly higher in patients with positive PCR results in the control group, compared to the patients with negative PCR results (p<0.001). Among patients with a history of COVID-19, there was a negative correlation between antibody levels and the time between the initial diagnosis and antibody testing. A positive correlation was found between ferritin levels at the initial diagnosis and the antibody levels (Figure 2).
Discussion
Compared to the other fields of medicine, healthcare workers working in the emergency department have a higher risk of contact with patients presenting with communicable diseases, since patients with acute symptoms frequently seek care in the emergency department for diagnosis. As expected, healthcare providers working in the field of emergency medicine are also at risk of getting infected with SARS-CoV-2.
Stringhini et al., reported a relatively low seroprevalence of 3.2% in their study including 2.3 million people from 50 countries [11]. Many other studies from Europe and China also exist and report varying percentages of seroprevalence in the general population ranging between 0.23 and 10.9% [11, 12]. Different studies from the Netherlands, England, and Italy reported a PCR positivity ranging between 3-18% among healthcare professionals [13]. Galanis et al., included 49 studies in their recent meta-analysis and demonstrated a seroprevalence ranging between 0-45,3% among healthcare workers and concluded that the seroprevalence among healthcare workers was significantly higher compared to the general population [14]. Other studies and meta-analyses demonstrated a variable seroprevalence among healthcare workers ranging between 7-12.4%, showing healthcare workers having a higher risk of infection with SARS-CoV-2 [15-17]. Compared to the general population, Grant et al. and Rudberg et al. found a higher rate of seropositivity among healthcare providers [18, 19]. Further analysis by Shields et al., demonstrated higher seropositivity among healthcare workers working in emergency medicine, home care and internal medicine [20]. Another study by Alserehi et al. demonstrated a higher rate of seropositivity in healthcare workers working at pandemic hospitals compared to their counterparts [21]. The number of studies focusing on seroprevalence with antibody levels is limited, and results vary due to the differences between the populations, type and timing of testing. However, similar to others, we also found out that healthcare professionals have a higher seropositivity compared to the general population.
Ferritin is an iron-binding protein and levels are important to determine the iron levels in a patient. In addition, it is a critical marker of inflammation, and its increase is correlated with the level of inflammation [22]. Lin et al. demonstrated that high levels of ferritin are associated with the presence and increasing severity of COVID-19 [23]. Other studies showed a correlation between ferritin levels and disease progression and outcome prognosis [24]. In our study, we found out that higher levels of ferritin directly or indirectly result in a higher antibody level. Antibodies against SARS-Cov-2 decrease in time, as expected and our findings were concurrent with the other studies demonstrating the pattern of antibody levels following COVID-19 [25].
There are several limitations in our study. Samples in our control and healthcare worker groups were not matched and subgroup analyses were not performed. In addition, due to the cross-sectional nature of this single-centered study, different results can be obtained in further studies to be carried out in different periods of the pandemic, due to its unexpectable course and in different regions, where the density of cases changes.
Healthcare providers in emergency medicine may need to intervene before they have the opportunity to take the necessary personal protective measures adequately, especially in emergency situations. Healthcare professionals working in the emergency department have a higher prevalence of COVID-19 compared to the general population, which suggests an increased risk of communicating the disease. The higher rate of those who are asymptomatic but are seropositive in the community can be explained by the fact that healthcare professionals are more aware of the symptoms of the disease and have PCR tests done more frequently.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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9. Kumleben N, Bhopal R, Czypionka T, Gruer L, Kock R, Stebbing J, et al. Test, test, test for COVID-19 antibodies: the importance of sensitivity, specificity and predictive powers. Public Health. 2020;185:88-90. DOI: 10.1016/j.puhe.2020.06.006.
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11. Stringhini S, Wisniak A, Piumatti G, Azman AS, Lauer SA, Baysson H, et al. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study. Lancet. 2020;396(10247):313-19. DOI: 10.1016/S0140-6736(20)31304-0.
12. Xu TL, Ao MY, Zhou X, Zhu WF, Nie HY, Fang JH, et al. China’s practice to prevent and control COVID-19 in the context of large population movement. Infect Dis Poverty. 2020;9(1):115. DOI: 10.1186/s40249-020-00716-0.
13. Keeley AJ, Evans C, Colton H, Ankcorn M, Cope A, State A, et al. Roll-out of SARS-CoV-2 testing for healthcare workers at a large NHS Foundation Trust in the United Kingdom, March 2020. Euro Surveill. 2020;25(14):2000433. DOI: 10.2807/1560-7917.ES.2020.25.14.2000433.
14. Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Seroprevalence of SARS-CoV-2 antibodies and associated factors in healthcare workers: a systematic review and meta-analysis. J Hosp Infect. 2021;108:120-34.
15. Hossain A, Nasrullah SM, Tasnim Z, Hasan MK, Hasan MM. Seroprevalence of SARS-CoV-2 IgG antibodies among health care workers prior to vaccine administration in Europe, the USA and East Asia: A systematic review and meta-analysis. E Clinical Medicine. 2021;33:100770.
16. Godderis L, Boone A, Bakusic J. COVID-19: a new work-related disease threatening healthcare workers. Occup Med. (Lond) 2020;70(5):315-6.
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18. Grant JJ, Wilmore SMS, McCann NS, Donnelly O, Lai RWL, Kinsella MJ, et al. Seroprevalence of SARS-CoV-2 antibodies in healthcare workers at a London NHS Trust. Infect Control Hosp Epidemiol. 2021;42(2):212-14. DOI: 10.1017/ice.2020.402.
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Selin Celik, Ertugrul Altinbilek, Ozgur Cevrim, Nesrin Gareayaghi. Evaluation of COVID-19 antibody levels in emergency department healthcare workers. Ann Clin Anal Med 2024;15(1):7-10
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Alterations in expression of phosphatase and tensin homologous (PTEN) gene analyzed in the bronchial lavage samples of non-small cell lung cancer patients
Hilal Sahin 1, Dilhan Kuru 2, Nail Yilmaz 3, Ersan Atahan 4, Ayhan Deviren 2, Matem Tuncdemir 2
1 Department of Medical Biology and Genetic, Faculty of Medicine, Istanbul Atlas University, 2 Department of Medical Biology, Faculty of Medicine, Istanbul University-Cerrahpasa, 3 Department of Histology and Embryology, Faculty of Medicine, Beykent University, 4 Department of Chest Diseases, Faculty of Medicin, Istanbul University-Cerrahpasa, Istanbul, Turkey
DOI: 10.4328/ACAM.21695 Received: 2023-03-17 Accepted: 2023-06-05 Published Online: 2023-11-20 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):11-15
Corresponding Author: Hilal Sahin, Department of Medical Biology and Genetics, Faculty of medicine, Atlas University, 34408, Kagıthane, Istanbul, Turkey. E-mail: hilal.sahin@atlas.edu.tr P: +90 444 439 12 11 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7989-2037
This study was approved by the Ethics Committee of Istanbul University-Cerrahpasa (Date: 2016-08-19, No: 66018902-050.99-306809)
Aim: In this study, we aimed to analyze the expression of the Phosphatase and Tensin Homologous gene (PTEN) by interphase-fluorescence in situ-hybridization (iFISH), and localization and immunoreactivity of PTEN by immunocytochemistry method in bronchoalveolar lavage (BAL) fluid of patients with non-small cell lung cancer (NSCLC).
Material and Methods: BAL samples collected from 30 patients diagnosed with NSCLC and from 10 control subjects without any malignancy were included. iFISH was performed with a 10q23.3 PTEN DNA dual color FISH probe, analyzing multiple cells. Immunocytochemistry was based on the Streptavidin-Biotin-Peroxidase method and PTEN levels were semi-quantitatively scored.
Results: The percentage of cells with 2G/2R was 86.8% which was significantly lower than that of the control group (p<0.0001). Loss of the PTEN gene was 6.43% among all patients. The percentage of cells with monoallelic deletion (p=0.0246) and atypical signal (p=0.0001) and the percentage of monosomic cells (p=0.0001) were significantly higher in patients compared to controls. PTEN immunopositivity was significantly increased in patients compared to controls (p<0.0001).
Discussion: Increased abnormal signals and mutational cells in BAL samples of NSCLC patients suggest that the investigation of the PTEN gene in BAL by using iFISH may guide clinicians in differential diagnosis and therapeutic management of NSCLC. Being faster, easier and cost-effective in routine testing, the immunocytochemistry method can also be combined as a diagnostic tool with molecular methods.
Keywords: Non-Small Cell Lung Cancer, PTEN, Fluorescence in Situ Hybridization, Immunocytochemistry
Introduction
Lung cancer, the most common cancer in the world, accounts for approximately a third of cancer-related deaths [1]. Mostly derived from the primary bronchus tissue, the tumor is located centrally in the lung. Lung cancers are divided into two main groups according to the appearance of the cells observed under a microscope: small cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). The NSCLC group is responsible for 80-85% of all lung cancer cases and is divided into three major subtypes: Squamous cell carcinoma (SCC), adenocarcinoma and large cell lung carcinoma (LCLC) [2].
The main molecular alterations observed in lung cancer are mutational activation of oncogenes, inactivation of tumor suppressor genes, alterations manifested in genes involved in cell cycle regulation and DNA repair [3, 4]. Loss, insertion or mutation of different gene loci responsible for the cell proliferation in cancer cells leads to initiation and progression of the tumor.
One of the genetic alterations in cancers is associated with Phosphatase and Tensin Homologous gene (PTEN) that is the best-known tumor suppressor gene, which has a key role of a complex intra-cellular phosphoinositide signaling network [5]. PTEN is a critical regulator gene located in the q23.2 region of the long arm of the 10th chromosome and is involved in the regulation of multiple types of cancer [6]. This gene is associated with familial cancer syndromes, as one of the alleles is inherently inactive, and the increased risk of cancer can be inherited from generation to generation in the form of an autosomal dominant [7].
PTEN is involved in several processes, including aging, angiogenesis, apoptosis, cell cycle progression, cell contraction, and response to DNA damage [8]. Loss of function of PTEN as a tumor suppressor protein is one of the most common events observed in a lot of types of cancer [9]. Li et al. investigated the PTEN expression and its prognostic effects in primary NSCLC patients and reported that increased expression in NSCLC patients was associated with a good prognosis. They also found that a high level of the PTEN expression was correlated with a 43% reduction in mortality risk among all NSCLC patients [10].
In our study, we aimed to analyze PTEN gene expression using the interphase Fluorescent in situ Hybridization (iFISH) method and localization and immunoreactivity levels of PTEN by immunocytochemistry (ICC) method in bronchial lavage (BAL) fluid of NSCLC patients.
Material and Methods
Patient Selection
Among the patients admitted to the Department of Chest Diseases in Istanbul University Cerrahpasa Medical Faculty due to suspicion for lung diseases, a total of 30 cases diagnosed with NSCLC were selected in a blind manner independent of age, gender and tumor stage, and these cases were designated as the patient group. The inclusion criteria were adequate samples with a diagnosis of NSCLC. The control group consisted of 10 individuals who had no viral disease, no histopathologically confirmed malignancy in the lung, no smoking, but who underwent bronchoscopy for any other indication. Bronchial lavage fluids were collected from the individuals selected for the patient and control groups, after signing the ‘Informed Consent Form’ (with the Ethics Committee Decision dated 19.08.2016 and numbered 66018902-050.99-306809) for the study.
The demographics including age and gender were recorded. Cancer staging in patients was performed by a specialist pulmonologist, by using computerized tomography (CT) and positron emission tomography (PET) scans of the lungs, and according to the new 8th TNM staging system for lung cancer [11].
Sample Collection
The BAL samples selected for the study were secretions aspirated through a bronchoscopic tube after injecting 20 ml of cold and sterile saline to the suspicious region for a lesion during a bronchoscopy. The first two tubes were used for iFISH analysis, and the third tube was used for the ICC method.
iFISH Method
10q23.3 PTEN DNA dual color FISH probe (MyProbes Powered by Cytocell, UK), which was specially designed and checked for quality was applied to the cells obtained from the BAL samples, according to the manufacturer’s instructions. The smears were analyzed under a fluorescence microscope with 100x objective, using Texas red, FITC (green) and DAPI filters, and visualized with the “Isis FISH Imaging System” program.
Immunocytochemistry (ICC)
ICC staining based on the Streptavidin-Biotin-Peroxidase method was applied by using Histostain-Plus Bulk Kit (Mouse and Rabbit Specific HRP Zymed Lab. Ins. San Francisco CA, USA) containing AEC (ABC) Detection IHC Kit (ab93705).
The specificity of the immunostaining was confirmed by preparing a negative control slide in which all steps of ICC were applied except for the primary antibody, which was replaced by PBS. Positive immunostaining of PTEN in cells selected from ten random fields on slides was semi-quantitatively determined under a light microscope (LEICA DM500) at x40 magnification (-; no staining, +; poor staining, ++; moderate staining, +++; severe staining). According to this system, the scores were determined as (-): 0, (+): 1, (++): 2 and (+++): 3.
Statistical Methods
For all statistical analysis, GraphPad InStat Software (version 3.06) was used. The Kolmogorov-Smirnov test was used to test the normality of variables. Paired T-test was used to compare the two groups. One-way ANOVA test was used for multiple group comparisons. As a multiple comparison test for intragroup and intergroup, the Tukey-Kramer Multiple Comparisons test was applied. The significance level was chosen as p <0.05.
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
Patients
The patient group had 21 cases diagnosed with SCC (70%), 6 cases with adenocarcinoma (20%) and 3 cases with unclassified subtypes (10%) of NSCLC. 90% of patients were males (n=27) with a mean age of 65.7 years for males and 54.6 years for females. All cases included in the control group (n=10) were males, and the mean age was 60.6 years (Table 1).
According to the 8th staging guideline for NSCLC, 23.3% of the cases in the patient group were diagnosed at Stage IV (n=7), 56.7% at Stage III (n=17), 3.3% at Stage II of NSCLC (n=1), however 16.7% (n=5) could not be staged due to inadequate amount of sample or low differentiation of the tumor.
iFISH Findings
The chromosome insertions or losses were detected independently for each case. The microscopical images of the iFISH analysis were given in Figure 1. These images showed a cell containing a 3G3R signal in a case with adenocarcinoma (Figure 1A), an atypical cell containing a 6G3R signal in a case with adenocarcinoma (Figure 1B), a number of cells containing an atypical 1G2R signals in the case with squamous cell lung cancer (Figure 1C & 1D), a number of cells with monoallelic 2G1R, monosomy (1G1R) and normal (2G2R) signals in a case with squamous cell lung cancer. In the control group, a number of cells containing 2G2R signals and one cell with monoallelic deletion (2G1R) were observed.
Table 2 presents the comparison of the percentage of signals and cells in the samples of NSCLC and control cases. The median percentage of cells with normal signal in the control group was 93.7%, with monoallelic deletions 1.67%, the percentage of monosomic cells was 1.9% and with an atypical signal 2.68%, but no biallelic deletion was detected in the control group (Table 2). The median percentage of cells containing normal signal (2G/2R) in the patient group was 86.8%, while the median percentage of loss of PTEN gene was 6.43% in total, the median of monoallelic deleted cells was 2.67% and monosomic cells 3.76%. The percentage of total atypical signals was 5.67% in the patient group. In addition, we found that the percentage of cells containing normal signals in the patient group decreased by 11.2% compared to the control group (Table 2). The number of cells with atypical signals increased among patients at higher stages of lung cancer.
In the patient group, the median percentage of cells with biallelic deletion, monoallelic deletion, and percentage of monosomic cells and cells with atypical signals were significantly lower than the number of cells with normal signal (p < 0.001). This has also been observed in subtypes of NSCLC. In the control group, the median percentage of cells with monoallelic deletion, monosomic cells and atypical signals was significantly lower than the number of cells with normal signals (p < 0.0001). The median percentage of normal cells in the patient group was significantly lower than that of the control group (p < 0.0001). The number of cells with monoallelic deletion (p = 0.0246), monosomic cells (p = 0.0001) and cells with atypical signal (p = 0.0001) was significantly higher in the patient group compared to those of the control group (Table 2).
Immunocytochemical Findings
The micrographs of ICC staining for PTEN immunoreactivity observed in the BAL samples obtained from the patients are given in Figure 2. Epithelial cells in the control group had apparent nuclei with occasionally PTEN (+) heterochromatin regions and cytoplasm. PTEN (+) hyperplastic cells were observed around the epithelial cells (Figure 2A). The epithelial cells from the patients with SCC had PTEN (+) nucleus and dense cytoplasm or PTEN (+) epidermoidal-derived tumor cell accompanied with leukocytes. In the vicinity. PTEN (+) round macrophages with a granular cytoplasm were observed in adenocarcinoma cases (Figure 2B). Active PTEN (+) macrophages with very clear cell boundaries or damaged and aged PTEN (+) macrophages filled with granules or vacuolized juvenile macrophage cell were remarkable in the samples of patients with SCC.
The statistical comparison of the immunostainings for PTEN in the control and patient groups is presented in Table 3. PTEN immunopositivity was significantly increased in the patient group compared to the control group (p < 0.0001). The immunopositivity was between moderate to severe in the patient group, while it was between poor to moderate in the control group. According to the subtypes of NSCLC diagnosed in the patient group (SCC, adenocarcinoma, and unclassified subtype), there was a significant increase in PTEN immunopositivity in samples of patients with SCC and unclassified subtypes compared to that of the control group (p < 0.001) (Table 3).
Discussion
Studies of the PTEN tumor suppressor gene have accelerated in the last decade, and it has been reported to have an important role in the progression of many cancers [12, 13]. The present findings of iFISH and ICC analysis of PTEN expression in BAL samples from the patients with NSCLC showed that the signal characteristics of cells can alter among cancer patients. To the best of our knowledge, our study is the first report showing a significantly higher percentage of cells with biallelic deletion, atypical signal, monoallelic deletion and a higher percentage of monosomic cells in the BAL samples of NSCLC patients than those of the control group. In contrast, the immunoreactivities of PTEN were significantly higher in samples of NSCLC patients than in the control group, and each patient had different intensities of cytoplasmic and nuclear PTEN expression.
Loss of PTEN expression was significantly more common in SCC cells, but PTEN expression was shown to have a significant effect on disease-free survival rate only in adenocarcinomas [14]. In the present study, the percentage of normal signals for PTEN expression in the samples of patient with NSCLS was significantly lower than in control cases. This decrease was observed in both subtypes of SCC and adenocarcinoma and even in unclassified NSCLC. More to the point, the percentages of cells with atypical signals, monoallelic deletions and of monosomic cells for PTEN expression were significantly higher than in the control group. These increases were observed in both subtypes of SCC and adenocarcinoma and even in unclassified NSCLC.
To study copy number variations of PTEN expression in NSCLC, previous studies have used FISH method in biopsies of resected or directly harvested cells from lung tissues of patients or on cell lines commercially purchased [16]. Nowadays, short-read and long-read DNA sequencing technologies are integrated into molecular techniques to find out the alterations in the PTEN gene in NSCLC [15]. We found that the total number of cells obtained from all samples decreased significantly compared to the control group, but no statistical significance was detected. We also demonstrated that the rate of monoallelic deletion, monosomic cell and atypical signaling decreased significantly in the control group compared to the NSCLC group.
As a prognostic biomarker, loss of PTEN has been reported to be useful for identifying low-risk cancer patients who are prone to progression of the disease and therefore require treatment. Xiao et al. demonstrated that decreased expression of PTEN correlated with poor overall survival in NSCLC patients and was indicative of a poor prognosis for disease-free survival and progression-free survival in patients with NSCLC [16]. In the present study, we observed the percentage of loss of PTEN gene as 6.74% in all patients with advanced stage of NSCLC, namely Stage-III and IV patients. However, as a limitation of present study, we did not follow-up patients and could not correlate the iFISH and ICC findings with the prognosis of the disease.
In the current study, we observed a significant increase in PTEN expressions immunocytochemically in the bronchial lavage fluids of NSCLC patients. Unfortunately, it is still unclear how nuclear and cytoplasmic PTEN expression correlates with disease prognosis exactly and how it affects patient survival. Although the expression of nuclear PTEN represents a new observation with interesting results of our study, it is undoubted that more precise and comprehensive studies including a large number of cases are needed to confirm these results.
In light of our findings of ICC showing the altered immunoreactivity of PTEN in cells collected from BAL samples, it is suggested that ICC staining method can be used as a diagnostic tool in terms of being faster, easier and more economical in routine testing. Acknowledging the molecular value of the iFISH technique, which provides more sensitive results than ICC, the investigation of cells that transferred from the lung tissue to BAL by using molecular cytogenetic methods will guide the clinicians in the management of the treatment of NSCLC. Indeed, more comprehensive and detailed studies planned with more parameters will allow a better understanding of the differentiation of lung cells in the tumorigenesis process at the molecular level focusing on whether PTEN expression could be a biomarker in terms of predicting the clinical stage and prognosis of NSCLC patients.
Acknowledgment
The authors are grateful to Dr. Şükriye Yılmaz and Dr. Ayşe Cirakoglu for their excellent FISH cell counting. The author would like to thank Dr. Elif Yaprak for the English language review and contribution to the experimental Immunocytochemistry design.
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.
Funding: This study was supported by Istanbul University Scientific Research Projects Unit. Project No: 23004.
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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8. Abdulkareem IH, Blair M. Phosphatase and tensin homologue deleted on chromosome 10. Niger Med J. 2013;54(2):79-86.
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Hilal Sahin, Dilhan Kuru, Nail Yilmaz, Ersan Atahan, Ayhan Deviren, Matem Tuncdemir. Alterations in expression of phosphatase and tensin homologous (PTEN) gene analyzed in the bronchial lavage samples of non-small cell lung cancer patients. Ann Clin Anal Med 2024;15(1):11-15
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Evaluation of brucellosis cases
Bülent Kaya, Suzan Şahin
Department of Infectious Diseases and Clinical Microbiology, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.21779 Received: 2023-06-06 Accepted: 2023-07-10 Published Online: 2023-11-23 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):16-20
Corresponding Author: Bülent Kaya, Department of Infectious Diseases and Clinical Microbiology, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey. E-mail: badeatakaya@hotmail.com P: +90 505 552 01 70 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3027-5868
This study was approved by the Ethics Committee of of Kartal Dr Lütfi Kırdar City Hospital (Date:2023-01-25, No: 2022/514/242/16)
Aim: In this study, we aimed to evaluate 145 brucellosis cases that were followed and treated in our clinic over a period of ten years in many aspects.
Material and Methods: One hundred and forty-five brucellosis cases followed in our clinic between January 01, 2001 and December 31, 2010 were analyzed retrospectively. Age, gender, risk factors, symptoms, findings, laboratory tests, blood cultures, serological tests, ultrasonography and magnetic resonance imaging, treatment and treatment side effects, the response of fever and pain symptoms to treatment, and relationships between the stages of the disease and laboratory values were examined.
Results: Of the 145 patients, 40% were female (n=58) and 60% were male (n=87); 58.6% of the patients had a history of drinking raw milk, eating fresh cheese, or dealing with animal husbandry, and 8.3% had a history of contamination in the laboratory. In 33.1%, the transmission route could not be detected. 59.3% of the patients were diagnosed with acute brucellosis (0-2 months), 32.4% were diagnosed with subacute brucellosis (2-12 months), 3.5% were diagnosed with chronic brucellosis (>12 months), 4.8% (n=7) had a relapse. The most common symptoms were fever (64.8%), malaise (51.7%), low back pain (48.3%), arthralgia (46.2%), sweating (42.8%), while the most common findings were spondylitis (31%), hepatomegaly (15.2%), and splenomegaly (13.8%). Brucella spp. grew in 17.9% of blood cultures.
Discussion: Brucella spp. may have various clinical presentations, affecting all organs. Brucellosis should also be considered in the differential diagnosis in risky groups presenting with fever, fatigue, arthralgia, spondylitis, hepatomegaly and splenomegaly.
Keywords: Brucellosis, Zoonotic Diseases, Brucella Spp
Introduction
Brucellosis, which is known by many other names, including undulant fever, recurrent Mediterranean fever, Cyprus fever, Maltese fever, cheese disease, is a zoonotic disease. It is endemic in the Mediterranean basin, where our country is located, in the Middle East, the Arabian Peninsula, India and Latin America. Sir David Bruce, a Scottish pathologist and microbiologist, during his military service in Malta in 1887, while examining a soldier who died of Maltese fever, noticed moving micrococci under a microscope and found that the causative agent was a bacterium. In 1897, this bacterium was named Brucella melitensis (Melita = Malta) in honor of Sir David Bruce. In the same year, Sir Almroth Edward Wright, a British bacteriologist and immunologist, developed the Wright test, which is used in the diagnosis of brucellosis.
While 500 thousand new cases are seen in the world every year, this number is thought to be 25-26 times higher. The incidence in endemic areas is 10%. B.melitensis, B.suis, B.canis, and B.abortus are types that are transmitted through mammals such as cattle and sheep and cause brucellosis in humans. The agents can be transmitted from animal to human or from human to human. Transmission from person to person occurs through blood and exudate, sexual contact, placenta, during childbirth and through breast milk. It can be transmitted through undercooked meat, unpasteurized milk and dairy products, through direct contact with intact skin or abrasions, mucous membranes and conjunctivae, and by inhalation in the microbiology laboratory. It can involve all systems and organs. It presents with various symptoms and findings, mainly fever, weakness, low back pain, spondylitis, hepatomegaly and splenomegaly.
Brucellosis is a zoonotic disease caused by Brucella spp., which is more common in developing countries, but is still neglected and is endemic in our country. Since it can affect all systems and organs, it has various clinical manifestations. In this study, we aimed to retrospectively analyze 145 cases of brucellosis that were observed and treated in our clinic over a period of ten years.
Material and Methods
One hundred and forty-five adult patients with brucellosis who were followed in the Infectious Diseases and Clinical Microbiology Clinic of our hospital between January 01, 2001 and December 31, 2010 were analyzed retrospectively. The date of admission, age, gender, risk factors (raw milk and fresh cheese consumption, contact with livestock, contamination from the laboratory, undetermined), and duration of symptoms before admission were recorded. Those who applied within the first 2 months after the symptoms started were evaluated as acute brucellosis, those who applied up to one year (2-12 months) after the second month were evaluated as subacute brucellosis, those who applied after one year were evaluated as chronic brucellosis, patients who recurred with the same symptoms and signs and laboratory values within one year after the end of treatment were considered relapsed.
Admission complaints and physical examination findings, fever and pain responses of the patients, complete blood count, liver function tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and microbiological examinations were recorded. Blood cultures were taken from all patients and standard tube agglutination (STA) test was performed. Blood cultures were performed using an automated BACTEC (Becton Dickinson Diagnostic Instruments, Sparks, MD) and samples were stored for at least two weeks. The diagnosis of brucellosis was confirmed by positive blood culture and/or positive STA test (≥1/160). Patients with negative results despite clinical suspicion were not included in the study. Radiologic examinations, requested according to clinical findings (ultrasonography, magnetic resonance imaging), involved organs and systems, relapse status, treatment regimens and durations, treatment-related side effects, and treatment changes were recorded.
In the analysis of the data, independent sample t-test, one way analysis of variance (ANOVA), Tukey-B (Post Hoc) multiple comparison and SPSS statistical program and correlation analysis were used. P-value <0.05 was considered significant
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
Of the 145 patients included in the study, 58 (40%) were female and 87 (60%) were male; 20% (n=29) of the patients were in the 14-25 age range, 17.2% (n=25) were in the 26-40 age range, 33.1% (n=48) were in the 41-60 age range, and 29.7% were (n=43) over 61 years of age. 57.2% (n=83) of the patients had a history of eating raw milk and fresh cheese, 8.3% (n=12) had a history of laboratory contamination, 1.4% (n=2) had a history of dealing with livestock, in 33.1% (n=48) of the patients route of transmission could not be determined.
Of the patients, 59.3% (n=86) were diagnosed with acute brucellosis, 32.4% (n=47) with subacute brucellosis, and 3.5% (n=5) with chronic brucellosis, and relapse was in 4.8% (n=7). No patient died. One patient was pregnant. Admission symptoms and findings are shown in Table 1.
Brucella spp. was grown in the blood culture of 17.9% (n=26) of the patients. All patients underwent STA test and positive (≥1/160) test results were included in the study. We did not have any patient who had growth in blood culture but a negative STA test.
In radiological examinations, vertebral involvement was seen in 31% (n=45), sacroiliitis in 9.7% (n=14), wrist joint involvement in 0.7% (n=1), leptomeningeal contrast involvement in 0.7% (n=1), and epididymo-orchitis in 1.4% (n=2). One patient (0.7%) was diagnosed with thoracic 4-5 spondylodiscitis and one patient (0.7%) was diagnosed with lumbar-5 – sacral-1 spondylodiscitis.
In the treatment, doxycycline 100 mg 2×1 and rifampicin 300 mg 1×2 were combined and given for at least 6 weeks. A single dose of intramuscular (IM) 1 g streptomycin was added to the treatment of patients with vertebra, joint involvement, sacroiliitis and neurological involvement for 21 days, and the treatment period was extended to 8-12 weeks. Rifampicin was combined with ceftriaxone in the pregnant patient (Table 2). Nausea was observed in three patients receiving doxycycline treatment, and the maculopapular rash was observed in one patient receiving trimethoprim-sulfamethoxazole (TMP-SXT).
Considering the fever (axillary fever <36.5) and pain (complaint) responses of the patients from the beginning of the treatment, in 90 (95.7%) of 94 patients, the fever decreased in the first week, and the fever response was more often obtained in the first four days (n=76, %80.8).
There were 105 patients with arthralgia, hip pain, shoulder and back pain. Pain response was obtained in 47 (44.8%) of these, within the first week and mostly on the sixth and seventh days, and in 16 (15.2%) within the second week. In 29 patients (27.6%), the pain was relieved at the end of the first two weeks, and in 13 patients (12.4%), the pain did not decrease at the end of the first two weeks and continued as it is.
The age range of 145 patients was 14-86, with a mean of 47.28 and a standard deviation (SD) of 19.416. Fever, White blood cell (WBC), hemoglobin (HB), hematocrit (HCT), platelet (PLT), erythrocyte sedimentation rate (ESR), C-reactive protein values (CRP), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and standard tube agglutination (STA) test results, means and standard deviations were recorded (Table 3).
Increased sedimentation, CRP and AST values were detected in brucellosis. Regarding the difference between genders, WBC, HB, HCT and PLT mean values were higher in men (p<0.05), while there was no significant difference between the mean values of ESR, CRP, ALT, AST and STA (p>0.05) (Table 3). There was no statistically significant difference between WBC, HB, HCT, PLT, CRP and ALT values regarding the differences between the stages of the disease (p>0.05). ESR, AST and STA values were significantly higher in acute brucellosis (p<0.05).
Discussion
Brucellosis is a zoonotic disease caused by Brucella spp. It is endemic in the Mediterranean basin, where our country is located, in the Middle East, Arabian Peninsula, India and Latin America [1,2]. While 500 thousand new cases are seen in the world every year, this number is thought to be 25-26 times higher [3,4]. The incidence in endemic areas is 10% [5]. Although agriculture and animal husbandry are limited in our region, we have many brucellosis patients presenting with different symptoms and findings due to internal migration from other regions. It is transmitted through mammals such as cattle and sheep. Brucella spp. has a low inoculum value, ten bacteria are enough to cause the disease. Brucella spp. can be transmitted from animal to human or from human to human. It can be transmitted from person to person through blood and exudate, through sexual contact, placenta, during birth and through breast milk [6,7]. It is transmitted through undercooked meat, unpasteurized milk and dairy products, and through direct contact with intact skin or abrasions, mucous membranes, and conjunctiva [1,7]. It can be transmitted in the microbiology laboratory by inhaling contaminated aerosols or sniffing growth media. The incubation period of brucellosis is 7 days-10 months, with an average of 2-4 months [7]. After infection, every system and organ can be involved, including the central nervous system, heart, bones and joints [7]. It occurs with non-specific symptoms such as fever, sweating and joint pain [1]. Brucellosis continues to be a very common and often neglected disease in developing countries [5,8].
Brucellosis affects all organs and systems and has various clinical presentations; therefore, diagnostic difficulties may occur [9]. 58.6% (n=85) of our 145 patients had a history of consumption of raw milk, fresh cheese, unpasteurized dairy products and contact with livestock. The rate of transmission through milk and dairy products was found to be 62.5-69% [9,10]. 81% of our patients were diagnosed in the autumn and winter seasons. The reason for this is that they spend their summer holidays in their hometowns and return to their places of residence with the opening of schools. Twelve patients (8.3%) were laboratory technicians and doctors working in microbiology and dealing with Brucella spp. cultures, and all of them were infected with Brucellosis by inhalation. The route of transmission could not be detected in 33.1% (n=48) of the patients, and this rate was found to be 55.2% in a study [11]. In our study, the age range of the patients was 14-86 years, with an average of 47.28 years. Of the 145 patients included in our study, 59.3% (n=86) were diagnosed in acute, 32.4% (n=47) in subacute, and 3.5% (n=5) chronic period; 4.8% (n=7) were followed up due to relapse. In a study, these rates were 74.4% for acute, 18.9% for subacute, 6.7% for chronic, and no relapse was found [1]. In a study conducted with pediatric patients, the relapse rate was found to be 7.4% [12]. In another study, acute brucellosis was seen with a rate of 66.2%, while in another study, the rate of relapse was found to be 4.7% [11,12].
The disease presents with a wide variety of clinical symptoms [13]. The most common symptoms were fever, malaise and low back pain. These symptoms were followed by arthralgia, sweating, chills, weight loss, loss of appetite, hip pain, myalgia, headache, shoulder and back pain, abdominal pain, nausea-vomiting, swelling in the testicles, numbness in the feet, rash, and double vision. In a study, the most common symptoms were found to be arthralgia, fatigue, fever, sweating, and low back pain, respectively, and were the same as the first five symptoms in our study [14].
High fever was present in 94 patients (64.8%). Fever response (axillary < 36.5) with treatment was observed predominantly (95.7%) within the first week. The fever of 80.8% of 94 patients returned to normal in the first four days. Fever regressed in the second week in 4.3% of the patients. Of 105 patients complaining of arthralgia, hip pain, shoulder and back pain, in 44.8% of them, pain disappeared at the end of the first week, and in 15.2% at the end of the second week. In 27.6% of 105 patients, at the end of the second week, the pain was relieved but not completely gone, and in 12.4%, the pain did not even decrease at the end of the second week.
Among the findings, spondylitis, hepatomegaly and splenomegaly took the first three places, followed by sacroiliitis, arthritis, lymphadenomegaly, neurological involvement, maculopapular rash, epididymo-orchitis, depression and mucositis. One of our patients was pregnant.
Blood cultures of all patients were sent. Brucella spp. grew in the blood cultures of 26 (17.9%) patients. In two different studies, the growth rates in blood cultures were found to be 18.1% and 21%, respectively [10,15]. This rate was 7.1% in pediatric patients [12] because less blood can be drawn for blood cultures from pediatric patients.
While STA positivity was 100% in all our patients, this rate was found to be between 88.2 and 99.4% in different studies [1,12]. Despite clinical suspicion, we did not include STA-negative patients, thus the rate in our study was 100%.
In radiological examinations, vertebral involvement was seen in 31% (n=45), sacroiliitis in 9.7% (n=14), wrist joint involvement in 0.7% (n=1), lepto-meningeal contrast involvement in 0.7% (n=1), and epididymo-orchitis in 1.4% (n=2). One patient (0.7%) was diagnosed with thoracic 4-5 spondylodiscitis, and one patient (0.7%) was diagnosed with lumbar-5 – sacral-1 spondylodiscitis. In a similar study, osteoarticular involvement was found to be 25.3%, in another study, it was 10%, and epididymo-orchitis was 0.9% [8,11].
Doxycycline 100 mg twice a day and rifampicin 600 mg once a day were mostly used in combination therapy. Patients received treatment for at least 6 weeks. Three patients using doxycycline were switched to TMP-SXT because of nausea. For the treatment of patients with vertebra, joint involvement, sacroiliitis and neurological involvement, 1 g of streptomycin IM per day was added for three weeks. Relapses were less common in patients given streptomycin. In a study, the combination of doxycycline and streptomycin with or without rifampicin was found to be more effective in osteoarticular involvement [11]. In our pregnant patient, rifampicin and ceftriaxone were combined. One patient treated with TMP-SXT developed a maculopapular rash and was switched to ciprofloxacin.
CRP, sedimentation and AST values increase significantly in brucellosis and may cause granulomatous hepatitis. When laboratory values were analyzed, WBC, HB, HCT and PLT were found to be higher in men, ESR, AST and STA values were higher in acute brucellosis, and ESR values were higher in patients over 61 years of age (p<0.05). In a study, CRP and sedimentation were found to be higher in patients with brucellosis compared to the control group without brucellosis 16].
Conclusion
Risk factors for brucellosis, which is endemic in our country, are consuming raw milk and dairy products, contact with animal husbandry and laboratory exposure through aerosols. Brucellosis has different clinical presentations because it involves all organs. Brucellosis should also be considered in the differential diagnosis in risky groups presenting with fever, fatigue, arthralgia, spondylitis, hepatomegaly and splenomegaly. While the most common combination of doxycycline and rifampicin is used in the treatment, the addition of streptomycin reduces the relapse rate in patients with complications.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
The authors declare no conflict of interest.
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Research of genetic abnormalities in diagnosis and treatment of childhood acute lymphoblastic leukemia at Hue Central Hospital
Tran Kiem Hao 1,2, Nguyen Thi Kim Hoa 1,2, Phan Hung Viet 3
1 Hue Pediatric Center, Hue Central Hospital, Hue, 2 Department of Pediatrics, Faculty of Medicine, Duy Tan University, Danang, 3 Department of Pediatrics, Faculty of Medicine, Hue University of Medicine and Pharmacy, Hue, Viet Nam
DOI: 10.4328/ACAM.21847 Received: 2023-08-06 Accepted: 2023-11-06 Published Online: 2023-11-10 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):21-24
Corresponding Author: Nguyen Thi Kim Hoa, Department of Pediatric Oncology-Hematology and Transplant, Hue Central Hospital, Hue, Viet Nam. E-mail: kimhoa.fmi@gmail.com P: +84 935 645 83 6 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2525-4368
This study was approved by the Ethics Committee of Pediatric Center – Hue Central Hospital (Date: 2017-10-20, No: 18/NCKH-BVH)
Aim: Acute lymphoblastic leukemia is the most common cancer in children and adolescents. The application of chemotherapy by risk group and genetic modification have significantly improved the survival rate of childhood acute lymphoblastic leukemia. In this study, we aimed to determine genetic abnormalities and investigate the correlation between gene abnormalities and treatment results of childhood acute lymphoblastic leukemia.
Material and Methods: This was a descriptive cross-sectional study on childhood acute lymphoblastic leukemia patients who were admitted to the hospital between November 2017 and May 2022.
Results: There were 83 new patients with acute lymphoblastic leukemia. The results of multiplex PCR tests showed that 24.1% of patients had genetic abnormalities, of which, 12.1% had TEL/AML1 fusion, 4.8% of had BCR/ABL1 fusion, 3.6% had E2A/PBX1 fusion, 2.4% had MLL/AF4 fusion and 1.2% had SET/NUP214 fusion. There were 12.1% of patients with a favorable prognosis, 80.7% of patients with an intermediate prognosis and 7.2% of patients with a poor prognosis. There were statistical correlations between the remission rate, the relapsed rate, the overall survival rate, the event-free survival rate and the genetic risk group. The overall survival rate and the event-free survival rate for the poor prognosis, intermediate prognosis and good prognosis risk groups after 2 years were 50.0 ± 25.0%, 0%; 86.7 ± 4.9%, 77.9 ± 6.1% and 100.0 ± 0.0%, 100.0 ± 0.0%.
Discussion: Genetic abnormalities help in classification, prognosis and treatment of childhood acute leukemia.
Keywords: Acute Lymphoblastic Leukemia, Children, Genetic Abnormalities
Introduction
Acute lymphoblastic leukemia (ALL) is the most common cancer in children and adolescents, accounting for 20% of all new cancers diagnosed in children under 15 years of age [1]. It is a disease of the hematopoietic system caused by the uncontrolled proliferation of one or more malignant immature cell lines. The incidence of acute lymphoblastic leukemia is about 2-5 cases per 100,000 children and ALL is the most common in children aged 2-5 years [2]. Diagnosis and classification of acute lymphoblastic leukemia is based on clinical features combined with morphological malignancies, cytochemical staining, immunocytochemical markers, and genetic tests. Regarding the treatment of childhood acute lymphoblastic leukemia, the application of chemotherapy by risk group and genetic modification has significantly improved the survival rate of childhood acute lymphoblastic leukemia. In developed countries, the overall survival rate for acute lymphoblastic leukemia has risen from 10% in the 1960s to more than 90% in recent years [1, 2]. Therefore, I carried out this study to determine genetic abnormalities and investigate the correlation between gene abnormalities and the treatment results of childhood acute lymphoblastic leukemia.
Material and Methods
Patients
The study included 83 children diagnosed with acute lymphoblastic leukemia treated at Pediatric Oncology – Hematology – Bone Marrow Transplant Department, Pediatric Center – Hue Central Hospital, from 11/2017 to 5/2022. All ethical regulations were followed, and this study was approved by the Hue Central Hospital Ethics Committee (Institutional Review Board No. 18/NCKH-BVH) on 20 October, 2017. Consent was obtained from all participants in this study
Inclusion criteria:
• The patient was diagnosed with acute lymphoblastic leukemia
• Age < 16
• All patients underwent multiplex RT-PCR genetic analysis, with the Hemavision 28N kit, 28 basic genetic mutations in acute lymphoblastic leukemia were detected.
Criteria for diagnosis of acute lymphoblastic leukemia: Clinical: Systemic symptoms: fever, fatigue, poor appetite. Anemia, bleeding under the skin or mucous membranes. Symptoms of extramedullary infiltrates: liver, spleen, lymphadenopathy, gingival hypertrophy, subcutaneous papules, central nervous system infiltrates, mediastinal infiltrates, or testicular infiltrates.
Peripheral blood count: There is usually a decrease in hemoglobin (Hb), the white blood cell count may be elevated, normal or decreased, but often there is a severe decrease in neutrophils, and peripheral bleeding may or may not be visible. The platelet count is usually low.
More than 20% of leukemic blasts were found in the bone marrow. According to the results of flow cytometry, acute lymphoblastic leukemia was diagnosed.
Exclusion criteria
• Patients were diagnosed ALL, L3
• Pediatric patients with secondary or relapsed acute lymphoblastic leukemia
• The child and the representative did not agree to participate in the study.
Method: This was a descriptive, prospective longitudinal study. The longitudinal follow-up time to the end of the study was June 1, 2022.
Data were analyzed according to genetic tests, the remission rate, the relapsed rate, overall survival rate. All statistical analysis was performed using SPSS v.18.0 (IBM Corp, Armonk, NY).
Results
A total of 83 new patients with ALL were identified from 11/2017 to 5/2022 who met eligible criteria. Among these patients, 48 were males and 35 were females, the male-to-female ratio was 1.37:1. The mean age was 5.2 ± 3.5 years. 61.4% of patients were standard risk, and 38.6% were high risk patients. The percentages of B-ALL and T-ALL were 84.3% and 15.7%, respectively
The results of the analysis with multiplex PCR showed that 24.1% of patients had genetic abnormalities in the following order: TEL/AML1 (12.1%), BCR/ABL1 (4.8%), E2A/PBX1 (3.6%), MLL/AF4 (2.4%) and SET/NUP214 (1.2%) (Table 1).
Prognostic grouping according to genetic mutation: good prognosis (12.1%), intermediate prognosis (80.7%), poor prognosis (7.2%) (Table 2). The difference in the distribution rate of gene fusion between the two groups of standard and high risk, or between the two groups B-ALL and T-ALL was not statistically significant. (p>0,05).
Results showed that 91.6% of ALL patients recovered based on blast cell count < 5% after the induction phase. The remission rate for the standard-risk group was 98.0%, while the rate for the high-risk group was 81.7%. The difference was statistically significant (p<0.05). Regarding the correlation between genetic abnormalities and the rate of remission in childhood acute lymphoblastic leukemia, it was shown that remission rates varied between groups, in which the poor prognosis group accounted for the lowest (66.6%), 94.0% for the intermediate prognosis group, and 90.0% for the good prognosis group. The difference was statistically significant (p<0.05).
In the good and intermediate prognosis groups, MRD<10-4 after induction therapy was 88.9% and 92.2%, respectively, while this rate was only 50% in the group with poor prognosis. There was a statistically significant difference between the three groups (p<0.02).
When doing the evaluation of ALL relapse rates based on genetic risk groups, the results showed that there was a difference in the relapse rates between the genetic risk groups, in which this rate of the poor prognosis group was highest (66.7%), followed by the intermediate prognosis group (11.1%), while the group with good prognosis did not show any recurrence. The difference was a statistically significant (p<0.05).
Regarding the evaluation of the overall survival rate according to genetic risk group, the result showed that at the end of the study, out of a total of 83 patients with ALL, 13 patients died, of which 3/6 patients belonged to the poor prognosis group, 10/67 patients belonged to the intermediate prognosis group and no patient in the good prognosis group died. The number of surviving patients was 70, accounting for 84.3%. At 3 years, overall survival rates for groups with good, intermediate, and poor prognosis were 100.0 ± 0.0%, 76.3 ± 7.1%, and 25.0 ± 21.7%, respectively. The difference was statistically significant (p<0.05). (Figure 1). Regarding the event-free survival rate, in the 2nd year, the event-free survival rate in the groups with good, intermediate and poor prognoses were: 100 ± 0.0%, 77.9 ± 6.1%, and 0%, respectively (Figure 2). The difference was statistically significant (p<0.05).
– At the end of the study, out of a total of 83 patients with ALL, 13 patients died, of which 3/6 patients belonged to the poor prognosis group, 10/67 patients belonged to the intermediate prognosis group and no patient in the good prognosis group died. The number of surviving patients was 70 patients, accounting for 84.3%. At 3 years, overall survival for the good, intermediate, and poor prognosis groups was 100.0 ± 0.0%, 76.3 ± 7.1%, and 25.0 ± 21.7%, respectively. The difference was statistically significant (p<0.05).
Discussion
The male/female ratio was 1.37:1 and the mean age was 5.2 ± 3.5 years, similar to some studies by Fadoo, Al-Sudairy, Jovanovska and Yasmeen [3-6] . Regarding cell lineages, B-call lineage accounted for a high percentage (84.3%), and T-cell lineage accounted for 15.7%. The result was similar to the results of studies in developing countries. According to Fadoo, there were 78.5% of B-cell patients and 17.5% of T-cell patients [3]. According to Al-Sudairy, there were 89.5% of pre-B cell patients and 10.5% of T-cell patients [4]
The results of the analysis with multiplex PCR showed that there were 24.1% of patients with genetic abnormalities, including 12.1% of patients with TEL/AML1 fusion, 4.8% of patients with BCR/ABL1 fusion, 3.6% of patients with E2A/PBX1 fusion, 2.4% of patients with MLL/AF4 fusion and 1.2% of patients with SET/NUP214 fusion. Our results were similar to those of other authors, such as Veerman and Aldrich [7, 8]. With the multiplex-PCR, our result found a new fusion compared with other previous results in Vietnam. It was SET/NUP214 fusion, which is a rare fusion gene and often occurs in T-ALL at 10-11 years of age [9, 10]. A patient with SET/NUP214 will have a high percentage of relapse [10]. Until now, SET/NUP214 is still poorly understood [9].
Based on genetic abnormalities, some authors such as Inaba, Pui classify patients into three risk genetic groups: favorable prognosis, intermediate prognosis and poor prognosis [11, 12]. In our result, 12.1% of patients had a favorable prognosis, 80.7% of patients had an intermediate prognosis and 7.2% had a poor prognosis.
The rate of remission after the induction phase for ALL was 91.6%, which was similar to that of other researchers all over the world, the rate achieved 90-98%. The result showed that the percentage of remission differed among the three risk genetic groups. The rate of remission for the poor prognosis group was 66.6%, the favorable prognosis group achieved 90.0% and in the intermediate prognosis group, it was 94.0%. The difference was statistically significant (p<0.05). Our results are similar to some studies by Pui, Lin, Toksvang and Cimino [12-15]. Thus, genetic abnormalities made a tremendous impact on the result of treatment. The good prognosis group had 88.9% MRD < 10-4 after induction phase and this percentage was only 50% for the poor prognosis group and 92.2% for the intermediate prognosis group. The difference was statistically significant (p<0.05). Our results are similar to the study by Borowitz [16]. The percentage of MRD < 10-4 after the induction phase in patients with TEL/AML1 fusion gene was 87.9%, however, that percentage was only 70.7% for patients with MLL rearrangement.
The poor prognosis group had the highest relapsed percentage, 66.7%, the intermediate prognosis group had 11.1% relapse and the good prognosis group had no relapse. The difference was statistically significant (p<0.05). Our results are similar to the study by Sanchez, the poor prognosis has the highest relapse rate. 23% of patients with BCR/ABL1 relapsed after achieving remission, in which, there was 10% of CNS relapse or CNS and bone marrow relapse [17].
Overall survival rates for the poor prognosis, intermediate prognosis and good prognosis risk groups after 3 years were 25.0 ± 21.7%, 76.3 ± 7.1% and 100.0 ± 0.0%. The difference was statistically significant (p<0,05). Our results are similar to the study by Pui, the overall survival rate for patients with BCR/ABL1 fusion gene was 48.0 ± 2.0%, and the patients without BCR/ABL1 fusion genes was 94.5 ± 1.8% [12]. Regarding event-free survival, event-free survival rates for the poor prognosis, intermediate prognosis and favorable prognosis risk groups after 2 years were 0%, 77.9 ± 6.1% and 100.0 ± 0.0%. The difference was statistically significant (p<0,05). Our results were similar to the study by Jeha, Pui [12, 18].
Conclusion
Genetic abnormalities help classify, predict and treat childhood acute lymphoblastic leukemia. There were statistical correlations between remission rate, relapse rate, overall survival, event-free survival and the genetic risk group.
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 compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
References
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2. Freireich EJ, Wiernik PH, Steensma DP. The leukemias: a half-century of discovery. J Clin Oncol. 2014;32(31):3463-9.
3. Fadoo Z, Nisar I, Yousuf F, Lakhani LS, Ashraf S, Imam U, et al. Clinical features and induction outcome of childhood acute lymphoblastic leukemia in a lower/middle income population: A multi-institutional report from Pakistan. Pediatr Blood Cancer. 2015;62(10):1700-8.
4. Al-Sudairy R, Al-Nasser A, Alsultan A, Al Ahmari A, Abosoudah I, Al-Hayek R, et al. Clinical characteristics and treatment outcome of childhood acute lymphoblastic leukemia in Saudi Arabia: a multi-institutional retrospective national collaborative study. Pediatr Blood Cancer. 2014;61(1):74-80.
5. Jovanovska A, Martinova K, Kocheva S, Trajkova-Antevska Z, Coneska-Jovanova B, Panovska-Stavridis I, et al. Clinical Significance of Minimal Residual Disease at the End of Remission Induction Therapy in Childhood Acute Lymphoblastic Leukemia. Open Access Maced J Med Sci. 2019;7(17):2818-23.
6. Yasmeen N, Ashraf S. Childhood acute lymphoblastic leukaemia; epidemiology and clinicopathological features. J Pak Med Assoc. 2009;59(3):150-3.
7. Veerman AJ, Kamps WA, van den Berg H, van den Berg E, Bokkerink JP, Bruin MC, et al. Dexamethasone-based therapy for childhood acute lymphoblastic leukaemia: results of the prospective Dutch Childhood Oncology Group (DCOG) protocol ALL-9 (1997-2004). Lancet Oncol. 2009;10(10):957-66.
8. Aldrich MC, Zhang L, Wiemels JL, Ma X, Loh ML, Metayer C, et al. Cytogenetics of Hispanic and White children with acute lymphoblastic leukemia in California. Cancer Epidemiol Biomarkers Prev. 2006;15(3):578-81.
9. Gao MG, Hong Y, Qin YZ, Chang YJ, Wang Y, Zhang XH, et al. Prognostic significance of SET-NUP214 fusion gene in acute leukemia after allogeneic hematopoietic stem cell transplantation. Medicine (Baltimore). 2020;99(50):e23569.
10. Xu X, Zhai Q, Jin H, Yu Y, Han D, Zhang H, et al. SET-NUP214 Fusion Gene Involved Early T-Cell Precursor Acute Lymphoblastic Leukemia in Adult with B Marker Expression. Int J Gen Med. 2021;14:659-64.
11. Inaba H, Pui CH. Advances in the Diagnosis and Treatment of Pediatric Acute Lymphoblastic Leukemia. J Clin Med. 2021;10(9):1926.
12. Pui CH, Carroll WL, Meshinchi S, Arceci RJ. Biology, risk stratification, and therapy of pediatric acute leukemias: an update. J Clin Oncol. 2011;29(5):551-65.
13. Lin PC, Chang TT, Lin SR, Chiou SS, Jang RC, Sheen JM. TEL/AML1 fusion gene in childhood acute lymphoblastic leukemia in southern Taiwan. Kaohsiung J Med Sci. 2008;24(6):289-96.
14. Toksvang LN, Lee SHR, Yang JJ, Schmiegelow K. Maintenance therapy for acute lymphoblastic leukemia: basic science and clinical translations. Leukemia. 2022;36(7):1749-58.
15. Cimino G, Cenfra N, Elia L, Sica S, Luppi M, Meloni G, et al. The therapeutic response and clinical outcome of adults with ALL1(MLL)/AF4 fusion positive acute lymphoblastic leukemia according to the GIMEMA experience. Haematologica. 2010;95(5):837-40.
16. Borowitz MJ, Devidas M, Hunger SP, Bowman WP, Carroll AJ, Carroll WL, et al. Clinical significance of minimal residual disease in childhood acute lymphoblastic leukemia and its relationship to other prognostic factors: a Children’s Oncology Group study. Blood. 2008;111(12):5477-85.
17. Sanchez R, Ayala R, Alonso RA, Martinez MP, Ribera J, Garcia O, et al. Clinical characteristics of patients with central nervous system relapse in BCR-ABL1-positive acute lymphoblastic leukemia: the importance of characterizing ABL1 mutations in cerebrospinal fluid. Ann Hematol. 2017;96(7):1069-75.
18. Jeha S, Choi J, Roberts KG, Pei D, Coustan-Smith E, Inaba H, et al. Clinical significance of novel subtypes of acute lymphoblastic leukemia in the context of minimal residual disease-directed therapy. Blood Cancer Discov. 2021;2(4):326-37.
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Tran Kiem Hao, Nguyen Thi Kim Hoa, Phan Hung Viet. Research of genetic abnormalities in diagnosis and treatment of childhood acute lymphoblastic leukemia at Hue Central Hospital. Ann Clin Anal Med 2024;15(1):21-24
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Cord blood quality: Examination of newborn weight and blood volume in autologous cord blood banking – A single-center experience
Melek Büyükkınacı Erol 1, 2, Durmus Burgucu 2, 3
1 Department of Obstetrics and Gynecology, Private Melek Büyükkınacı Erol Obstetrics and Gynecology Clinic, 2 Department of Gynecology and Obstetrics, The Mediterranean Stem Cell And Cellular Therapies Research Group, 3 Department of Physiology, Akdeniz University Technopark Babylife Cord Blood Bank and Human Cell-Tissue Production Center, Antalya, Turkey
DOI: 10.4328/ACAM.21869 Received: 2023-08-14 Accepted: 2023-09-16 Published Online: 2023-10-28 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):25-27
Corresponding Author: Durmuş Burgucu, Department of Physiology, Akdeniz University Technopark Babylife Cord Blood Bank, and Human Cell-Tissue Production Center, Akdeniz University, Campus, Antalya, Turkey. E-mail: dburgucu@akdeniz.edu.tr P: +90 242 226 16 80 F: +90 242 226 16 79 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3980-982X
This study was approved by the Ethics Committee of Akdeniz University Faculty of Medicine Clinical Research (Date: 21-02-2018, No: 147)
Aim: Cord blood, sourced from umbilical cords, is extensively utilized as hematopoietic stem cells in marrow transplants. This study examined the correlation between cord blood quality and newborn weight, with an emphasis on volume and weight. Influential factors included volume, neonatal weight, placental weight, cord length, maternal age, birth sequence, gestational age, and environmental conditions. While the association between newborn weight and cord blood quality has been established, this study investigates the relationship within Turkey’s autologous cord blood banking.
Material and Methods: This study adopted a cross-sectional and retrospective design, utilizing data collected from the KordData program between September 1, 2018, and January 1, 2019. The dataset comprised information on 50 female and 50 male newborns. Pearson’s correlation tests were used to evaluate the correlation between newborn weight and blood volume.
Results: The study revealed that newborn weight and collected cord blood volume were positively correlated for both male and female infants. The average birth weight of female infants was 3274 g, with an average cord blood volume of 84.2 ml. Male infants had an average birth weight of 3319 grams, with an average collected blood volume of 90.9 ml.
Discussion: This study is consistent aligns with existing literature, emphasizing the positive correlation between newborn weight and cord blood volume. Addressing collection challenges is crucial for success, and requires medical expertise. This sheds light on the relationship in cord blood banking, emphasizing the role of cord blood volume in stem cell sourcing. Despite these limitations, further research is required to confirm these results.
Keywords: Cord Blood, Birth Weight, Hematopoietic Stem Cell
Introduction
Over the past 30 years, cord blood has proven its effectiveness and success effective and successful as a source of hematopoietic stem cells, particularly in bone marrow transplantation [1,2]. Derived from the umbilical cord tissue, placental extension and cord blood quality are influenced by various factors. Among these, the collected blood volume, newborn weight, placental weight, cord length, maternal age, and factors such as birth order and gestational week were the most notable. Additionally, modifiable environmental factors, such as maternal smoking, impact cord blood stem cell quality [3]. Essential for cord blood to be used in stem cell and cellular therapies, quality control tests involve calculating CD34+ cells (hematopoietic stem cells) and total nucleated cell (TNC) counts [4,5,6]. Forty-five articles exploring the relationship between newborn weight and cord blood quality were found in the literature [7]. These articles revealed positive correlations among thirty-seven studies with volume, thirty-three with TNC, and 30 with CD34+ cell count and colony-forming unit (CFU) count [7,8]. Although data on this topic are scarce in the Turkish literature, no data exist regarding autologous cord blood banking. Newborn weight has been deemed a paramount parameter for predicting cord blood quality, with the added advantage of being assessable by obstetricians and gynecologists before birth [9]. Cord blood collection may be influenced by structural factors such as newborn characteristics and the collection process itself. The primary goal is to maximize the collected blood volume [10]. This study aimed to examine the relationship between two pivotal parameters determining cord blood quality, blood volume and newborn weight, in individuals seeking autologous cord blood banking services in Turkey.
Material and Methods
This study adopted a cross-sectional retrospective design. Data recorded in the Akdeniz University Technopark Babylife Cord Blood Bank and Human Cell-Tissue Production Center Data program between September 1, 2018, and January 1, 2019, were scanned and subjected to statistical analysis. The study examined involved examining data from 50 female and 50 male newborns, and Pearson’s correlation tests were performed using SPSS 21.0. The Pearson correlation coefficient (r) was determined and the p-value was found to be less than 0.05, indicating statistical significance. Ethical approval was granted by the Akdeniz University Faculty of Medicine Clinical Research Ethics Committee on February 21, 2018 (Decision number No. 147).
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
The average birth weight of female infants was 3274 g, with an average cord blood volume of 84.2 ml. Male infants had an average birth weight of 3319 g (Figure 1A), with an average collected blood volume of 90.9 ml (Figure 1B). To eliminate the influence of sex, the correlation between infant weight and collected blood volume was assessed separately in female and male infants. Positive correlations were identified in both the groups (Figures 2,-3).
Discussion
This study, based on data from individuals seeking autologous cord blood banking in the Turkish population, supports the findings in the literature. A positive relationship between infant weight and blood volume was observed. This underscores the critical role of collected cord blood volume in determining stem cell source adequacy and treatment potential [7,8]. Cord blood collection challenges include rapid clotting, which can affect the collection process and result in situations in which clotting occurs during collection. Similarly, technical difficulties or factors such as baby positioning during collection may lead to insufficient blood collection. These challenges affect collection reliability and successful outcomes. Obstetricians, gynecologists, and midwives play a pivotal role in addressing these challenges by informing expectant mothers of cord blood before birth. This minimizes collection problems and ensures successful completion, increasing awareness and informed decision-making by pregnant women [9]. Hematopoietic stem cell therapies plays a crucial role in various clinical applications. Hematopoietic stem cells in the cord blood are preferred for treating blood cancers and similar disorders. Furthermore, stem cells found in cord blood show potential for tissue regeneration and regenerative therapies. Lymphocyte types in the cord blood also contribute significantly to clinical applications. T lymphocytes and natural killer (NK) cells play vital roles in regulating immune responses and cancer immunotherapy [10].
Conclusion
This study presents the results of a cross-sectional and retrospective investigation of individuals seeking autologous cord blood banking in Turkey. These results highlight the positive relationship between infant birth weight and collected cord blood volume, emphasizing the critical role of collected cord blood volume in determining collection effectiveness and stem cell source adequacy. This study underscores the importance of the experience and expertise of obstetricians, gynecologists, and midwives in the cord blood collection process. Limitations include the study’s cross-sectional and retrospective nature, which affects data collection conditions, and data being derived from a single autologous cord blood bank, which limits the generalizability of the results. Further comprehensive and controlled prospective studies are required to confirm these findings.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some
of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
1. Kurtzberg J, Troy JD, Page KM, El Ayoubi HR, Volt F, Maria Scigliuolo G, et al. Unrelated Donor Cord Blood Transplantation in Children: Lessons Learned Over 3 Decades. Stem Cells Transl Med. 2023;12(1):26-38.
2. Sanchez-Petitto G, Rezvani K, Daher M, Rafei H, Kebriaei P, Shpall EJ, et al. Umbilical Cord Blood Transplantation: Connecting Its Origin to Its Future. Stem Cells Transl Med. 2023;12(2):55-71.
3. Burgucu D. Effect of smoking on the hematopoietic stem cell count in cord blood. Ann Clin Anal Med. 2021;12(Suppl. 1): S83-5.
4. Wang X, Gong S, Zhu W, Fu H, Sun H. A systematic review and meta-analysis of cord blood collection practices. Transfusion. 2019;59(6):1993-2004.
5. Salge-Bartels U, Huber HM, Kleiner K, Volkers P, Seitz R, Heiden M. Evaluation of Quality Parameters for Cord Blood Donations. Transfus Med Hemother. 2009;36(5):317-24.
6. Naseri Mobaraki S, Abroun S, Atashi A, Kaviani S. Evaluation of Expansion and Maintenance of Umbilical Cord Blood CD34+ Cells in The Co-Culture with Umbilical Cord Blood-Derived Mesenchymal Stem Cells in The Presence of Microcarrier Beads. Cell J. 2023;25(3):184-93.
7. Omori A, Chiba T, Kashiwakura I. Relationship between radiosensitivity of human neonatal hematopoietic stem/progenitor cells and individual maternal/ neonatal obstetric factors. J Radiat Res. 2010;51(6):755-63.
8. Kudo Y, Minegishi M, Seki O, Takahashi H, Suzuki A, Narita A, et al. Quality assessment of umbilical cord blood units at the time of transplantation. Int J Hematol. 2011;93(5):645-51.
9. Solves P, Perales A, Moraga R, Saucedo E, Soler MA, Monleon J. Maternal, neonatal and collection factors influencing the haematopoietic content of cord blood units. Acta Haematol. 2005;113(4):241-6.
10. Berrien-Elliott MM, Jacobs MT, Fehniger TA. Allogeneic natural killer cell therapy. Blood. 2023;141(8):856-68.
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Melek Büyükkınacı Erol, Durmus Burgucu. Cord Blood Quality: Examination of Newborn Weight and Blood Volume in Autologous Cord Blood Banking – A Single-Center Experience. Ann Clin Anal Med 2024;15(1):25-27
Citations in Google Scholar: Google Scholar
Pattern of analgesics’ use and side effects among Saudis in Arar, Saudi Arabia
Ekramy Elmorsy 1,2, Shmoukh Mushref M Alruwaili 3, Razan Ibrahim Ali Alsayer 3, Nouf Khalid J Alanazi 3, Khulud Hamed Saud Alshammari 3, Dana Ahmed Abdullah Albalawi 3
1 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Mansoura University, Mansoura, Egypt, 2 Department of Pathology, Northern Border University, Arar, Saudi Arabia, 3 Medical Student, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
DOI: 10.4328/ACAM.21919 Received: 2023-08-30 Accepted: 2023-11-06 Published Online: 2023-11-10 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):28-32
Corresponding Author: Ekramy Elmosry, Department of Pathology, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia. E-mail: Ekramy.elmorsy@nbu.edu.sa P: +966 501 275 8 35 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7444-2499
This study was approved by the Ethics Committee of Northern Borer University (Date: 2023-2-02, No: 26/44/H)
Aim: The current study was conducted to evaluate the pattern of analgesic use and the occurrence of side effects among the Saudi population in Arar, Saudi Arabia.
Material and Methods: The study was conducted via a cross-sectional electronic questionnaire among Saudi citizens in Arar city, Saudi Arabia. The questionnaire contains 11 questions about the demographics of participants, pattern of use, side effect, and source of information.
Results: Three hundred and ninety subjects aged 12 to 70 years (98 males and 292 females) participated in the study. Generally, paracetamol was the most used analgesic (50%), followed by Ibuprofen (40%). Combined use of analgesics was reported by 49 participants (12.%). There was a significant difference in the types of analgesics used according to the gender and age of the participants (p<0.0001). Regarding the frequency of analgesic use, 308 (78.7%) reported using analgesics when indicated, while daily, weekly, and monthly use were also reported among 5.6%, 8.2% and 7.4% of participants, respectively. Headache was the most reported indication for analgesic use (66.4%). Most participants (227, 58.2%) reported using analgesics after meals. Side effects were reported in 111 participants (28.5%). Drowsiness was the most common side effect (11.3%). Side effects were significantly higher among participants using NSAIDs analgesics (p-value 0.0005).
Discussion: The pattern of analgesic use in Arar is generally satisfactory and rationalized without reported misuse. Healthcare professionals are the most common source of awareness, which shows the effectiveness of outreach awareness campaigns.
Keywords: Analgesics, Paracetamol, NSAIDS, Arar
Introduction
The practice of using drugs that have not been prescribed, recommended, or controlled by a certified healthcare professional is also known as “over-the-counter” (OTC) medication [1]. Self-medication is a term that can be used to describe patients who treat self-diagnosed disorders or symptoms with non-prescription medications without consulting a doctor and under medical supervision [2,3]. For instance, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (paracetamol) are analgesic types of OTC medications that are commonly used worldwide [4,5]. Fortunately, they are considered safe when used correctly.
The analgesic effect occurs when the prostaglandin is inhibited in the hypothalamus by using paracetamol. Furthermore, it can function in the peripheral nervous system by increasing the pain threshold and inhibiting prostaglandin synthesis in the central nervous system to block pain impulse generation. It is frequently used for fever and pain relief. However, it has some side effects such as disorientation, dizziness, gastrointestinal bleeding, laryngeal edema and nephrotoxicity [6].
Unintentional paracetamol overdose has the potential to result in liver failure [7]. Additionally, NSAIDs like Diclofenac, Ibuprofen, and Aspirin act by inhibiting cyclooxygenase (COX 1-2); they provide analgesic effect, anti-inflammatory, and antipyretic properties, and may also prevent platelet function. The long-term use of NSAIDs may result in duodenal or gastric ulcers [8].
Many previous studies have evidenced that over the past three decades, analgesic use has remarkably increased in both developing and developed countries [9]. For example, one study conducted a systematic review of Middle Eastern countries and found that these areas frequently use OTC drugs, with KSA ranking fourth at 35.4% (after Iran, Pakistan, and Jordan) [10]. Moreover, some local studies found that analgesics, specifically Diclofenac sodium, were the most prescribed class of medication in KSA, with a percentage of 67 % [11]. According to reports, self-medication with OTC analgesics is a global public health issue [12,13]. Finally, a study conducted in central Saudi Arabia reported that 41.8% of OTC medications involved analgesics [14].
Inappropriate or irrational use of analgesics leads to increased morbidity and mortality rates and deterioration of the quality of life, and may also lead to misuse of healthcare resources and increased healthcare costs [9]. Public awareness of the side effects of medications is mandatory, especially for OTC medications, to prevent their abuse and hazardous effects. Hence the current study aimed to evaluate the pattern of use, side effects and sources of information among the population of Arar, Northern Border province, to help local health authorities evaluate the magnitude of the problem of analgesic misuse in Arar.
Material and Methods
Ethical issues: The study was approved by the local bioethics committee of Northern Borer University on 2/2/2023 (Decision No. 26/44/H). The aim of the study was clarified to the participants and their data were kept confidential at all stages of the study.
Study design
The study was conducted as a cross-sectional study between January to March 2023 using an online Google form, which was distributed by the research team in the different areas of Arar and through the common social communications platforms.
Participants and sample size
The sample size was identified by utilizing the equation n = z2p (1-p)/e2 (n = sample size, z = degree of confidence based on standard normal distribution, p = approximate proportion of the population exhibiting the trait, and e = tolerated margin of error). A proper sampling method was utilized. Expected sample for robust data was expected to be over 350 participants from various age groups, occupations, and educational levels. Only responses collected from Saudi citizens above 18 years of age were considered for data analysis. Data were collected using the adapted questionnaire from Karami et al. [8] after their permission, with a few modifications, that was distributed online to the public population on specific social media platforms, including WhatsApp and Twitter, which included questions relevant to the study objectives.
Results
As the questionnaire was modified from another referenced one, thus, being a self-constructed one, it was validated by a test of validity (Cronbach’s alpha test) with an alpha coefficient of all questionnaire items of 0.82. Three hundred and ninety subjects (98 males and 292 females) aged from 12 to 70 years (average 56.1±12.2 years) participated in the study; 65.9% of participants reported university and postgraduate education (Table 1).
Around 97% of female respondents and 73% of male respondents reported using at least one analgesic. According to the type of analgesics used, generally, paracetamol was the most used analgesic among 195 participants (50%), followed by Ibuprofen (40%). Forty-nine participants (12%) reported usage of more than one type of analgesics. There was a significant difference in the types of used analgesics according to the gender and age of the participants (p<0.0001; chi-square df: 23.55, 4 and 71.75, 16, respectively). Ibuprofen was the most used analgesic among females (46%) and participants aged below 20 years (70%) (Figure 1). According to the frequency of analgesic use, 308 (78.7%) reported using analgesics when indicated, while daily, weekly, and monthly use were also reported among 5.6%, 8.2% and 7.4% of participants, respectively due to chronic and repeated pain. Headache, dental pain, fever, and menstrual pain were the most reported indications for analgesic use among participants (66.4%, 31%, 27.4%, and 24.4%, respectively).
Regarding timing of administration, 227 (58.2%) participants reported using analgesics after meals, while 96 participants (24.6%) did not report a definite timing. Side effects were reported in 111 participants (28.5%). Drowsiness, heartburn, nausea and vomiting were the most common side effects (11.3%, 5.9% and 5.9%, respectively) (Table 2). Thirty-nine participants reported more than one side effect. After the exclusion of participants who reported using paracetamol with NSAIDs (13 participants), side effects were significantly higher among participants using NSAIDs analgesics (p-value 0.0005) with the risk of side effects being approximately twice as high.
Interestingly, participants’ top source of information about analgesics was healthcare professionals (about 50%), followed by family and friends, internet sources, and the media among 32, 20, and 10% of participants, respectively.
Discussion
The present study examined patterns of analgesic use in the general population as well as the side effects of analgesics. According to the respondents, the use of analgesics was more prevalent among female participants than male respondents, which is consistent with surveys conducted in the Kingdom of Norway and Saudi Arabia, as well as what was reported in studies conducted in the United States that found that women are more conservative about analgesics than males [15, 16 , 17].
Paracetamol, followed by ibuprofen (NSAID), was the most used analgesic in Arar, KSA, according to previous studies conducted in Saudi Arabia [15,16, 17]. However, in Germany, another study showed the opposite result [18] according to their pattern of use. Paracetamol is now available in many shops, aiding many patients in the treatment of minor complaints, while still ignoring the danger of dependence or overuse. Additionally, ibuprofen and diclofenac were the second most popular OTC analgesics optioned by the general population. This high rate of NSAID use is most likely due to its high availability, low cost, and excellent safety record [19]. They are most often used for more severe pain, such as toothache or pain that does not respond to paracetamol. Furthermore, a low frequency of repeated use was reported in this study, with 78.7% of the participants using them as needed and 7.4% using them only every few months. Daily (5.6%) and weekly (8.2%) use were consistent with results from a previous study in the Eastern region [20]. In this study, female gender was associated with a higher frequency of analgesics use (p =). This was consistent with the findings of three previous studies [21]. This is understandable as past research has shown that females exhibit a higher sensitivity to pain than males [22]. Higher level of education was markedly associated with lower frequency of analgesic use (p = 0.000), which is consistent with many previous studies [23]. Drowsiness, heartburn, nausea and vomiting were the most common reported side effects (11.3%, 5.9% and 5.9%, respectively). This is similar to a previous study conducted in 2001 in Italy that demonstrated mainly gastrointestinal symptoms reported by 5.5% of users and occurring primarily with diclofenac, piroxicam, ibuprofen, and ketoprofen [24]. In addition, the use and availability of OTC NSAIDs are increasing as a result, and the side effects were significantly higher among participants using NSAID analgesics (p-value 0.0005), with the risk of side effects being approximately twice as high). It is known that non-steroidal anti-inflammatory drugs (NSAIDs) when used therapeutically have greater adverse effects than paracetamol [25]. However, this study had a few limitations. First, the sample size was small and needs to be enlarged to increase its statistical power, specifically, the number of participants with a level of education lower than high school. Second, the survey only used the brand names of the most popular drugs; thus, not all brands were included.
The main limitation of the current study was that the number of female participants was nearly triple the number of males hence further analytical tools were recommended to validate the results obtained in this research.
Conclusion:
Analgesics were reported to be used by all participants, with common combinations between the different types. Paracetamol was the most used among males, while ibuprofen was most common among females and young age groups. Around 79% of participants only used analgesics when indicated. Headache and dental pain were reported to be the most common indications. taken by people for a variety of conditions, including headache, fever, and toothache. Analgesics were commonly used after meals. Side effects were reported in only around 25% of participants, with drowsiness and gastrointestinal manifestations being the most common. To conclude, the pattern of use of analgesics in Arar is generally accepted and rationalized without reported abuse among participants and accepted levels of occurrence and types of side effects. Healthcare professionals are the most common use which shows the effectiveness of counselling and outreach awareness campaigns.
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 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.
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 compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
References
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6. van den Anker JN. Optimising the management of fever and pain in children. Int J Clin Pract Suppl. 2013;(178):26-32.
7. Roberts E, Delgado Nunes V, Buckner S, Latchem S, Constanti M, Miller P, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis. 2016;75(3):552-9.
8. Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol. 2020;180:114147.
9. Kim J, Kinney K, Nyquist M, Capellari E, Vordenberg SE. Factors that influence how adults select oral over-the-counter analgesics: A systematic review. J Am Pharm Assoc. 2022;62(4):1113-23.
10. Babakor SD, Al Ghamdi MM. Prevalence and determinants of over-the-counter analgesics usage among patients attending primary health care centers in Jeddah, Saudi Arabia. J Young Pharm. 2018;10(1):91.
11. AlKhamees OA, AlNemer KA, Bin Maneea MW, AlSugair FA, AlEnizi BH, Alharf AA. Top 10 most used drugs in the Kingdom of Saudi Arabia 2010-2015. Saudi Pharm J. 2018;26(2):211-16.
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13. Ibrahim NK, Alamoudi BM, Baamer WO, Al-Raddadi RM. Self-medication with analgesics among medical students and interns in King Abdulaziz University, Jeddah, Saudi Arabia. Pak J Med Sci. 2015;31(1):14-18.
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Ekramy Elmorsy, Shmoukh Mushraf M Alruwaili, Razan Ibrahim Ali Alsayer, Nouf Khalid J Alanazi, Khloud Hamed Saud Alshammari, Dana Ahmad Abdullah Albalawi. Pattern of analgesics’ use and side effects among Saudis in Arar, Saudi Arabia. Ann Clin Anal Med 2024;15(1):28-32
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Antibacterial effectiveness of combined sodium hypochlorite and diode laser therapy with different parameters against S. Aureus biofilm
Semanur Özüdoğru 1, Fikret Özgür Coşkun 2, Mustafa Reha Coşkun 3, Mitat Şahin 3,4
1 Department of Pedodontics, Faculty of Dentistry, Istanbul Medeniyet University, Istanbul, Turkey, 2 Department of Prosthodontics, Faculty of Dentistry, Kafkas University, Kars, Turkey, 3 Department of Microbiology, Faculty of Veterinary Medicine, Kafkas University, Kars, Turkey, 4 Department of Microbiology, Faculty of Veterinary Medicine, Kyrgyz-Turkish Manas University, Bishkek, Kyrgystan
DOI: 10.4328/ACAM.21971 Received: 2023-09-12 Accepted: 2023-10-28 Published Online: 2023-11-14 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):33-36
Corresponding Author: Semanur Özüdoğru, Department of Pedodontics, Faculty of Dentistry, Istanbul Medeniyet University, Istanbul, Turkey. E-mail: dtsema@hotmail.com P: +90 543 211 77 30 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7967-9121
This study was approved by the Ethics Committee of Kafkas University (Date: 2022-01-26, No: 80576354-050-99/51)
Aim: In this study, we aimed to assess the antibacterial efficacy of both single and combined sodium hypochlorite (NaOCl) and diode laser on Staphylococcus aureus (S. aureus) biofilm.
Material and Methods: Eighty-four premolars were randomly assigned to groups. The Experimental groups were as follows: group 1; 5.25% NaOCl; groups 2-4; diode laser (0,7; 1,5; 2,5 W); Groups 5-7; combined laser and NaOCl. Statistical evaluations were made by Kruskal -Wallis and Mann- Whitney U tests.
Results: The 2.5 W diode laser showed a high potential for elimination of S.aureus, similar to NaOCl (p>0.05). 0,7 W and 1,5 W diode lasers showed less antibacterial activity than the other groups (p<0.05). There was no difference between single and combined applications (p>0.05).
Discussion: Diode laser application did not show a synergistic effect with NaOCl. The 2,5 W laser parameter was also found to be sufficient on its own. The effectiveness of laser irrigation has been shown to depend on parameters.
Keywords: Biofilm, Diode Laser, Sodium Hypochlorite, Staphylococcus Aureus
Introduction
Biofilm is a complex polymicrobial community that can contain different types of microorganisms and can adhere to surfaces [1,2]. Root canal irrigation aims to achieve the goal of destroying intracanal biofilms as well as killing bacteria [3,4]. Sodium hypochlorite (NaOCl) is considered the most effective solution of for the root canal irrigation solutions [5,6]. Apart from In addition to having side effects such as concentration-dependent efficacy depending on concentration and toxic effect on for tissues in the periapical region, it cannot sufficiently penetrate all microorganisms in the canal [7,8]. In recent years, laser irradiation hasve begun to be used in endodontic treatment [9]. It has been reported that the performance of root canal treatment increases when used for disinfection in endodontic practice [10,11]. Diode laser application is expected to have a higher penetration depth and bactericidal effect compared to the limited penetration behavior of chemical disinfectants [12].
In the literature, there are limited studies on the comparison of the combined use of endodontic irrigation methods in terms of antibacterial properties [13-15]. Therefore, an understanding of the interactions between irrigation applications will be will be helpful for optimal treatment in root canal treatment cases [16]. Theis current study aimeds to evaluate the antibacterial activity of both single and combined use of NaOCl and diode laser (0.7; 1.5; 2.5 W) treatments on S. aureus biofilm in vitro. The null hypothesis is that there is no difference between the groups.
Material and Methods
This study was conducted between February and April 2021 atin Kafkas University Medical Faculty Hospital of Kars, Turkey. The study received Ethical approval with a number of No. 80576354-050-99/51 was obtained for the study from the Ethics Committee of Kafkas University.
Preparation of tooth specimens
The sample of the study consisted of 84 human teeth that were extracted for periodontal or orthodontic reasons, single root, single canal, and untreated endodontically. The teeth wereas cleaned with a hand curette and the root length was fixed at 14 mm. The root canals of the teeth were prepared with X1-X3 rotary ProTaper NEXT and sterilized using 5.25% NaOCl, 17% EDTA, saline solution, 5 ml each. The apical foramen of each root was covered with composite resin, and the outer surface of the root was covered with 2 layers of nail polish. The samples were placed in 2 ml tubes and sterilized in an autoclave at 121°C for 15 minutes.
Biofilm Formation
S. aureus ATCC 25923 strain was passaged into Tryptic Soy Agar (TSA, Oxoid) to obtain fresh culture and incubated overnight incubation in Tryptic Soy Broth (TSB, Oxoid, Milan, Italy). McFarland turbidity was adjusted with a crystalspecTM instrument. The McFarland standard number 0.5 was used to cure blood agar plates to achieve 1.5 X 108 colony-forming units (CFU/ml) of bacterial growth. A 1/100 ratio of fresh culture was added into TSB with 2% D-glucose, and 1 ml was taken and added to the tooth. Incubation was carried out at 37°C under aerobic conditions for 48 hours.
Preparation of experimental and control groups
The Samples were divided into 7 experimental groups and positive (n:10, steril salin)-negative (n:4, no preparation) control groups. The Experimental groups were as follows:
Group 1 (n:10); The irrigation procedure of the samples was carried out with 5 ml of 5.25% NaOCl for 1 minute.
Groups 2-4 (n:10); Diode laser (Epic, Biolase Tech., CA, USA) with a wavelength of 940 nm was applied in continuous mode (CW) with the help of an endodontic tip (ezTip Endo, 200 µm, 14 mm). Laser irradiation was transmitted from the apical of the root to the coronal in circular motions, that is, 3 times 20 s application period (ap) and 15 s waiting period (wp). Fibers were sterilized for each tooth between irradiations.
Groups 5-7 (n:10); Laser irradiation was applied directly to the remaining solution after irrigation with 5% NaOCl, as in groups 2-4.
The final irrigation was carried out with sterile saline for all groups.
Bacterial evaluation
Samples were taken from the root canals of the teeth subjected to bacterial inoculation before and after the disinfection process. The collection of samples was carried out by scraping the all surfaces with a sterile #25 K-File (Dentsply, Maillefer) for 20 s and then keeping the paper cone placed in the canal for 30 seconds. Then, the samples were placed in microcentrifuge tubes containing 1 ml of PBS solution and sonicated for 5 minutes followed by vortexing for 2 minutes. Then, bacterial counts were performed.
Statistic Evaluation
Statistical analysis was performed using IBM SPSS Statistics 18 (IBM SPSS, Turkey). Kruskal- Wallis and Mann- Whitney U and Wilcoxon sign tests were used. The p< 0.05 level was consideredaccepted significance.
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
When analyzed Through the analysis before and after the root canal disinfection treatments, a significant decrease was found in the number of CFUs in all groups (p< 0.05) (Table 1) (Figure 1). The decrease in the number of CFUs was more significant in all disinfection protocols when compared to the control group.
Pair and multiple comparisons of the groups are shown in the Table 2. A significant difference was found in comparisons between groups (p= 0,020). The percentage decrease rate in groups 2 and 3 was found to be significantly lower than in Group 1 (p= 0,009; p= 0,001) ; no significant difference was found among the other groups. No significant difference was found between groups 2 and 3 (p= 0,113).
Discussion
Successful root canal treatment depends on the complete removal of intracanal microorganisms [10]. The aim of this study is to assess and compare the synergistic effect of different disinfection methods and irrigation agents on S. aureus biofilm. In this study, the null hypothesis was rejected.
The advantages of lasers over conventional methods in endodontic treatment have been tried to be investigated [9-11]. Many different wavelengths and settings were used in the studies [11,12]. This study was performed with a 940 nm diode laser in continuous mode (CW). In the current study, we also used a laser in combination with NaOCl. This study observed that after 48 hours, all experimental protocols decreased the bacterial load, while groups 2 and 3, which were only the laser group, achieved less disinfection.
Diode laser irradiation was reported to contribute to a significant reduction of bacteria in primary teeth to disinfect the root canal in an in vivo study [13]. An another in vivo study showed that 2% chlorhexidine, 1% NaOCl and diode laser irradiation (4x5s ap; 20s wp) were successful in reducing root canal infection, but there was no significant difference between them [14]. In the current study, the laser irradiation protocol was 3×20 s ap and 15 s wp. Studies have similarly reported diode laser irradiation as a possible complement to existing protocols for disinfection of the root canal system.
When Kushwah et al. [15] compared the protocols of with 3% NaOCl, ozonated water, diode laser (3 W; 4×5 s ap, 10 wp), their bacterial activities were found to be similar to our study. One another study showed that the application of laser (4×5 s ap) alone did not have sufficient antimicrobial activity [16]. On the contrary, in our study, a 2.5 W laser was found to have similar antibacterial effects as NaOCl. The difference between the two studies may be due to application times and power.
The study concluded that the 3W diode laser in continuous mode was more effective than pulse mode and 5.25% NaOCl [17]. In the current study, only the continuous mode of the laser was used. In another study, 2.5% NaOCl, diode laser (pulse mode; 2.5 W), and the combination of laser with NaOCl were reported to have similar antibacterial activity [18]. In our study, continuous mode was used at 2.5 W power and the results were similar.
In this study, current observations indicate that irrigation with NaOCl and 2.5 W diode laser irradiation is effective on Staphylococcus aureus. Further studies are needed to evaluate the disinfection effectiveness of different parameters of the diode laser alone in root canal treatment from different perspectives.
Limitations of the study
Considering that there are many bacterial species responsible for root canal infections, a single bacterial species was examined in this study. Only the effectiveness of the continuous mode of the diode laser has been investigated.
Conclusion
The potential application of the diode laser in 0.7 W and 1.5 W applications should not replace conventional treatment regimens, but should be seen as a possible adjunct. The microbial efficiency of 2.5 W diode laser application is similar to 5.25% NaOCl.
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.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
References
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2. Fidalgo TK, Barcelos R, Portela MB, Soares RM, Gleiser R, Silva-Filho FC. Inhibitory activity of root canal irrigants against Candida albicans, Enterococcus faecalis and Staphylococcus aureus. Braz Oral Res. 2010;24(4):406-412.
3. Borges CC, Estrela C, Lopes FC, Palma-Dibb RG, Pecora JD, De Araújo Estrela CR, et al. Effect of different diode laser wavelengths on root dentin decontamination infected with Enterococcus faecalis. J Photochem Photobiol B. 2017;176:1-8.
4. Torabi S, Joharchi K, Kalhori KAM, Sohrabi M, Fekrazad R. Evaluation of antimicrobial photodynamic therapy on wounds infected by Staphylococcus aureus in animal models. Photodiagnosis Photodyn Ther. 2021;33:102092.
5. Abraham S, Vaswani SD, Najan HB, Mehta DL, Kamble AB, Chaudhari SD. Scanning electron microscopic evaluation of smear layer removal at the apical third of root canals using diode laser, endoActivator, and ultrasonics with chitosan: An in vitro study. J Conserv Dent. 2019;22(2):149-154.
6. Asnaashari M, Safavi N. Disinfection of contaminated canals by different laser wavelengths, while performing root canal therapy. J Lasers Med Sci. 2013;Winter;4(1):8-16.
7. Sarda RA, Shetty RM, Tamrakar A, Shetty SY. Antimicrobial efficacy of photodynamic therapy, diode laser, and sodium hypochlorite and their combinations on endodontic pathogens. Photodiagnosis Photodyn Ther. 2019;28:265-272.
8. Astuti SD, Rulaningtyas R, Putra AP, & Arifianto D. The efficacy of photodynamic inactivation with laser diode on Staphylococcus aureus biofilm with various ages of biofilm. Infectious Disease Reports. 2020;12(Suppl. 1):, S68-74.
9. Subramani SM, Anjana G, Raghavan I, Manoharan V, Joy A. Evaluation of Antimicrobial Efficacy and Penetration Depth of Various Irrigants into the Dentinal Tubules with and without Lasers: A Stereomicroscopic Study. Int J Clin Pediatr Dent. 2019;12(4):273-279.
10. Moradi Eslami L, Vatanpour M, Aminzadeh N, Mehrvarzfar P, Taheri S. The comparison of intracanal medicaments, diode laser and photodynamic therapy on removing the biofilm of Enterococcus faecalis and Candida albicans in the root canal system (ex-vivo study). Photodiagnosis Photodyn Ther. 2019;26:157-161.
11. Hendi SS, Shiri M, Poormoradi B, Alikhani MY, Afshar S, Farmani A. Antibacterial Effects of a 940 nm Diode Laser With/ Without Silver Nanoparticles Against Enterococcus faecalis. J Lasers Med Sci. 2021;12:e73.
12. Shaktawat AS, Verma KG, Goyal V, Jasuja P, Sukhija SJ, Mathur A. Antimicrobial efficacy of 980 nm diode laser on Enterococcus feacalis in conjunction with various irrigation regimes in infected root canals: An in vitro study. J Indian Soc Pedod Prev Dent. 2018;36(4):347-351.
13. Botu RK, Rachuri P, Martha S, Raparla M, Matilda S, Yemparla S. Comparative Evaluation of the Efficacy of Chlorhexidine, Diode Laser, and Saline in Reducing the Microbial Count in Primary Teeth Root Canals: An In Vivo Study. Int J Clin Pediatr Dent. 2023;16(3):459-463.
14. Walia V, Goswami M, Mishra S, Walia N, Sahay D. Comparative Evaluation of the Efficacy of Chlorhexidine, Sodium Hypochlorite, the Diode Laser and Saline in Reducing the Microbial Count in Primary Teeth Root Canals – An In Vivo Study. J Lasers Med Sci. 2019;10(4):268-274.
15. Kushwah J, Mishra R, Bhadauria V. Antibacterial Efficacy of Sodium Hypochlorite, Ozonated Water, and 980 nm Diode Laser Used for Disinfection of Root Canal against Enterococcus faecalis: A Microbiological Study. Int J Clin Pediatr Dent. 2020;13(6):694-699.
16. Goel P, Galhotra V, Makkar S, Mohan J, Bala N, Kaur T. An In-vitro Study Comparing the Antimicrobial Efficacy of 0.2% Chitosan, 3% Sodium Hypochlorite, 2% Chlorhexidine against Enterococcus faecalis, Alone and in Conjunction with Diode Laser. Int J Clin Pediatr Dent. 2022;15(1):109-114.
17. Mishra A, Koul M, Abdullah A, Khan N, Dhawan P, Bhat A. Comparative Evaluation of Antimicrobial Efficacy of Diode Laser (Continuous Mode), Diode Laser (Pulse Mode), and 5.25% of Sodium Hypochlorite in Disinfection of Root Canal: A Short Study. Int J Clin Pediatr Dent. 2022;15(5):579-583.
18. Mathew T, Bm S, Gv P, Jose J. Comparative Evaluation of the Antibacterial Efficacy of Chlorhexidine and 810 nm Diode Laser in the Disinfection of Root Canals Contaminated With Enterococcus faecalis: An In Vitro Study. Cureus. 2022;14(8):e28596.
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Semanur Özüdoğru, Fikret Özgür Coşkun, Mustafa Reha Coşkun, Mitat Şahin. Antibacterial effectiveness of combined sodium hypochlorite and diode laser therapy with different parameters against S. Aureus biofilm. Ann Clin Anal Med 2024;15(1):33-36
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Uropathogens pattern in urinary tract infections among children in Arar, Saudi arabia
Shehab Ahmed Alenazi
Department of Pediatrics, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
DOI: 10.4328/ACAM.22000 Received: 2023-09-29 Accepted: 2023-10-31 Published Online: 2023-11-10 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):37-41
Corresponding Author: Shehab Ahmed Alenaz, Department of Pediatrics, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia. Email: alenazishehabi@gmail.com P: +96 655 538 55 78 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6231-2785
This study was approved by the Ethics Committee of Northern Border University (Date: 2019-05-13, No: H-09-A-51)
Aim: The current study evaluated UTI among Saudi children in the Northern Border region regarding their predisposing factors, causative uropathogens and antibiotic sensitivity.
Material and Methods: The retrospective study enrolled children (0-14 years old) who attended to Arar Maternity & Pediatric Hospital from in 2017-2022 with discharge a final discharge diagnosis as of UTI according to following the American Academy of Pediatrics (AAP) Clinical Practice Guidelines.
Results: UTI was reported in 606 cases during the study period. It was more prevalent among boys’ male infants under one year of below the age of one year, while in girls, it was more common in girls at the age above 6 years. High- grade fever, dysuriea, foul- smelling urine and loin pain were the most commonest presentations. Recurrent UTI was reported in 30.4% of UTI cases. Constipation was the most commonest reported risk factors (32.7% of the diagnosed children). Structural anomalies were the most commonest predisposing factors among recurrent UTI cases. Escherichia coli (E.coli) and Klebsiella were the most commonest causative organisms (56.4 %, and 28.9 % of cases, respectively). Culture and sensitivity test data showed that E.coli were most sensitive to IMP, Ceftriaxone (CTR) & TZP in about 98.5 %, 84.8 % and 74.6 % of cases, respectively. While Klebsiella was sensitive to IMP, TZP & Amikacin (AMK) in about 42.3 %, 34.3 % and 33.7 % of cases, respectively.
Discussion: The Ccurrent data showed that UTI is a common health problem among children in the Northern Border region and provide insights give data intoabout its uropathogens and their antibiotic response characteristics, which can help in management plans.
Keywords: Urinary Tract Infection, Klebsiella, E.Coli, Microbial Sensitivity, Arar
Introduction
Urinary tract infections (UTI) are considered to be the a serious health problem among children; worldwide,with reported around 6 million children suffering from UTI attend consult outpatient departments and nearly 300,000 are admitted to the ward -admitted children worldwide [1]. Urinary tract infections (UTIs) are amongst the most commonest infections in children that if not timely treated, can lead to renal injury and systemic illnesses such as hypertension or even kidney failure in the future [2]. It is reported that 3% to 5% of girls develop their first attack of UTI by 5 years of age, whereas, about 1% of boys who develop their first UTI in the first year of life, especially those who have not beenare uncircumcised [3]. It is also reported that recurrent UTI also is a very common problem in pediatric patients, as it may lead to renal scarring, hypertension and even end-stage kidney disease [4]. Mainly UTI could can mainly be caused by bacteria, but other organisms could may also be responsible, e.g. viruses, parasites and fungi. Gram-negative bacteria are most common, especially E.coli, which is 70-90% responsible for 70-90% of UTIs in children [5]. Other groups of uropathogens are proteus, klebsiella, pseudomonas and actinobacter, etc., whereas only 10 % could may be Gram-positive bacteria like enterococcus, staphylococcus and strepreptococcus agalactiae [6].
As the antibiotic use has been on the rise in the recent years, the incidence of multidrug resistance among the uropathogens has increased worldwide [7]. One study showed that more than 80% of uropathogens in developing countries are now resistant to trimethoprim or trimethoprim-sulfamethoxazole [8]. Many clinicians in developing countries encountered that UTI alone could be the cause of significant morbidity and mortality [9, 10]. Several other studies have documented the emergence of resistant uropathogens and their susceptibility pattern to commonly used antimicrobial agents in order to guide the choice of empiric therapy all over the world [11,12]. As resistance rates differ worldwide against to commonly used drugs against bacterial infection differ worldwide, the knowledge of local etiology and susceptibility profile could support the most effective empirical treatment. We found very limited data about the present study in other areas of Saudi Arabia. To the best of our knowledge, there are currently no published similarat present, no such studies have been published describing the prevalence and spectrum of uropathogens in pediatric patients and their antimicrobial susceptibility patterns in the Northern Border province. Therefore, this research was conducted to investigate with the aim of investigating the prevalence and patterns of antibiotic resistance of uropathogens among pediatric patients (0-14 years) at Maternity & Pediatric Hospital, Arar city, Kingdom of Saudi Arabia.
Material and Methods
Arar city is the capital of the Northern Border region of Saudi Arabia. This study is a retrospective The current study is a retrospective study in which the medical records of children who attended to the Maternity & Pediatric Hospital in Arar and were diagnosed as with UTI between in the duration from 1st January 1, 2013 to and 31st December 31, 2018 were collected and reviewed. Were collected and studied. The study design was approved by the local bioethics committee of Northern Border University to get access to the patients’ data. Data confidentiality will bewas considered in all research steps.
The For children (0-14 years old) with a final discharge final diagnosis as of Urinary tract infection (UTI), medical records data were collected regarding their demographic data (ages and genders), clinical presentations, predisposing factors for UTI and the laboratory and radiology investigations data were collected for further analysis. Also, the microbial culture results were included with their culture and antibiotics sensitivity assays. UTI was diagnosed following the American Academy of Pediatrics (AAP) Clinical Practice Guidelines [13]., UTI was diagnosed in cases showed bothwhen ≥50,000 cfu/mL of a single uropathogenic organism was detected with a positive urinalysis (at least one of the following criteria were was found: WBC ≥5 cells/hpf, leucocyte esterase positive or presence of bacteria). In addition, patients withshowed the bacterial colony counts of 10,000–100,000 cfu/mL (with pyuria/bacteriuria in urinalysis), were also diagnosed as awith UTI. Recurrent UTI was diagnosed as with at least 3 attacks of UTI within 12 months with complete clinical resolution in between the attacks.
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
According to the medical records of Arar Maternity & Pediatric Hospital, patients records 606 children were diagnosed as with UTI during the selected study years (2017-2022). Data regards on the sex and ages of the children enrolled in the study are shown in Table (1). There was a statistically different (p=0.0002; X2=16.96, 2) prevalence of UTI between males and females patients in the different age groups. Most of the children enrolled in the study were under one year of below the age of one year. UTI showed a higher prevalence among children under one year ofbelow the age of one year (46% of the diagnosed cases). Recurrent UTI was reported in 184 cases (30.4% of UTI cases). Recurrent UTI was more common among female children (53/81 cases). Recurrent cases were mainly diagnosed at the age below 1 year (98 cases), followed by the age group 1 to 5 years, with reported 65 cases. Regarding the cases management, 338 cases were managed as outpatients (55.8%), while admission was indicated for 268 (43.2%) cases for appropriate management.
Regarding the clinical presentation of children enrolled in the study, high- grade fever, dysuriea, foul- smelling urine and loin pain were the most commonest presentations among the studied cases records (about 50%, 32%, 27.2 , and 27.1 % of cases, respectively). Clinical presentations in relation to the ages and sex of the children enrolled in the study are shown in Figure 1.
According to the patient records, the associated predisposing factors for UTI were reported in 400 cases of the children enrolled in the study. Constipation was the most commonest reported risk factors (32.7% of the diagnosed children). Constipation was the most commonest predisposing factors among children diagnosed as with recurrent UTI (55/184 cases), followed by the Structural anomalies (43/184 cases).
Regarding the bacterial isolated from urine cultures of the diagnosed cases urine culture, E.coli was the most commonest isolated bacteriuma in the cases managed in the outpatient clinics (242/338 cases), while Klebsiella was the most commonest among the admitted cases (105/268 cases).
Culture and sensitivity test in the records of the patients included in the study showed that most bacterial isolates were sensitive to Imipenem (IMP), followed by Tazobactam-piperacillin (TZP). While the lowest sensitivity was shown to Vancomycin (VAN). E.Coli isolates were sensitive to ceftriaxone in 84.8% of cases, while klebsiella isolates were mainly sensitive in around 29% of the diagnosed klebsiella UTI cases (Table 3).
Discussion
Urinary tract infection is a major health condition among children. The current study had investigated the problem among children admittedattended to Arar Maternity and Pediatric Hospital during the time period from January 2017 to December 2022 through a retrospective study of the patients records. According to the hospital patients records for the selected study years (2017-2022), 606 children were diagnosed as with UTI during the selected study years (2017-2022). A There was statistically different prevalence of UTI was revealed amongbetween males and females patients in the different age groups. UTI showed a higher prevalence among children under one year ofbelow the age of one year. Recurrent UTI was reported in 184 cases (30.4% of UTI cases) with a higher prevalence among female children (53/81 cases). Recurrent UTI was reported in 81 cases (13.4% of UTI cases) with a higher prevalence among female children (53/81 cases). Recurrent cases were mainly diagnosed at the age below 1 year. Regarding the cases management, 338 cases were managed as outpatients (55.8%), while admission was indicated for 268 (43.2%) cases for proper management. High- grade fever, dysuriea, foul- smelling urine and loin pain were the most commonest presentations among the studied cases records. Constipation was the most commonest reported risk factors (32.7% of the diagnosed children). Structural anomalies were the most commonest predisposing factors among children diagnosed as with recurrent UTI. E.coli was the most commonest isolated bacteria in the cases managed in the outpatient clinics, while Klebsiella was the most commonest among the admitted cases. Culture and sensitivity tests in the records of the patients included in the study showed that most bacterial isolates were sensitive to IMP, followed by TZP. While Tthe lowest sensitivity was shown to the antibiotic VAN.
Urinary tract infection (UTI) is the second most commonest bacterial infections of in childhood after middle ear infections. Among febrile infants and children with urinary symptoms, 6%–8% were shown to be UTI [6,14]. Prevalence varies with age and gender. The current data showed that UTIs are higher among female children and infants. This is in accordance with other studies, which showed that UTI prevalence varies with age, peaking in young infants and toddlers. With The higher prevalence reported among females [6], this can be explained by the shorter female urethral distance from the foreskin surface area in females. Also, UTI is significantly higher among the uncircumcised boys (21%), while UTI was reported only in 2% of circumcised boys and 5% of girls during the first year of life [15]. During toddler years, toilet training can lead to volitional holding and bladder stasis, promoting UTIs [16]. Regarding the recurrence of UTI, the current study ratio (30.4%) is the same as the early reported by Karen et al. (2015) [17].
Constipation was the most commonest reported risk factors (32.7% of the diagnosed children). Structural anomalies were the most commonest predisposing factors among children diagnosed as with recurrent UTI. This is in aggreemment with the previously published data showing that impaired urine with urinary stasis, is associated with higher rates of UTI. The impaired normal voiding may be due to structural urinary tract congenital anomalies or functional disorders such as neurogenic bladder, constipation and behavioural withholding [16]. Common risk factors for recurrence include also vesicoureteralvesicoureteric reflux and bladder and intestinal dysfunction were considered as leading risk factors for recurrent cases of UTI [17].
The current data showed that E.coli was the most commonest isolated bacteria in the cases managed in the outpatients, while Klebsiella was the most commonest among the admitted cases. Hameed et al. (2019) [18] reported that E. coli is the most common cause of community-acquired UTIs in children causing three-quarters of all infections in a tertiary hospital in Riyadh, Saudi Arabia. Also, another regional study about children with UTI from Oman showed that E. coli, was responsible for about two-thirds of all diagnosed UTIs among children, while K. pneumoniae was the second most common isolated uropathogen. Internationally, most pediatric UTIs are caused by Gram- negative coliform bacteria [16]. Escherichia coli (E.coli) was has been reported to be found in bacterial cultures of about 80% of UTI cases among children as they have their characteristic fimbriae to that attach to the uroepithelial cell surface, to overcome being flushed by the normal vioiding of urine. Other reported common uropathogens include Klebsiella, Proteus, Enterobacter and Enterococcus species [4,19].
Regarding to the current culture sensietivity data, E.coli and K. pneumonia showed the highest patterns of resistant to the tested antibiotics. E.coli was found to be resistant to co-trimoxazole and amoxicillin/clavulinic acid in about 86.4% of the E.coli UTI cases. This findidng minimizes the role of these antibiotics as empirical therapy for community-acquired UTIs. Also, third- generation cephalospsorin ceftriaxone showed very potent effect against E.coli with a reported 85% sensietiviety, which supports its use as an antibiotic of chioice for empirical therapy of UTI cases. This finding is supportedig to by Hameed et al.’s study (2019) [18] study concluison in Riyadh. While K. pneumonia showed the highest sensietiviety to IMP (around 40% of the diagnosed cases only).
There are The several strengths of our study as is that it was based on a long study duration of five years to investigate properly the burden of the problem of UTI in the Northern Border region of Saudi Arabia with strict inclusion criteria in for diagnosis of UTIs based on AAP definition (positive urinalysis and urine culture).
Limitations
The main limitation of this study is mainly due to beingits retrospective design with some lack of shortage in data recording in some patients files, which were excluded from the current study scope.
Conclusion
The reported data clarify, for the first time, the burden of the problem of UTI problem among the children in Arar. Urinary tract infections were more prevalent among boys’ male infants under one year of below the age of one year, while in girls, itthey weres more common in girls at the age above 6 years. High- grade fever, dysuriea, foul- smelling urine and loin pain were the most commonest presentations. Recurrent UTI was reported in 30.4% of UTI cases. Constipation was the most commonest reported risk factors. Structural anomalies were the most commonest predisposing factors among recurrent UTI cases. Escherichia coli (E.coli) and Klebsiella were the most commonest causative organisms. Culture and sensitivity test data showed that E.coli were most sensitive to IMP, Ceftriaxone (CTR) & TZP, While Klebsiella was sensitive to IMP, TZP & Amikacin (AMK).
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.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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3. A‘t Hoen L, Bogaert G, Radmayr C, Dogan HS, Nijman RJ, Quaedackers J, et al. Update of the EAU/ESPU guidelines on urinary tract infections in children. J Pediatr Urol. 2021;17(2):200-7.
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7. Lee DS, Lee SJ, Choe HS. Community-acquired urinary tract infection by Escherichia coli in the era of antibiotic resistance. BioMed Res Int. 2018;2018. DOI: 10.1155/2018/7656752.
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Shehab Ahmed Alenazi. Uropathogens pattern in urinary tract ınfections among children in Arar, Saudi arabia. Ann Clin Anal Med 2024;15(1):37-41
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Synergistic effect of ferulic acid and caffeic acid on metabolic syndrome and immune response in rats
Nesrin I. Tarbiah 1, Fares K. Khalifa 1,2, Nuha A. Alkhattabi 1, Abeer A. Banjabi1, Reem F. Ghazali 3, Reem Y. Alzahri 4, Norah Abdu Almerabi 5, Ahd A. Mansour 6
1 Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia, 2 Department of Biochemistry and Nutrition, Faculty of Women for Arts Science and Education, Ain Shams University, Cairo, Egypt, 3 Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, 4 Department of Biology, College of Science, University of Jeddah, Saudi Arabia, 5 Department of Pharma. D, Faculty of Pharmacy, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia, 6 Department of Medical Laboratory Sciences, MLS program, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
DOI: 10.4328/ACAM.22005 Received: 2023-10-05 Accepted: 2023-11-13 Published Online: 2023-11-15 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):42-46
Corresponding Author: Nesrin I. Tarbiah, Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia. E-mail: ntarabah@kau.edu.sa P: +96 650 567 12 53 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8706-2663
This study was approved by the Ethics Committee of Ain Shams University evaluated and approved the experimental procedures of this study (Date: 2023-03-01, No: sci1432309001)
Aim: The aim of the study is to evaluate the synergistic modulatory effects of ferulic acid (FA) in combination with caffeic acid (CA) on the immune response and metabolic syndrome in male rats fed high-fat diets (HFD).
Material and Methods: Forty-five adult male albino rats (Sprague-Dawley) were divided into five groups: G1, controls fed basal fat diet (BFD); G2, high-fat modified diet containing 20% fat (HFD); G3, rats fed HFD and received FA (150 mg/day) orally; G4, rats fed HFD supplemented with CA (0.8 g/ 100 g diet), and G5, Rats fed HFD and received both FA (150 mg/day) and CA (0.8 g/ 100 g diet).
Results: Serum concentrations of TG, TC, LDL-c, glucose, insulin, oxidative stress biomarkers, and proinflammatory cytokines were elevated in rats fed a high-fat diet compared with the BFD group. Significant adjustments were observed after the administration of FA and CA. The maximum improvement was viewed in rats administered with CA in combination with FA.
Discussion: FA and CA significantly counteracted the pronounced oxidative stress effect of HFD by the inhibition of lipid peroxidation, restoration of antioxidant status, and metabolic syndrome biomarker levels. In conclusion, these findings indicate the synergistic protective effect of FA and CA on risk factors that can lead to metabolic syndrome and immune response imbalance during HFD-associated oxidative stress in rats.
Keywords: High-Fat Diet, Metabolic Syndrome, Immune Response, Oxidative Stress, Caffeic Acid, Ferulic Acid, Phenolic Acids
Introduction
Metabolic syndrome (MetS) is a condition where the body metabolizes proteins, fats, carbohydrates, and other substances in a disorderly manner. It is characterized by a combination of risk factors, including diabetes, high cholesterol levels, high blood pressure and obesity [1]. The primary culprits behind MetS are lifestyles and unhealthy eating habits like consuming high-calorie diets. It is proved that 20 -30% of adults are affected by MetS [2]. Therefore, it is crucial to identify strategies to combat this issue. Extensive research has demonstrated that incorporating wholegrain foods and dietary fiber into our diets can have positive impacts on lowering the risk of MetS and its correlated disorders [3].
Nutritional supplements frequently contain phenolic acids, like caffeic acid (CA) and ferulic acid (FA), which are characterized by antioxidant properties, hypoglycemic, hypolipidemic [4,5], anti-inflammatory, and immunomodulatory roles [6]. FA is a phenolic acid compound, found in cereals, fruits, vegetables, and other edible plants [7]. It is recognized for its anti-inflammatory properties, which contribute to its ability to perform several beneficial functions in the body. These include regulating glucose tolerance and lipid metabolism, which leads to improving liver health [8].
CA is a secondary metabolite that is derived from natural sources, such as olives, berries, potatoes, and carrots, also it is predominantly obtained from coffee beans. It belongs to the family of hydroxycinnamic acid, which is a major constituent of the daily human diet [9]. Numerous in vitro and in vivo experiments demonstrated that CA possesses anti-atherosclerotic, immunostimulant, cardioprotective anti-proliferative benefits [10] as well as its ability to improve inflammation and oxidative stress in chronic metabolic diseases. The strategy of synergistic effects aims to enhance potency through treatment with a combination of therapeutic agents. Successful combinations involving agents and natural products can effectively attain desired outcomes while reducing toxicity levels [11]. Based on this, the aim of this study is to examine the synergistic modulatory effects of FA in combination with CA on the immune response and MetS in male rats fed high-fat diets (HFD).
Material and Methods
Ethical approval
The study was conducted from March 2023 to May 2023. The Research Ethics Committee of Ain Shams University evaluated and approved the experimental procedures of this study (Code sci1432309001) before starting the experiment (1 March 2023).
Chemicals
CA (≥95%) was purchased from Sigma-Aldrich (St Louis, MO, USA.). FA (purity >98%) was purchased from Source Naturals Co., Miami, FL, USA. Commercial assay kits including glucose, total cholesterol (TC), triacylglycerols (TG), high-density lipoprotein-cholesterol (HDL-c), low-density lipoprotein-cholesterol (LDL-c), free fatty acid (FFA) were obtained from Siemens Healthcare Diagnostics, USA. Malondialdehyde (MDA), superoxide dismutase (SOD), and reduced glutathione (GSH) kits were purchased from BioVision Inc. Co., USA. Insulin, tumor necrosis factor-α (TNF-α), nuclear factor kappa B (NF-kB), interleukine-6 (IL-6), and interferon-γ (IFN-γ) were analyzed by enzyme-linked immunosorbent assay (ELISA) kits obtained from BioVision Inc. Co., USA. Also, pyruvate carboxylases (PC) assay colorimetric kits, and phosphoenol pyruvate carboxy kinase (PEPCK) were purchased from (BioVision Inc. Co., USA).
Animals and Experimental Design
Fifty adult male albino rats (Sprague-Dawley) weighing 127.2-134.3 g were used in this study. Animals were kept in stainless steel cages in an air-conditioned animal house at 24°C and fed a basal diet, allowed water ad libitum throughout the experimental period (8 weeks). The rats were randomly divided into five groups (10 rats/group) as follows:
G1: Rats fed a basal fat diet (BFD).
G2: Rats fed a high fat diet (25%) (HFD).
G3: Rats fed HFD and received FA (150 mg/day) by oral gavage (HFD+FA).
G4: Rats fed HFD supplemented with CA (0.8 g /100 g diet) (HFD+ CA).
G5: Rats fed HFD supplemented with CA (0.8 g /100 g diet) and FA orally (150 mg/day) (HFD +FA + CA).
Sample Collection and Biochemical Assessment:
After eight weeks, blood was drawn from the hepatic portal vein of ether-anesthetized rats that had fasted overnight. Blood tubes were centrifuged at 4000 x g for 15 minutes at 25°C to separate the serum. Serum samples were collected in sterile plastic tubes and kept frozen at -20 ºC for later biochemical testing. The liver was separated, rinsed, and washed with saline solution (NaCl 0.9%), then blotted on filter paper. The liver was rapidly freeze-clamped and stored at -20 ºC for liver enzyme analysis. Liver enzymes (PC and PEPCK) and serum biochemical parameters were determined according to analytical methods. The oral glucose tolerance test (OGTT) was operated on with oral gavage of glucose (2 g/kg b.w.) after 12 hours of fasting on the first day of week eight. Blood glucose concentrations were monitored by the tail blood using a glucometer with one-touch ultra test trips at 0 (before glucose infusion), 30, 60, 90, and 120 (post-infusion) of gavage.
Statistical Analysis
Data were statistically evaluated. Data were presented as mean ± standard error of the mean (SEM), and one-way analysis of variance (1-way ANOVA) test. Differences were considered significant at P ≤ 0.01.
Results
Serum concentrations of TG, TC, and LDL-c were elevated significantly (p≤0.01) in rats fed a high-fat diet compared with the BFD group and gradually normalized by FA and CA supplementation. The level of serum HDL-c was significantly lowered (p≤0.01) in the HFD group compared to BFD and gradually increased by adding FA and CA (G3-G5). The maximum improvement in serum levels of lipid profile was observed in rats administered with CA in combination with FA (Figure 1). Glucose administration raised glucose levels after 30 minutes. Then, it gradually returned to baseline levels within 90 minutes. However, when rats were fed HFD for 56 days, their glucose levels peaked at 30 minutes after receiving glucose. All groups showed normalized blood glucose levels within 60-90 minutes except for rats fed a high-fat diet (G2). However, when CA was supplemented alone or in combination with FA, blood sugar levels significantly approached normal levels (Figure 2). HFD rats had significantly increased serum FFA, fasting glucose and insulin levels compared with the BFD group (p≤ 0.01). Supplementation of FA combined with CA significantly lowered the values of FFA, glucose and insulin by 45.2%, 26.6 and 22.1.1%, respectively compared with HFD rats (Table 1). Results revealed the reduction of hepatic PC and PEP-CK activities in rats fed HFD (by -28.3% for PC, and -41.3% for PEPCK, respectively) compared to control rats. Supplementation with FA and CA modulated the activities of both enzymes as compared to rats fed a high-fat diet. The maximum improvement in liver activities of both enzymes was observed in rats fed a diet supplemented with CA in combination with FA (by +42.1% for PC, and +58.3% for PEPCK respectively) compared with the HFD group (Table 2). In this study, SOD activity was significantly decreased (p≤ 0.01) in HF diet-fed rats compared to the control group. Serum levels of MDA, GSH, and SOD activities were significantly (p ≤ 0.01) restored by CA and FA supplementation compared with HF diet-fed rats (Figure 3). Compared with the control group, an apparent increase of the values of IFN-γ, TNF-α, IL-6, and NF- kB was observed in the HFD group by 3.5, 2.7, 2.4 and 2.2-fold, respectively. The levels of IFN-γ, TNF-α, IL-6, and NF-kB displayed a significant decrease after administration with FA separately or combined with CA. The results postulated that FA combined with CA exhibited an improving effect in HFD-caused inflammation in rats (Table 3).
Discussion
High-fat and high-energy diet is widely recognized as a factor contributing to the onset of various health issues. This study demonstrates that rats administered HFD suffered from glucose intolerance, dyslipidemia, and oxidative stress in their livers with a parallel increase in serum glucose and lipid levels, including cholesterol and triglycerides levels. Dyslipidemia refers to abnormal levels of lipids circulating in the body [12].
Meanwhile, supplementing FA and CA decreased serum lipid levels in the rat group fed high fat, thus avoiding glucose intolerance. Supplementation of CA combined with FA also reduced oxidative stress and lipid peroxidation in both serum and liver by repairing the cellular antioxidants.
Hyperglycemia-related oxidative stress is considered as one of the main reasons for metabolic and hormonal imbalances. Overnutrition may result in insulin resistance in tissues, which generally respond to insulin for glucose uptake [13]. Over time this resistance leads to increased fasting glucose levels and diminished insulin-mediated glucose clearance. As a result, there will be negative feedback signaling inadequate insulin response prompting the pancreatic β-cells to produce more insulin. If this state of insulin resistance persists without correction it eventually causes hyperglycemia and type 2 diabetes that leads to type 2 diabetes [14].
Administering CA and FA enhanced glucose utilization in the current study, as shown by OGTT results, and the results are supported by previous experiments [15]. It was suggested that FA diminished HFD-induced glucose synthesis possibly by suppressing glucose-6-phosphatase, consequently slowing hepatic gluconeogenesis. Furthermore, PC and PEPCK are considered as key enzymes that regulate hepatic gluconeogenesis and glucose production. Results of the present study showed that CA and FA displayed tremendous synergistic effects on modulation of the glucose metabolism by management of PEPCK and PC activities in high fat-fed rats. Son et al. [16] exposed that FA boosted the level of glycogenesis by decreasing PEPCK levels. These results suggest that FA can adjust glucose homeostasis by restoring hepatic glucose metabolism disturbance. A previous study showed that administrating FA reduced insulin resistance and diminished levels of TG, free fatty acids, cholesterol, and phospholipids in rats fed HFD. In addition, the modulatory effect of FA on lipid homeostasis was correlated to decreased lipogenic enzymes such as fatty acid synthase and acetyl-CoA carboxylase [8].
CA elevated insulin sensitivity by reducing proinflammatory cytokines and increasing adiponectin under the hyperglycemic state. One previous work showed that MetS diet in rats increased blood glucose, TG, and LDL-c, and decreased the HDL-c, the group that received CA showed a reduction in serum insulin, TNF-α, and IL-6. Similarly, CA-supplemented rat groups showed the highest liver levels of SOD, CAT, and GPx antioxidant enzymes, after four weeks of caffeic acid administration compared to FA, gallic acid, and protocatechuic acid [17]. This suggests that CA showed high scavenging activity and effectiveness among the recorded phenolic acids that keep against hyperglycemic injuries.
In a recent in vivo study, CA supplementation reduced body weight and prevented fat accumulation on HFD obese mice exposed that CA was able to reduce body weight and fat accumulation also it improved lipid profile with an increased HDL-c [18]. This suggests that CA is capable of reducing FFA production, thus demonstrating its hepatoprotective capability. Results showed that the co-treatment of FA and CA was able to reduce the serum level of TC by 47.1% from the positive control group (HFD), which was much higher than the mono treatment groups (FA by 29.2% and CA by 36.3%). Similarly, the combination of FA and CA reduced the serum level of LDL-c by 47.1% versus 31.1% by FA and 24.5% by CA. Thus, both CA and FA exhibited excellent synergistic effects on modulation of the lipid profile in high-fat-fed rats.
CA has shown potential antihyperglycemic effects. It also possesses antioxidant and anti-inflammatory properties. The protective effects of CA may be attributed to its ability to activate and defend cellular antioxidant enzymes due to its role in transferring hydrogen atoms and single electrons while also chelating metal ions [19]. As demonstrated in the current study, rats fed a high-fat diet had higher levels of the lipid peroxidation product MDA. The decreased SOD activity and GSH observed in the current study could be related to the rise in oxidative stress. According to the findings of this study, there was an increase in MDA levels in rats fed a high-fat diet. This increase was linked to the reduction in activities of SOD and GSH. These results agreed with studies, which suggested that the tissue antioxidant defenses may be compromised when animals are fed a high-fat diet [20].
Administrating FA clearly reduced the MDA production and boosted antioxidant enzymes (SOD and GSH) activities, this enhances scavenging free radicals [21], helping to reduce lipid peroxidation and oxidative stress caused by HFD in the liver. Additionally, the levels of TNF-α, NF- kB, and IL-6 were significantly reduced after FA consumption. Additionally, FA may decrease lipid peroxidation, resulting in decreased levels of MDA and LDL-C [22].
Inflammation develops after ingestion of HFD in the peripheral tissues including the liver, adipose tissue, and skeletal muscles. Alterations in the gut microbiota brought on by HFDs and direct effects of FFAs on intestinal cells may be the initial step in the development of chronic systemic inflammation. The second step may involve increasing intestinal lipopolysaccharide (LPS), pro-inflammatory cytokines, and FFA transport into the systemic circulation and portal circulation, which would result in systemic low-grade inflammation [23]. Elevated serum FFAs and LPS can upregulate the expression of Toll-like receptors in circulating macrophages, allowing macrophage activation, which in turn produces pro-inflammatory cytokines.
In the inflammatory process, cytokines are crucial mediators in the body’s immune response. An extremely crucial factor in determining the proper immune response is the interaction between pro-inflammatory and anti-inflammatory cytokines throughout homeostasis and inflammation associated with diseases. The results of the present study showed that HFD resulted in a significant increase in IFN-γ, TNF-α, IL-6, and NF- kB serum levels. IFNγ is predominantly produced by natural killer T cells during the innate immune response and by CD4+ T helper (Th1) cells and CD8+ cytotoxic T cells in the humoral immune response, that are essential for the detection of tumor cells, immunoregulation, and inflammation [24].
Our experimental results demonstrated that each of CA and FA showed a strong synergistic antioxidant and anti-inflammatory activity. The immunomodulatory role of antioxidants is demonstrated in the capability of these molecules to influence important signaling pathways responsible for inflammation. NF-kB regulates the expression of many genes directly related to inflammation. According to recent research, certain polyphenols can alter the activity of NF-kB and lessen cellular inflammation [25]. Suppression of NF-kB is dependent on the action of polyphenolic compounds. The reduction of the expression of certain pro-inflammatory cytokines is one of the most prevalent ways in whereby polyphenols exert their immunomodulatory effects.
Conclusion
Several disease conditions primarily require combination therapy due to their complex pathophysiology and progression. The combination of CA with different compounds has been widely examined for various types of disorders. CA, owing to its free radical scavenging property, was able to increase the antioxidant efficacy of agents such as FA for better treatment outcomes. As the results of the present study showed, CA was exhibited to be synergistic with FA for modulation of MetS and immune response. Through this study, we can conclude that CA and FA possess excellent promise for managing MetS through their anti-obesity properties, and antidiabetic, and hypolipidemic, activities. Although there are a lot of studies on CA and other phenolic acids, no previous research indicated that CA and FA had synergistic effects against immune disturbance and metabolic implications induced by HFD.
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 compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Nesrin I. Tarbiah, Fares K. Khalifa, Nuha Alkhattabi, Abeer Abdalrahman Banjabi, Reem F. Ghazali, Reem Y. Alzahri, Norah Abdu Almerabi, Ahd A. Mansour. Synergistic effect of ferulic acid and caffeic acid on metabolic syndrome and immune response in rats. Ann Clin Anal Med 2024;15(1):42-46
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Evaluation of nutritional status of patients with gastrointestinal system tumours receiving chemo-radiotherapy
Nazan Son 1, Ezgi Atıcı 2
1 Department of Nutrition and Dietetics, Faculty of Health Sciences, Anadolu University, Eskisehir, 2 Department of Nutrition and Dietetics, Ceylan Hospital, Bursa, Turkey
DOI: 10.4328/ACAM.22006 Received: 2023-10-05 Accepted: 2023-11-06 Published Online: 2023-11-14 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):47-51
Corresponding Author: Nazan Son, Department of Nutrition and Dietetics, Faculty of Health Sciences, Anadolu University, Eskisehir, Turkey. E-mail: nazanson@gmail.com P: +90 505 448 14 41 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3614-3604
This study was approved by the Ethics Committee of Okan University (Date: 2021-01-27, No: 132)
Aim: This study was planned to examine the nutritional problems of patients diagnosed with gastrointestinal tract (GIS) cancer and to evaluate the effects of professional nutritional support on the outcome of their treatment.
Material and Methods: This study was carried out with 24 (33.3% females, 66.7% males) volunteer participants aged 18 and above, who were diagnosed with GIS cancer and planned to have concurrent chemotherapy and radiotherapy treatment (chemoradiotherapy=CRT). The participants were asked, questions on socio-demographic characteristics and nutritional habits, anthropometric measurements were taken, biochemical data were recorded, Subjective Global Assessment (SGA) and Mini Nutritional Assessment (MNA) scales were applied, and nutritional training deemed necessary were given to them. The participants were re-evaluated after three months and the data were compared with the initial findings.
Results: There was no significant difference between the pre-and post-treatment Body Mass Index (BMI). A significant difference was found between the SGD and MNA values before and after CRT (p=0.000).
Discussion: In cancer patients, alongtogether with the medical treatment plan, the patient’s nutritional evaluation and providing giving the necessary Medical Nutrition Therapy (MNT) enable the individual to act consciously. Increasing the level of nutritional awareness makes it easier for an individual to fight the disease while increasing the effectiveness of treatment. In conclusion, it should be noted that a dietitian should be available in institutions providing care to cancer patients should have a dietitian.
Keywords: Gastrointestinal Cancer, Nutrition, Malnutrition, Subjective Global Assessment, Mini Nutritional Assessment.
Introduction
Cancer is among the most important health problems all over the world. It is known to be theranked second leading among the causes of death in the world [1-3]. The causes of cancer can be grouped under two headings as environmental and genetic causes. For example; Smoking, consumed food and beverages, obesity, hormones, viruses, physical and chemical agents are some of the environmental factors. [4]. According to data from the International Agency for Research on Cancer in 2018, 18.1 million people have beenwere diagnosed with cancer worldwide, and it is estimated that 24 million people will have cancer in 2035 [3]. According to Globocan 2020 data, GIS cancers are the leading cause of cancer-related death. In 2020, 5 million new GIS cancer diagnoses were causeding approximately 3.5 million deaths [4]. While the population of Turkey was 84.339,067 in 2020, a total of 233,834 new cancer cases were detected in the same year. Of this number, 126,335 resulted in death [5].
There are five main treatment options in cancer treatment: chemotherapy, radiotherapy, surgical treatment, immunotherapy, and hormone therapy. In recent years, the application of concomitant CRT has becomeis an important practice in cancer treatment. This practice has become a standard treatment for advanced cancer types [6]. Many cancer treatments affect patients’ appetite, food intake, and the use/absorption of nutrients in the body. Especially in patients who have undergone gastrointestinal surgery, malabsorption of nutrients develops since swallowing and gastrointestinal motility are affected [7]. The purpose of MNT in cancer patients is to prevent and treat nutritional deficiencies, reduce the side effects of treatment, prevent weight loss, support the effectiveness of cancer treatment, reduce the rate of complications and mortality, and improve quality of life [8]. Personalized nutrition training has been reported to increase the patient’s food consumption and quality of life, and reduce the complications related to the disease in cancer patients who cannot have enough nutrients [4,7]. Therefore, this study was conducted to evaluate the effectiveness and necessity of MNT given to patients who have been diagnosed with GIS cancer before starting CRT treatment.
Material and Methods
The population of this prospective cohort study consisted of patients who were newly diagnosed with GIS cancer in Bursa Ali Osman Sönmez Oncology Hospital between 01 March 2021 and 01 June 2021. The study was carried out with a total of 24 patients, 8 females (33.3%) and 16 males (66.7%) aged 18 years and older, who were diagnosed with GIS cancer and were scheduled for CRT treatment. Before the treatment, all patients were given nutritional training and nutritional follow-up of the patients was carried out. Patients over 85 years of age and those with the presence of metastases were not included in the study.
The same Dietitian has givengave nutrition training to the participants individually before the treatment and their nutrition follow-ups were carried out.
Socio-demographic Data Collection Form included questions about gender, age, weight, height, education level, occupation, monthly income, presence of additional disease and physical activity levels of the patients, and their BMI values were calculated and evaluated with the data obtained from this form.
Eating Habits Questionnaire Form included questions about the number of main and snack meals consumed by the patients, whether they skipped meals, what type of food they consumed between main meals, and the frequency of eating outside the home in order to evaluate the nutritional status of individuals. Furthermore, the three-day food consumption of the patients was recorded with the form created and evaluated by the same dietitian.
Anthropometric measurements of the participants were taken as per the standards. The body weight (kg), height (cm), triceps skinfold thickness (TSF), mid-upper arm circumference (MUAC), and Midarm Muscle Area (MMA) measurements of the participants were taken and recorded by the researcher.
Collection of biochemical parameters: Total protein, Albumin, Hemoglobin, total cholesterol, HDL cholesterol (mg/dL), LDL-cholesterol (mg/dL), Triglycerides, C-reactive protein (CRP), CEA, CA19-9, and white blood cell (WBC), SGOT(BOTTOM), SGPT(AST), fasting blood glucose, urea, creatinine, calcium, iron and vitamin B12 values of the patients have beenwere obtained from the patient files and recorded.
Scales applied to participants:
The MNA was developed by Vellas et al. [9]. The Turkish validity and reliability study of the scale was carried out by Sarıkaya in 2013 [10].
The SGD was developed by Detsky et al. to assess malnutrition status. It consists of two parts: dietary history and physical examination. In the scoring of the scale, SGD-A indicates normal nutritional status, SGD-B suspected malnutrition and SGD-C severe malnutrition [11].
Statistical analysis of data:
Analysis of the data was performed with the SPSS 25.0.0 program, while numerical variables were measured with mean ± standard deviation and lower-higher, categorical variables were shown as numbers and percentages. “Wilcoxon signed-rank test” was used for quantitative initial measurement and final measurement comparisons. The level of statistical significance was determined as p<0.05.
Ethics Committee Approval
Ethics Committee approval for the study was obtained on 27.01.2021 from the Ethics Committee of Okan University.
Results
Of the 24 study participants in the study, 33% were female. The mean age was 60.13±11.72 years. The educational status of the participants was as follows: 45.8% were primary school graduates, while 20.8% were university graduates. The mMonthly incomes of 12.5% of the participants wasere 2500 TL or less, 45.8% had a monthly income of were between 2501-5000 TL, 33.3%: were between 5001-10000 TL, and 8.3%: were 10001 TL and above. Among the participants, 45.8% of them did not have any chronic disease. When the daily physical activity levels were examined, 54.2% of the participants were found to perform physical activity. 16.7% of the participants actively smoked and 20.8% of social drinkers consumed alcohol. A total of 70.8% of the participants had an immediate family member who was diagnosed with cancer. The Iinformation about the nutritional habits of the participants is as follows. While 50% of the participants have had two main meals, 50% have had three main meals a day. Of these, A total of 37.5% of them hadve one snack a day, 25% had two and 8.3% had three snacks. While 25% of the participants preferred candy, chocolate and wafers as snacks, 16.7% of them consumed bagels, biscuits, and cookies and 12.5% of them consumedhave carbonated drinks and soda water. Ready-made food is was consumed by 41.7% of the participants.
The findings regarding the comparison of the anthropometric characteristics of the participants before and after CRT are presentedgiven in Table 2. There was no statistically significant difference between the body weight and mean BMI values of the participants (p>0.05).
The only Only a statistically significant difference was found between the midarm muscle circumference values of the participants before CRT and after CRT (p=0.016).
There was no statistically significant difference in the biochemical parameters of the participants before and after CRT, except for the ferritin value (p=0.026).
As per the SGD, the results of the participants before CRT were found to be 50% SGD-A, 29.2% SGD-B, 20.8% SGD-C, and after CRT, 54.2% of them were found to be SGD-A, % 37.5% SGD-B, and 8.3% to SGD-C. According to the MNA, before CRT, 12.5% of the participants were found to have malnutrition, 45.8% were at risk of malnutrition, 41.7% were in the normal nutrition group, while 8.3% had malnutrition, 37.5% were at risk of malnutrition and 54.2% of them had normal nutrition after CRT. A significant difference was found between the SGD and MNA values of the participants before and after CRT (p=0.000). (Table 1).
Correlation of participants’ daily calorie intakes, BMI, and MNA values before and after CRT, Nno significant relationship was found between the daily calorie intake, BMI and MNA levels of the participants before and after CRT (p>0.05) (Table 3).
Discussion
Malnutrition, poor nutrition and muscle loss are frequently observed in cancer patients. This condition negatively affects the clinical results of patients and leads to an increase in the length of their stay in the hospital [12]. This study was planned to evaluate how nutritional status before and after CRT in individuals with GIS cancer and professional support affect the treatment.
Some studies have reported that gender-specific cancer It has been reported in some studies that the incidence of cancer in terms of gender in Turkey is higher in males than in females [13]. In some studies conducted in different countries of the world, the incidence of cancer has also been reported also to be higher in males compared to females [14-15]. The fact that the majority of the participants in our study were male supports this literature finding. There are studies reporting that low socioeconomic [14,16] and low educational status [16] trigger the incidence of cancer. Our results have been in line with this information.
It is noted in the literature that patients with a family history of gastrointestinal cancer tend to be diagnosed with cancer at a younger age than those without [15]. Among our study the participants of our study, 70.8% of them had an immediate family member who hads been diagnosed with a type of cancer.
Half of the participants in our study stated that they skipped a main meal daily. Similar to our study results, two different studies reported that almost half of the participants skipped one of the main meals [17]. But, in our study, the daily calorie consumption and macronutrient distribution of the participants before and after CRT were similar, and no statistically significant difference was found (p>0.05).
Malnutrition is closely associated with a worse prognosis and poor quality of life [18]. In the ir study by Demirel et al. conducted with patients with head and neck cancer in our country, Demirel et al. they found a significant relationship between SGD and MNA (p˂0.001) [19].
In our study, the mean MNA score of the participants before CRT was 21.38±4.30, while it was 23.42±3.67 after CRT, and a significant difference was found between the scores (p=0.008). This changing situation in favour of the participants shows that individuals consume food consciously to meet their daily energy needs, despite the side effects that may develop due to CRT. This also shows us that patients care about nutritional advice about coping with the disease, and they act diligently and consciously on their own. It also indicates that they have been in compliance with the treatment. The results of our study emphasize the importance of MNT.
In the study conducted by Hong et al. with the participants who were treated for cancer, they reported finding lower TST values in male participants, and lower MUAC, MMC, and MMA values in both male and female participants compared to the baseline values [20]. In our study, while the MUAC value of the participants did not change, the MMC and MMA values increased (Table 2). This was believed to be due to the fact that the participants were able to continue their daily activities as a result of their compliance with MNT and feeling well during the treatment process.
Biochemical Characteristics of Patients Before and After CRT:
Many biochemical parameters need to be evaluated before a malnutrition diagnosis can be made. It can play an important role in the diagnosis of the disease at an early stage [21].
In the study of by Kabata et al., the albumin value of the participants was 3.8, total protein value was 7 (4.5-7.9) [22];, Lee et al. was found that total protein was 5.8 (4.5-7.9) [23]. In our study, total protein ıt was found to be total protein 63.95±28.19 (64-83) before CRT, while it was 64.92±10.15 after CRT.
It was proven in a meta-analysis study that a low haemoglobin value causes a poor prognosis [24]. In our study, the haemoglobin value of the participants was found to be higher than the value before CRT. The CRP level of the participants was found to be high in our study. Inflammation in some tissues with the development of cancer or an increase in CRP level may be observed as the body’s immune response [24].
In another study conducted with a total of 4707 patients and Huang et al. Were associated with inflammatory markers ferritin and CRP [25]. Apart from CRT, the level of iron in the blood is also affected by liver diseases and inflammation [1]. There was a statistically significant difference only in the ferritin value among the biochemical parameters of the participants before and after CRT in our study (p=0.026). This difference was in favour of the patients and in the direction of increase. No significant difference was observed in other data.
Conclusion:
our study results once again revealed the importance of MNT in cancer patients. Having a Nutritionist in the units providing oncology healthcare services and giving the necessary MNT to the patients would not only enable faster improvements in the health parameters of the patients but would also increase their quality of life. It would also contribute to the economy of the countries by reducing treatment costs.
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.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Download attachments: 10.4328.ACAM.22006
Nazan Son, Ezgi Atıcı. Evaluation of nutritional status of patients with gastrointestinal system tumours receiving chemo-radiotherapy. Ann Clin Anal Med 2024;15(1):47-51
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Three-dimensional anatomical modeling of cases with atrial septal defect and ventricular septal defect, which are congenital heart anomalies
Ömer Göç 1, Mehmet Salih Aydın 2, İsmail Demircioğlu 3, Reşat Dikme 1, Osman Tunç 4
1 Department of Perfusion Techniques Program, Faculty of Medicine, Harran University, Şanlıurfa, 2 Department of Cardiovascular Surgery, Faculty of Medicine, Harran University, Şanlıurfa, 3 Department of Anatomy, Faculty of Veterinary, Harran University, Şanlıurfa, 4 BTECH Company, METU Technocity, Ankara, Turkey
DOI: 10.4328/ACAM.22009 Received: 2023-10-06 Accepted: 2023-11-06 Published Online: 2023-11-14 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):52-56
Corresponding Author: Ömer Göç, Department of Perfusion Techniques Program, Vocational School of Health Services, Harran University, Şanlıurfa, Turkey. E-mail: omergoc@harran.edu.tr P: +90 505 351 41 05 F: +90 414 318 32 09 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3047-6232
This study was approved by the Ethics Committee of Harran University (Date: 2020-12-07, No: HRU/20.21.06)
Aim: In this study, surgical approaches were determined by making 3D anatomical modelling of paediatric cases with congenital atrial septal defect and ventricular septal defects using computed tomography data.
Material and Methods: Computed Tomography Angiography data from ten male and ten female patients with congenital atrial septal defect and ventricular septal defect were utilizsed in the present study. After obtaining the computed tomography images of the patients in DICOM format, 3D anatomical modelling was built by transferring them to the three-dimensional modelling software MIMICS 20.01 (The Materialise Group, Leuven, Belgium). Then, 3D printers generated a 3D-printed heart model.
Results: The intracardiac and vascular structures of different types of congenital heart diseases, such as atrial septal defect and ventricular septal defect were imaged through the 3D organ models. Then, conclusions were drawn about interventional or surgical procedures that can be followed for the restoration of atrial septal defect and ventricular septal defect.
Discussion: The three-dimensional modelling of the intracardiac structure, performed in this study, enables better imaging of the defects or pathologies and easier follow-up of the the course of the disease and provides great support to the preoperative planning of paediatric cardiologists and cardiac surgeons. Thisese modelling helps to observe the risks of complicated surgeries in more detail. This allows to identify operational risks and take surgical actions and the duration of the operation can be shortened through patient-specific planning. When cumulatively assessed, this method reduces the costs. Another significant advantage of these outcomes is their use in patient education in addition to the education of assistants and medical students. Additionally, 3D printing material systems, integrated functional applications, the state-of-the-art technology products in patient-specific organ models, limitations in the field, current status and future perspectives were comprehensively discussed.
Keywords: Congenital Heart Anomalies, 3D Three-Dimensional Anatomical Model, Computed Tomography
Introduction
Today, rapid advances in the field of medical imaging have enabled to diagnose diseases easily and monitor the course of the diseases. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) is a detailed non-invasive imaging technology for the anatomical structure of organs or tissues and allows to measure their area and volume [1]. By this means, scientists and physicians can get detailed information about the anatomical structures of organs or tissues [2]. The advanced medical imaging tools allow performing enable to carry out key procedures such as simulation, advanced surgical planning, and radiotherapy planning except for diagnosis. Three-dimensional (3D) printed models can be produced by utilizsing MRI and CT scan data of patients in order to print custom-fit prosthesis, orthosis, and implant or go through procedures before complex high-risk surgeries. 3D printed models provide a better understanding of anatomy [3].
3D printed models have been employed both preoperatively and intraoperatively to assist in planning, decision making and intraoperative guidance in complex cardiac surgery [4]. 3D printed models yield effective outcomes in patients with congenital heart defects that require surgical repair [5]. In complicated congenital heart anomalies, 3D virtual surgery planning is very important in the face of risky situations. Anatomical points required for the operation can be planned by the team throughby segmentation after obtaining athe CT is taken of the patient. Thus, the operation it is reported that to be the operation is performed more safely and quickly [6].
More than 4 .000 surgeries are unnecessarily performed only in the United States of America annually due to a lack of proper planning and failure to make the right decision, and poor imaging of the area to be operated during the preoperative process [7]. Therefore, effective clinical training and preoperative planning can play a vital role to in reducinge these incidents. Imaging techniques such as CT, MRI, and 3D virtual imaging are significant imaging techniques utilizsed as critical tools to gather information about patients’ anatomy for diagnosis and preoperative planning. However, these methods and devices can cause misinterpretation as the precise recognition of direction and size in images can may sometimes be unclear [6]. Additionally, these imaging techniques do not provide kinaesthetic feedback, which is essential for assessing and adjusting the use of surgical tools in preoperative rehearsal [8]. The development ofDeveloping physical organ models with anatomically accurate characteristics and quantitative feedback might may make it easy for surgeons to identify surgical target regions during preoperative rehearsal. Even this can may allow full adaptation to the surgery by providing preoperative information and training to the patients. In recent years, rapid prototyping methods such as 3D printing combined with 3D imaging techniques have enabled the production of such vital models.
Congenital heart disease (CHD) abnormalities are congenital abnormalities of the cardiovascular system. Some of these abnormalities can be diagnosed at birth, while others may not manifest until adulthood and may not be diagnosed [9]. A study conducted in England reported that congenital heart disease was diagnosed in almost 1 in 100 live births [10]. It was reported in a study conducted in Turkey in 2006 that the prevalence of CHD was 7.77/1000 and VSD (32.6%) ranked first among these diseases, followed by patent ductus arteriosus (PDA) (15.9%) and ASD (13.1%) [11].
The aim of this study is to make three-dimensional anatomical modelling of paediatric cases with congenital ASD and VSD using CT angiography data and to determine surgical approaches accordingly.
Material and Methods
Ethicsal committee approval
The present study was approved by the local ethics committee (Approval No.number: 07.12.2020 HRU/20.21.06).
Collection of Image Materials
CT angiography images of 10 female and 10 male patients, who were diagnosed with ASD and VSD and aged between 0-18 years, were used in the study. Based on the obtained images, iIntracardiac structure and vascular structure modellings of different types of congenital heart diseases were built by using the obtained images. The printed material was generated from a modelled case using a three-dimensional printer. Ethical approval was obtained from the Harran University Clinical Research Ethics Committee (Decision No: HRU/20.21.06).
Creating Three-Dimensional Models
After the CT angiography (64-slice multidetector spiral computed tomography, General Electronic Revolution) images of the patients were taken in DICOM format, and they were transferred to the three-dimensional modelling software MIMICS 20.01 (The Materialise Group, Leuven, Belgium) and converted into a work file. When the data wereas transferred to the software, the data set of the sequence to be studied wasere selected. After assigning the threshold value of the tissues in the ongoing progress, the modelling process was initiated. The segmentation processes were performed in different approaches using the “edit mask” commands on the three-dimensional heart models, and the intracardiac structure model was obtained in the heart models. While taking the printed materials from MIMICS-based 3D models, laser technology based on SLA resin (GREY resin) was employed. A Formlabs Form 3 3D Printer (Formlabs Inc, Massachusetts, USA) was employed during the 3D printing stage.
The study received For the study, an approval was taken from Harran University, Faculty of Medicine, Clinical Trials Ethics Committee with the (decision numbered No. HRU/20.21.06 and dated 07.12.2020).
Results
Heart Models Created from CT Images
In the present study, intracardiac structure and vascular structure modellings of different types of congenital heart diseases were created. Figure 1 shows the 3D printed heart model, which was created from the CT data of patients with congenital ASD and VSD in such a way that the intracardiac structure is visible. Figure 2 shows the double outlet right ventricle defect. Figure 3 shows the image of the printed material obtained from the 3D-modelled hearts in such a way that the intracardiac structure is visible.
Discussion
ASD and VSD are the two most common congenital malformations that are frequently observed in congenital heart defects. Upon literature reviews, it has been observed that severe congenital heart diseases are more common in boys, but diseases such as ASD and patent ductus arteriosus are more common in girls [12,13]. Congenital anomalies, which can may be diagnosed late with the developments in technology, can be diagnosed early in at approximately 11 weeks [14].
Echocardiography is generally employed to diagnose CHDs, especially ASD and VSD. However, CT can be used as an alternative to cardiac catheterizsation if echocardiography fails to produce preoperative information [15].
Another advantage of CT is that it contributes to creatinge 3D modelling through cross-sectional imaging. In the comprehensive assessment of anatomical and pathological structures that cannot be achieved by other methods and tactile examination of these printing materials, medical models are more advantageous than classical image modelling [16].
A thorough understanding of cardiac anatomy and a highly experienced operator are required for safely use of invasive and surgical methods in the treatment of ASD and VSD. At this point, it is important to employ 3D modelling and printed materials in the diagnosis of defects and in the planning of the operation. 3D models are widely used in the field of industry, and have recently become widespread in the medical field and have been employed in many surgical disciplines such as cardiology, anatomy education, archaeology and forensic medicine [21]. [21] These models are of prime importance for pre-operative planning [17,18].
By taking the printed material from these models, which provide a great convenience in understanding the complexity of cases and planning operations, it is possible to create personalizsed patient-specific medical models can be created specific to the patient, as well as develop designs forand prostheseis and orthoseis design can be made [19,20].
Anwar et al., [21] reported that 3D printed models are an important technology in congenital heart diseases and occupyhold a significant place in the field of surgery due to the easy planningability to plan easily with 3D printed materials and the lack of complications. It has also beenalso reported that 3D models can facilitate communication between multidisciplinary teams and thereby potentially reduce medical errors [24]. Yoo et al., [22] reported that the use of 3D printing willould continue to expand with further advancements in imaging and printing technologies and the development of new printing materials. It has been reported that the printing of biological tissues and tissue engineering willould lead the way for a new era in personalizsed medicine [23].
CT was used to create three-dimensional models of paediatric patients diagnosed with ASD and VSD in the present study. The printed materials were produced from these models using three-dimensional printing technology in order to better understand the operative approaches of the cases. These images were stored in a virtual medium to be utilizsed as a digital library.
The printer technology used to producefrom which 3D printed materials are produced and the materials used in printing are being upgraded every day. “Segmentation” is an essential step before obtaining 3D printed material [17]. The CT images in the present study were produced by segmenting the 3D models created using the “MIMICS 20.1” software. Segmentation is of utmost importance in 3D anatomical modelling and virtual surgical planning with respect to the process of section-by-section separation by following the anatomical boundaries in the tissues around the tissues that are needed or critical for surgical planning. It has been reported that these methods outperform traditional methods [20,25]. In the present study ASD and VSD were modelled in paediatric patients in a digital environment, the usability of these data as a library was ensured, and it was also demonstrated that surgical approaches could be tangibly determined using by taking 3D printed material. The beneficial aspects of 3D models were described as improving the understanding of complex cardiovascular structures, providing guidance for surgical planning and simulation of interventional procedures, as well as enhancing doctor-to- patient communication in the manuscript by Sun and Wee [25].
Given the CT report of the case from which the printed material was obtained in the study,; it was determined upon the examination performed in the axial plane with a 5-mm section thickness after administration of intravenous contrast agent that the right upper pulmonary veins opened to the venacava superior a (supracardiac type partial pulmonary venous return anomaly) and an appearance that may be compatible with patent foramen ovale was observed at the level of the foramen ovale. The abnormalities in CT were clearly identified in the 3D model of the related case. In another case diagnosed with tetralogy of Fallot, all of the abnormalities listed in the CT report were observed in the 3D anatomical model. Similarly, in the other cases included in the present study, the same abnormalities were identified in CT reports and 3D organ modelling. VSD can be clearly observed in the intracardiac structure of the printed model of the case in which we created a 3D-printed organ model.
The thesis study was carried out to create 3D anatomical models of paediatric cases with ASD and VSD, which are common congenital heart defects in Turkey, using CT and to determine surgical approaches and presented cardiac data for ASD and VSD in these patients. The three-dimensional modelling of the intracardiac structure, which was performed in this study, enables better imaging of the defects or pathologies and easier follow-up of the diagnosis and provides a great contribution to the preoperative planning of paediatric cardiologists and cardiac surgeons. These modellings help to observe the risks of complicated surgeries in more detail. The pathological condition of the heart can be monitored before the patient is operated by means of these printed models, and no adverse conditions such as surprising pathological conditions will be encountered during the operation. This allows to identify operational risks and to take surgical actions and the duration of the operation can be shortened through patient-specific planning. When cumulatively analyzsed, this method reduces the costs. Another significant advantage of these outcomes is their use in patient education in addition to the education of assistants and medical students.
The MIMICS Innovation Suite software utilizsed in the present study is CE-certified software and is the most widely used software in medical and other research. The ability to integrate special modules into MIMICS, which is modular software, offers a significant advantage.
Conclusion
planning, and surgical rehearsal (simulation).
In the medical field, 3D-printed models may be utilizsed to build personalizsed prostheses, orthoses, or implants. These models could also be used to produce laboratory equipment. Organs may also be modelled and printed for transplantation through 3D printing technology.
The 3D models and printing have allowed enabled us to image the intracardiac and vascular structures of different types of congenital heart diseases such as ASD and VSD, and through direct comparisons between the model and real anatomy, conclusions were drawn about interventional or surgical procedures that can be applied in the repair of ASD and VSD.
As this technology advances further, biocompatible organs would will soon be created by using biomaterial printing materials and cells. It is thought that even in the future, heart muscle cells and vascular cells with the ability to contract could be produced using these methods and heart tissue that can beat can be produced by synchronizing these with each other. Through these methods and inventions, 3D tissues and organs may be employed as a novel way to substitute organs for donor shortages. Furthermore, by means of the 3D model and printed organ, the most suitable interventional or surgical procedures for the patient may be performed by exchanging ideas on the created model with doctors from across the globe.
Consequently, 3D modelling and printing, when combined with medical imaging methods, is both a powerful diagnostic tool for patients and enables to make a regular planning prior to operational intervention for patients. Meanwhile, 3D modelling and printing, which contribute to assistant training and personal experience, are being successfully used to build personalizsed prostheses. Much greater work would will be achieved in the future as technological advances in both medical imaging and 3D modelling and printing continue. Thanks to modern With today’s technologiesy, it is possible to combine materials with different properties, depending on the manufacturing method, in order to capture different elasticity or colour in a model. This method and technology allow for creating more realistic models with a more natural appearance for educational or research purposes. Furthermore, due to these printed models, personal measurements that may be incorrect in ECO, CT, MRI, or other relevant imaging techniques are prevented, and more exact measures would can be achieved through model-supported measurements, thus it is believed that significant errors could can be prevented.
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.
Funding: This study was supported by the Scientific Research Projects Coordination Uniıt, Harran University (Project Noumber: 21026).
Conflict of Interest
The authors declare that there is no conflict of interest.
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5. Full MDBS, Laycock SD, Brown JRI, Jakeways M. 3D printing of an aortic aneurysm to facilitate decision making and device selection for endovascular aneurysm repair in complex neck anatomy. J Endovasc Ther. 2013;20(6):863-867.
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9. Dankowski R, Baszko A, Sutherland M, Firek L, Kalmucki P, Wróblewska K, et al. 3D heart model printing for preparation of percutaneous structural interventions: description of the technology and case report. Kardiol Pol. 2014;72(6):546-551.
10. Hoffman J, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002;39(12):1890-1900.
11. Dadvand P, Rankin J, Shirley MD, Rushton S, Pless-Mulloli T. Descriptive epidemiology of congenital heart disease in Northern England. Paediatric and Pperinatal Eepidemiology. 2009;23(1):58-65.
12. Başpinar O, Karaaslan S, Oran B, Baysal T, Elmaci AM, Yorulmaz A. Prevalence and distribution of children with congenital heart diseases in the central Anatolian region, Turkey. Turk J Pediatr. 2006;48(3):237-243.
13. Morris CD. Lessons from epidemiology for the care of women with congenital heart disease. Prog Pediatr Cardiol. 2004;19(1):5-112.
14. Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, et al. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation. 2014;129(21):2183-2242.
15. Hutchinson D, McBrien A, Howley L, Yamamoto Y, Sekar P, Motan T, et al. First-trimester fetal echocardiography: identification of cardiac structures for screening from 6 to 13 weeks’ gestational age. J Am Soc Echocardiogr. 2017;30(8):763-772.
16. Elzenga NJ, Von Suylen RJ, Frohn-Mulder I, Essed CE, Bos E, Quaegebeur JMet al. Juxtaductal pulmonary artery coarctation. An underestimated cause of branch pulmonary artery stenosis in patients with pulmonary atresia or stenosis and a ventricular septal defect. J Thorac Cardiovasc Surg. 1990;100(3):416-424.
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Download attachments: 10.4328.ACAM.22009
Ömer Göç, Mehmet Salih Aydın, İsmail Demircioğlu, Reşat Dikme, Osman Tunç. Three-dimensional anatomical modeling of cases with atrial septal defect and ventricular septal defect, which are congenital heart anomalies. Ann Clin Anal Med 2024;15(1):52-56
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An investigation on the relationship of preoperative CEA/CA 19-9 levels with clinicopathological features and recurrence in colorectal cancer
Burak Uçaner, Rahman Şenocak
Department of General Surgery, Faculty of Medicine, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.22010 Received: 2023-10-09 Accepted: 2023-11-13 Published Online: 2023-11-20 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):57-61
Corresponding Author: Burak Uçaner, Department of General Surgery, Faculty of Medicine, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey. E-mail: burakucaner@hotmail.com P: +90 535 301 95 61 F: +90 312 304 27 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5420-3810
This study was approved by the Ethics Committee of University of Health Sciences Gülhane Training and Research Hospital Local Ethics Committee (Date: 2021-09-23, No: 46418926)
Aim: The clinical benefits of carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA 19-9) levels for diagnosis and prognosis in colorectal cancer are controversial, and studies on this subject have reported various results. This study aimed to reveal whether the preoperative CEA and CA 19-9 levels were correlated with clinicopathological features, recurrence, and overall survival and investigate the tumor marker with more predictive characteristics.
Material and Methods: An analysis was performed of on the records of 142 patients who were hospitalized due to colorectal cancer and underwent surgery was performed. The demographic, biochemical, and pathological characteristics of patients were investigated retrospectively.
Results: A significant difference was observed in the CRP level measured in the preoperative period. In multivariate analyses, only age (HR=1.19, 95% CI 1.05-1.34, p=0.004) and recurrence (HR=20.65, 95% CI 3.14-135.62, p=0.002) were found to affect overall survival. Nevertheless, CEA and CA19-9 elevations were not predictive of overall survival. CEA and CA 19-9 elevations did not have a superiority over each other in predicting the clinicopathological pattern of the disease. Nonetheless, it was determined that the elevated CEA+CA 19-9 indicated a more aggressive pathology in terms of clinicopathological pattern. It was not found predictive of recurrence and overall survival, which are significant markers in the prognosis of the disease.
Discussion: It was concluded that the preoperative serum tumor marker elevation, which was the subject of our study, should be considered in decisions related to neoadjuvant/adjuvant chemoradiotherapy (CRT) and more aggressive treatment in advanced cancer.
Keywords: Colorectal Cancer, Carcinoembryonic Antigen (CEA), Cancer Antigen 19-9 (CA 19-9), Neoadjuvant Therapy
Introduction
Colorectal cancers rank third among the most common cancers in the world and fourth in deaths due to cancer. Colorectal cancers are most commonly localized in the rectum, and the second most common location is the sigmoid colon [1]. Colorectal cancers can be treated with surgery, chemotherapy, and/or radiotherapy, and adjuvant treatment can be administered as an alternative. Various tumor markers can be used in cancer diagnosis and postoperative patient follow-up [2]. Carcinoembryonic antigen (CEA) is an oncofetal tumor marker and is essential in the diagnosis process in 70% of patients. Similarly, cancer antigen 19-9 (CA 19-9) level is one of the most common tumor markers used in colorectal cancers [3, 4].
A relationship between elevated preoperative serum CA 19-9 levels and poor prognosis was determined depending on the stage of the disease, and this relationship may be more effective than CEA; however, the effect of CA 19-9 was found to be limited in studies proving the contrary. In addition, the 5-year survival rate was reported to be lower in patients with elevated CEA and CA 19-9 [5]. It is not recommended to use the preoperative tumor marker level as a screening test or for diagnostic purposes; however, it can be used to give an idea about the spread of the disease. This study aimed to reveal whether the preoperative CEA and CA 19-9 levels were correlated with clinicopathological features, recurrence, and overall survival and investigate the more predictive tumor marker.
Material and Methods
This study investigated patients who were hospitalized and underwent surgery due to colorectal cancer between November 2016 and June 2021 in the General Surgery Clinic of University of Health Sciences Gülhane Training and Research Hospital based on their file records. Our study was approved by the decision of the University of Health Sciences Gülhane Training and Research Hospital Local Ethics Committee dated 23.09.2021 and numbered 46418926. Patients with unknown tumor marker values in the preoperative period, patients with inflammatory bowel disease such as ulcerative colitis and Crohn’s disease, patients who underwent surgery due to benign pathologies such as diverticular diseases of the colon, patients undergoing surgery under emergency conditions, and patients under the age of 18 were excluded from the study.
The study included 142 patients who met the determined criteria. Data including CEA/CA 19-9 as preoperative biomarkers, biochemical parameters, computed tomography reports, and histopathological reports (tumor diameter, histopathological features of the tumor, length of the removed intestinal segment, the distance of the tumor to the proximal and distal surgical margins, number of metastatic and reactive lymph nodes, tumor budding level, histopathological pattern of the tumor, tumor diameter, and tumor stage), recurrence, colorectal obstruction, and follow-up periods of the patients were collected retrospectively. The patients were classified into four groups according to their tumor marker levels. The study was conducted by analyzing patients in four groups where one group consisted of patients with elevated serum CEA (CA 19-9 normal), one group consisted of patients with elevated serum CA 19-9 (CEA normal), one group consisted of patients with elevated levels in both tumor markers, and the last group consisted of patients with tumor markers within normal limits. Demographic, biochemical, clinical, and entire pathological data of the patients in the four groups were examined by comparing them with each other, and the effects of tumor marker levels on the clinicopathological characteristics of the patients were investigated.
Statistical Analysis
Statistical analysis was performed using the SPSS version 22.0 software. Descriptive statistics were expressed as numbers, percentages, mean and standard deviation, and median (min-max). The compliance of variables with Whether the variables conformed to normal distribution was evaluated using visual and analytical methods. Normally distributed continuous variables were analyzed within the group using the “Student’s T-test and One Way ANOVA”, and the variables with non-normal distribution were analyzed using the “Mann-Whitney U test and Kruskal-Wallis Test”. Nominal values were compared using the “Chi-square analysis” and the “Fisher’s Exact Test”. The effect of elevated CEA and CA19.9 on survival was tested using the “Kaplan-Meier analysis” . The variables assumed to be associated with survival after univariant analyses and clinical evaluation were evaluated by multivariant analyses using the “Cox proportional hazards model.” The regression model was expressed as Hazard Ratio (HR), a 95% confidence interval (CI). Comparisons with a p-value below 0.05 were considered statistically significant in the statistical analyses of the study.
Ethical Approval
Ethics Committee approval for the study was obtained.
Results
The CEA and CA19-9 groups were compared in terms of tumor-related characteristics. Significant differences were observed in terms of tumor diameter (p=0.009), budding score (p=0.025), lymphovascular invasion (p=0.001), and number of metastatic lymph nodes (p=0.006). Paired analyses concluded that patients with elevated levels of both tumor markers had a greater tumor diameter compared to patients with only elevated CA19-9 levels (p=0.001), and patients with elevated CA19-9 levels had greater tumor diameter compared to patients with both tumor markers at normal levels (p=0.031). In terms of elevated CEA+CA, the tumor budding score was moderate or high in 56.5% of patients with elevated CEA only, 15% of patients with elevated CA19-9 only, 36.4% of patients with both tumor markers at elevated levels, and 48.1% of patients with both tumor markers at normal levels. The rate of lymphovascular invasion was 77.3% in patients with elevated CEA+CA19-9 levels and 40.3% in patients with both tumor markers at normal levels. The number of metastatic lymph nodes in patients with elevated CEA+CA19-9 was higher compared to patients with only elevated CEA levels (p=0.007), patients with only elevated CA19-9 levels (p=0.002), and patients with both tumor markers at normal levels (p=0.023). On the other hand, no difference was observed between the groups in terms of recurrence and mortality (Table 1).
The survival period was 46.4 months for patients with only elevated CEA, 46.2 months for patients with only elevated CA19-9, 50.1 months for patients with CEA+CA19-9 elevation, and 48.2 months for patients with both tumor markers at normal levels. No difference was observed between the groups according to survival periods (Table 2).
The effect of elevated CEA and CA19-9 levels on survival was evaluated using the Cox proportional hazards model. The multivariant model included factors that were associated with mortality in univariant analyses and considered clinically significant. Factors in the model were tested for collinearity. The final version of the model included age, gender, budding score, recurrence, and CEA and CA19-9 elevations (-2 log likelihood= 45.418, X2=42.637, p<0.001). According to the multivariant analyses, only age (HR=1.19, 95% CI 1.05-1.34, p=0.004) and recurrence (HR=20.65, 95% CI 3.14-135.62, p=0.002) were determined to affect survival. Nevertheless, the CEA and CA19-9 elevations did not predict survival (Table 3).
Discussion
Colorectal cancers rank second in the world after lung cancer among deaths due to cancer and are the most common cancer of the gastrointestinal system [6, 7]. Knowing the prognostic factors affecting the course of the disease, accurate staging, and selection of selecting the best treatment for the patient and the disease are quite important in colorectal cancers.
The literature on the tumor markers used more effectively used in the diagnosis and follow-up of colorectal cancer, alone or in combination, contains controversial and different outcomes. CEA is an oncofetal protein used in diagnosing colorectal cancer; however, it has been listed as an independent prognostic criterion concerning colorectal cancer in some consensus treatment guidelines [8, 9]. The literature also contains studied arguing that CEA is an independent variable in predicting the prognostic outcome [10, 11]. Chen et al. suggested including the CEA level in the staging system [12].
Chronic inflammation has a significant role in the pathogenesis of colorectal cancer. It has been reported that especially patients who develop colorectal cancer have higher CRP levels, and the development of colorectal cancer increased 1.88 times in patients with a CRP level higher than 1.19 mcg/mL [13]. Our study concluded that the CRP level measured in the preoperative period was significantly higher in groups with elevated CA 19-9 and CEA+CA 19-9 levels compared to the group with normal CEA+CA 19-9 levels (p=0.014). In their study, Zhou et al. found that the CRP level measured in the preoperative period was higher in patients with elevated serum CEA and CA 19-9 levels compared to patients with normal serum tumor marker levels [14]. We think that the preoperative CRP elevation is associated with advanced clinicopathological characteristics.
According to our study data, tumor diameter (p=0.009), lymphovascular invasion (p=0.001), and number of metastatic lymph nodes (p=0.006) were found to be significant. Our results indicated that elevation of both tumor markers led to more metastatic lymph node involvement, it was associated with larger tumor diameter and greater lymphovascular invasion, and there was no significant difference between CEA and CA 19-9.
In some studies on the relationship between tumor marker elevation and tumor pathology, tumor diameter, lymphovascular invasion, and the number of metastatic lymph nodes were reported to be significantly higher in patients with elevated serum CEA and CA 19-9 levels [15-17].
In their study, Lakemayer et al. recommended thatusing only CEA be used with other screening methods to determine colorectal cancer prognosis, predict neoadjuvant chemoradiotherapy decisions, and predict and monitor chemotherapy or radiotherapy after curative resection. It was not recommended to use the CA 19-9 alone for detecting colorectal cancer prognosis, monitoring ongoing therapy, or follow-up due to its poor sensitivity [18]. On the other hand, our study and the study of Lakemayer revealed that patients with elevated serum CEA levels received neoadjuvant therapy at a higher rate, and serum CEA elevation emerged as a parameter to be considered when deciding on neoadjuvant therapy. We can recommend neoadjuvant chemotherapy/CRT for patients with both tumor markers at elevated levels of both tumor markers. In the study by Partyka et al., it was recommended to monitor the CEA level when CEA and CA 19-9 levels were used to diagnose the disease and monitor prognosis [19]. In another study by Gao et al., it was demonstrated that measuring serum tumor markers in combination rather than using CEA alone had a better sensitivity in diagnosing colorectal cancer and predicting the prognosis [20]. When groups with only elevated CEA or CA 19-9 levels were compared, this study showed that they were not superior to each other concerning the clinicopathological results.
Study Limitations
The limitations of our study included the retrospective design and the lack of analysis of zing both tumor marker levels of in all patients in the preoperative period. Moreover, most patients with rectal colorectal cancer underwent neoadjuvant CRT; however, the heterogeneity caused by the fact that most patients with colon cancer did not receive neoadjuvant CRT also affected the results of our study.
Conclusion
The elevated CEA or CA 19-9 levels do not have a significant advantage over each other in predicting the clinicopathological pattern of the disease. Nevertheless, the elevated CEA+CA 19-9 levels indicate a more aggressive pathology in terms of clinicopathological pattern. Despite all, they have no predictive effect on recurrence and overall survival in predicting the prognosis of the disease. Multicentered, multilayered, and prospective studies, including postoperative treatments, are needed to confirm the clinical significance of combining tumor markers, homogeneous stage, and tumor localization. The analysis of these markers in combination canould provide significant data for clinical evaluation and patient management.
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.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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The effectiveness of laparoscopic burch in diabetic patients
Ramazan Adan, Veli Mihmanlı
Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascıoglu City Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22033 Received: 2023-11-03 Accepted: 2023-12-11 Published Online: 2023-12-27 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):62-65
Corresponding Author: Ramazan Adan, Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascıoglu City Hospital, Istanbul, Turkey. E-mail: radan187@outlook.com P: +90 212 314 55 55 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0605-1533
This study was approved by the Ethics Committee of Istanbul Health Sciences University, Prof. Dr. Cemil Tascıoğlu and Clinical Research (Date: 2022-12-26, No: 367)
Aim: In this study, our aim is to evaluate the effectiveness and surgical outcomes of the laparoscopic (L/S) burch procedure in cases where mesh excision was performed due to mesh erosion in women who have undergone midurethral sling and continue to experience stress urinary incontinence. The primary outcome of this study was the improvement of stress urinary incontinence (SUI) (no symptoms), improvement of stress urinary symptoms in ICIQ-SF, and negative stress test, defined as surgical success with less than 2 grams of urine leakage in a one-hour pad test.
Material and Methods: Eleven patients who underwent mesh excision in the tertiary gynecology unit between 2021 and 2022 were included in the study. Patients who underwent laparoscopic burch were assessed in the postoperative period with a stress test and a one-hour pad test, and they were asked to fill out the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). The follow-up periods were 3, 6, and 12 months postoperatively. The alpha significance level was set at p < 0.05.
Results: In postoperative follow-ups, statistically significant improvement was found in terms of the effort test and pad weight in patients with cured stress urinary incontinence (P < 0.001). However, in patients who did not show progress after the surgery, no statistical change was observed in ICIQ-SF values (P = 0.062).
Discussion: The laparoscopic Burch procedure is a comfortable and safe surgical procedure as a secondary surgery in cases of midurethral sling with mesh excision.
Keywords: Urinary Incontinence, Burch Colposuspension, Minimally Invasive Technique
Introduction
Stress urinary incontinence (SUI) is described as involuntary urine leakage during activities like exertion, sneezing, or coughing [1]. Among the primary causes of SUI are decreased pelvic floor support, urethral hypermobility, and intrinsic sphincter dysfunction resulting from structural impairment of the urethral sphincter [2]. The popularity of mid-urethral sling procedures has increased over the past twenty years and has become the primary treatment option for SUI in women. Success rates of the minimally invasive technique have been reported to be between 70-95%, and due to its easy use and effectiveness in the short to medium term, it was widely considered the gold standard until recently. One of the most important reasons for this is the ease of application, the minimally invasive approach, and the comparable results when compared to other more extensive procedures like Burch urethropexy [4]. However, with the increased use of synthetic mesh, complications related to its implantation have begun to emerge. One of the most common complications of mesh surgery is the visibility of the mesh in the vagina and dyspareunia. More rare and serious complications include perforations of the bladder, urethra, and intestines [5]. The incidence of mesh erosion in the literature ranges from 0% to 0.6% [6]. Approximately 50% of women who present with symptomatic sling complaints require secondary surgical treatment after less invasive methods (mid-urethral sling) have failed [7]. When conservative measures are insufficient in treating a complication, the surgical removal or revision of the mid-urethral sling (MUS) has been proven to alleviate symptoms associated with some of the complications mentioned above related to the mesh. However, sometimes this situation leaves the patient with recurrent or worsening stress urinary incontinence. The aim of this study is to investigate the surgical outcomes of laparoscopic burch urethropexy for diabetic stress urinary incontinence that requires the removal of mid-urethral sling either vaginally or laparoscopically.
Material and Methods
This prospective cohort study was conducted on 11 diabetic patients whose ages range between 20-70 and who had mid-urethral slings performed for stress incontinence between February 2021 and December 2022 and experienced mesh erosion. The degree of SUI was determined after the initial surgery (first sling implantation) through a 1-hour pad test and cough test.
Patients with detrusor overactivity, urge incontinence, neurogenic bladder, or those with complex prolapse requiring additional surgery were excluded from the study. All patients underwent urodynamic studies after their previous mid-urethral sling surgery. Patients with endocrine abnormalities (such as systemic hypo/hyperthyroidism, hyperprolactinemia, diabetes insipidus, Cushing’s syndrome, and congenital adrenal hyperplasia) receiving drug treatment, those with malignancies, a history of pelvic radiotherapy, and known psychiatric issues were also excluded from the study.
All patients included in the study underwent a detailed clinical evaluation, pelvic and abdominal physical examination, and ultrasound assessment. The L/S burch procedure was performed through a 10 mm umbilical port and two suprapubic median 5 mm trocars, and the paravaginal tissues were approximated to the Cooper ligament with nonabsorbable sutures. No gross perioperative or postoperative complications occurred. Catheters were removed 12 hours after surgery.
Patients who underwent laparoscopic burch were evaluated with a stress test and a one-hour pad test in the postoperative period, and they were asked to fill out the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Follow-up intervals were at 3, 6, and 12 months after surgery. The primary outcome of this study was the surgical success defined as the improvement of SUI (no symptoms), improvement of SUI symptoms in ICIQ-SF, and less than 2g of urine leakage in the stress test and one-hour pad test.
This study was approved by the Ethics Committee of Istanbul Health Sciences University, Prof. Dr. Cemil Tascıoğlu and Clinical Research (Date: 26.12.2022, No: 367). All procedures were carried out in accordance with the ethical rules and the principles of the Declaration of Helsinki.
Statistical Analysis
Statistical analysis was conducted using SPSS software (version 15.0 on Windows). Descriptive statistics included counts and percentages for categorical variables, and for numerical variables, means, standard deviations, minimum, maximum, and medians were reported. Group comparisons for proportions were performed using the Chi-square test. Independent group comparisons for numerical variables were conducted using the Student t-test when the assumption of normal distribution was met and the Mann-Whitney U test when it was not met. The alpha significance level was set at p < 0.05.
Results
The characteristic and demographic data of patients who underwent secondary surgery were observed in Table 1.
The average operation duration was 57.1 minutes (ranging from 40 to 88 minutes). Regarding perioperative complications in our patients, one case experienced bladder perforation, and three cases had mesenteric perforation, which were managed laparoscopically during the perioperative period. Three patients had a history of previous abdominal surgeries and cesarean sections. There was no significant bleeding requiring conversion to laparotomy in any of the current patients. In cases with bladder perforation, urinary catheters were removed at postoperative 12 hours for all patients except for those who had a catheter placed on the 7th postoperative day. In one patient who couldn’t spontaneously urinate in the postoperative period, clean intermittent catheterization was performed, and symptoms disappeared after one month. One patient developed de novo urge and urgency incontinence, which was completely resolved with anticholinergic treatment at 6 months postoperatively. The average postoperative residual volume and length of hospital stay were 30 mL and 1.5 days, respectively. After surgery, patients were categorized into two groups based on the results at 6 months (urinary incontinence positive and negative). The comparison of surgical outcomes between groups is summarized in Table 2. There was no statistically significant difference between the groups. In follow-up months after surgery, we observed statistically significant improvement in effort test and pad weight (P < .001) in patients with improved stress urinary incontinence. However, in patients who did not improve after surgery, there was no statistically significant change in ICIQ-SF values (P = 0.062).
Discussion
The warning issued by the FDA (Food and Drug Administration) regarding vaginal mesh for prolapse has increased interest in mid-urethral slings and raised questions. This is because complications can arise in early and late stages of stress urinary incontinence surgeries involving mesh. Cases like urinary retention are often considered early complications, while mesh erosion is encountered more as a late complication [8].
In a study involving 188,454 adult women, the risk of mesh revision/removal after nine years of follow-up was relatively low at 3.7%. Most revisions/removals occurred within the first four years following sling surgery, with mesh erosion being the primary indication. The study also found that the risk factors for revision/removal differed for two main indications, and age had a stronger impact on mesh erosion. It was surprising that mesh erosion was more common in younger sexually active women, despite having irregular tissue quality and poorer healing due to urogenital atrophy [9]. In our study, cases requiring mesh excision were in the older age group, possibly influenced by the negative effects of diabetes on tissue regeneration and wound healing due to autonomic factors.
A recent study found that after 10 years, mid-urethral slings had a success rate of 63.3% for both stress urinary incontinence and mixed urinary incontinence, with nearly an 80% improvement rate. Nevertheless, 17.7% of women experienced ongoing symptoms related to sling-associated complications 10 years after surgery [10]. In a multicenter prospective study conducted in the United Kingdom and Ireland, the primary treatment of stress incontinence was compared between tension-free vaginal tape and colposuspension. After a 5-year follow-up, both procedures were found to be similar in terms of urinary incontinence treatment and quality of life improvement, but colposuspension had a higher incidence of posterior vaginal wall prolapse [11]. Our study did not observe de novo enterocoele or cuff prolapse. Results obtained from a meta-analysis indicated that laparoscopic cases had lower morbidity, shorter hospital stays, significantly fewer postoperative complications (RR 0.74, 95% CI 0.58-0.96), less estimated blood loss, and shorter catheterization duration, with the main drawback being longer surgery duration compared to open colposuspension [12]. One limitation of our study was the small patient cohort, and larger prospective randomized studies will strengthen the data on this subject.
Conclusion
LS Burch operation is a comfortable and safe surgical procedure for secondary surgery in mid-urethral sling cases where mesh excision has been performed.
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 compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
References
1. Aleksandrov A, Meshulam M, Rabischong B, Botchorishvili R. Laparoscopic TOT-like burch colposuspension: Back to the future? J Minim Invasive Gynecol. 2021;28(1):24-25.
2. Savaş Özdemir, Fatih Şahin, Gül Özel Doğan, Özlem Baytekin. Evaluation of maternal serum galectin-9 levels in pregnancies with the threat of preterm birth. Ann Clin Anal Med 2023;14(7):651-4.
3. Călinescu BC, Neacșu A, Martiniuc AE, Dumitrescu D, Stănică CD, Roșu GA, et al. Surgical treatments for women with stress urinary incontinence: A systematic Review. Life (Basel). 2023;13(7):1480.
4. Kusuda M, Kagami K, Takahashi I, Nozaki T, Sakamoto I. Comparison of transvaginal mesh surgery and robot-assisted sacrocolpopexy for pelvic organ prolapse. BMC Surg. 2022;22(1):268.
5. Chughtai B, Barber MD, Mao J, Forde JC, Normand ST, Sedrakyan A. Association between the amount of vaginal mesh used with mesh erosions and repeated surgery after repairing pelvic organ prolapse and stress urinary ıncontinence. JAMA Surg. 2017;152(3):257-263.
6. Trabuco EC, Carranza D, El Nashar SA, Weaver AL, McGree ME, Elliott DS, et al. Reoperation for urinary ıncontinence after retropubic and transobturator sling procedures. Obstet Gynecol. 2019;134(2):333-342.
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9. Dejene SZ, Funk MJ, Pate V, Wu JM. Long-term outcomes after midurethral mesh sling surgery for stress urinary ıncontinence. Female Pelvic Med Reconstr Surg. 2022;28(4):188-193.
10. Alexandridis V, Lundmark Drca A, Ek M, Westergren Söderberg M, Andrada Hamer M, Teleman P. Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study. Int Urogynecol J. 2023;34(6):1307-1315.
11. Veit-Rubin N, Dubuisson J, Ford A, Dubuisson JB, Mourad S, Digesu A. Burch colposuspension. Neurourol Urodyn. 2019;38(2):553-562.
12. Tappy E, Pan E, Corton M. Robotic burch colposuspension: anatomical and technical considerations. Int Urogynecol J. 2023;34(7):1653-1657.
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Pathogen prevalence in IBD and non-IBD patients using multiplex PCR stool test
Sidre Erganis 1, Hasan Bostanci 2, Funda Escan 1, Kursat Dikmen 2, Cagri Buyukkasap 2, Mehmet Arhan 3, Secil Ozkan 4, Isil Fidan 1, Kayhan Caglar 1
Gulendam Bozdayi 1
1 Department of Medical Microbiology, 2 Department of General Surgery, 3 Department of Internal Medicine Gastroenterology, 4 Department of Public Health, Faculty of Medicine, Gazi University, Ankara, Turkey
DOI: 10.4328/ACAM.22036 Received: 2023-11-04 Accepted: 2023-12-04 Published Online: 2023-12-09 Printed: 2024-01-01 Ann Clin Anal Med 2024;15(1):66-70
Corresponding Author: Sidre Erganis, Department of Medical Microbiology, Faculty of Medicine, Gazi University, Ankara, Turkey. E-mail: sdrerganis.gazi@gmail.com P: +90 554 670 94 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8068-796X
This study was approved by the Ethics Committee of Gazi University Faculty of Medicine (Date: 2023-06-02, No: 110)
Aim: The aim of this study was to investigate the distribution of gastroenteritis agents in diarrhea patients with and without IBD using the gastrointestinal panel (GIP) test and also to evaluate its potential effect on infection control and patient prognosis by providing early diagnosis of the causative agent of gastroenteritis.
Material and Methods: Our study is a retrospective cohort analysis. A total of 266 patients with diarrhea were included in the study conducted at Gazi University, School of Medicine. Data on age, sex, UC/CD presence, stool culture, microscopic examination, and gastrointestinal pathogen PCR stool test results were collected.
Results: 266 patients with diarrhea underwent 339 GI panel tests. Among the 266 patients studied, 13 patients were determined as IBD. 154 enteric pathogens were detected in 101 patients by GIP testing. EPEC (22.8%) was the most common pathogen in both IBD and non-IBD patients. In addition, ETEC, EAEC, C.difficile and C.parvum were found in IBD patients, and no viral pathogen was detected. No significant difference was observed in IBD subtype and gender distribution.
Dıscussion: This study found that patients with IBD had fewer bacterial and parasitic pathogens detected compared to those without IBD, potentially due to non-infectious causes of diarrhea and altered systemic immunity. Identifying any fecal pathogen is significant for treatment in IBD patients. PCR-based stool tests are advantageous over conventional methods in pathogen detection. This study found that patients with IBD had fewer bacterial and parasitic pathogens detected compared to those without IBD, potentially due to non-infectious causes of diarrhea and altered systemic immunity. Identifying any fecal pathogen is significant for treatment in IBD patients. PCR-based stool tests are advantageous over conventional methods in pathogen detection.
Keywords: Diarrhea, Gastroenteritis, Inflammatory Bowel Disease, Multiplex PCR, Stool Testing
Introduction
Inflammatory bowel diseases (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), are inflammatory conditions of the gastrointestinal system that are characterized by periods of relapse and remission. IBD has been a health problem around the world with a steadily rising prevalence. IBD includes a complicated interaction between genetic, environmental, microbial variables, and immune responses, despite the fact that the etiology is still mainly unclear [1].
It is known that many bacteria, viruses, fungi and parasites play a triggering role in the pathogenesis of IBD and exacerbation of the existing disease [2]. The symptoms and signs of enteric infections and IBD exacerbation are very similar. Therefore, it is very difficult to distinguish between these two conditions clinically [3].
IBD patients, especially those with Clostridium difficile infection (CDI), experience higher morbidity, mortality and healthcare costs. They are at high risk for gastrointestinal infections. Detection of pathogens is crucial during IBD relapses, as gastroenteritis can lead to hospitalizations. Difficulty in distinguishing between IBD exacerbation and enteric infection delays the diagnosis and adversely affects the patient’s clinic [2].
Microscopic examinations, cultures, enzyme immunoassays (EIA), and multiplex molecular tests are used to detect enteric pathogens. Stool culture can detect only a limited number of pathogens and require long turnaround times to result. In addition, the sensitivity of immunoassays is not very high [4]. Syndromic gastrointestinal (GI) panel tests can identify most pathogens in as little as one hour and have high sensitivity and specificity [2].
The aim of this study was to investigate the distribution of gastroenteritis agents in patients with diarrhea with and without IBD by the GI panel test. Our secondary aim was to evaluate the potential effect on infection control and patient prognosis by providing early diagnosis.
Material and Methods
Sample Collection
We conducted a retrospective cohort analysis using data from the electronic medical record at Gazi University, School of Medicine, Medical Virology Laboratory. The study was approved by the Ethics Committee of Gazi University Faculty of Medicine (Date: February 6, 2023, No: 110). Individuals (18-94) who underwent stool gastrointestinal pathogen polymerase chain reaction (PCR) testing in outpatient and/or inpatient settings were included in the study during the period from June 2019 to December 2022. A total of 266 eligible patients were identified, all of whom were included in the study. Data collected included patient age, sex, presence of UC, or CD and results of stool culture, microscopic examination, and gastrointestinal pathogen PCR stool test.
Enteric Pathogen Testing
Fecal leukocytes, erythrocytes and parasites were investigated in direct wet mount, and the presence of parasites was investigated with trichrome and kinyoun acid fast (KAF) stainings. Stool cultures were performed by inoculation of fresh fecal specimens on eosin methylene blue agar and incubated at 37°C for 18-24 hours for further evaluation.
Multiplex Gastrointestinal Panel stool test
We used two different brands of multiplex gastrointestinal panel tests: FilmArray Gastrointestinal Panel (BioFire Diagnostics, Salt Lake City, UT, USA) and QIAstat Gastrointestinal Panel (Qiagen, Hilden, Germany). Both assays are real-time, multiplex PCR-based platforms with integrated nucleic acid extraction.
Both GI panel PCR tests can detect 22 pathogens in feces including 13 bacteria, 5 viruses, and 4 parasites including enteropathogenic E.coli (EPEC), enteroaggregative E. coli (EAEC), enterotoxigenic E.coli (ETEC), E.coli O157, Shigella/enteroinvasive E.coli (EIEC), Shiga-like toxin-producing E.coli (STEC), Salmonella, Clostridium difficile (Toxin A/B), Campylobacter (jejuni, coli, and upsaliensis), Yersinia enterocolitica, Plesiomonas shigelloides, Vibrio (parahaemolyticus, vulnificus, and cholerae), Giardia lamblia, Entamoeba histolytica, Cryptosporidium spp., Cyclospora cayetanensis, norovirus GI/GII, adenovirus (AdV) F40/41, rotavirus A, astrovirus and sapovirus (I, II, IV, and V). The multiplex PCR process takes about an hour. The clinical sensitivity and specifity is 94.5% to 100% for all targets [3,5].
We also evaluated the surgical data of the 13 IBD patients who underwent stool gastrointestinal panel test.
Statistical Analyses
Statistical analysis was performed using the Chi-square test. A value of p<0.05 was considered significant in the analysis.
Results
Over the data collection period, 266 patients with diarrhea underwent 339 GI panel tests. Out of the 266 patients, 126 (%47.4) were female and 140 (%52.6) were male. When analyzed by gender, there was no statistically significant difference between males and females (p>0.05) (Table 1).
The average age of the patients was 50 (range, 18-94) (standard deviation SD +/- 17.99) years. The rates of IBD patients in the 18-49 and 50-94 age groups were 8.8% and 1.4%, respectively. Pathogen positivity in IBD patients in the 18-49 age group was higher than that of the older age group. There were statistically significant differences in terms of the age groups (p=0.0051) (Table 1).
We identified 13 patients with IBD and 253 patients without IBD who underwent 15 and 324 GI panel tests, respectively (Table 1). One or more pathogens were found in 101 of 266 patients by GI panel test. There was no statistical difference in terms of GI panel test positivity between the groups with and without IBD (Table 1). Of the 13 IBD patients, eight of them had CD whereas five had UC. Colonoscopy was performed in all IBD patients except one of them. The number of IBD patients with positive GI panel tests is 5 and 8 had negative results. (Table 2).
EPEC was detected in two of Crohn’s patients, and C.parvum was detected in one. EPEC and ETEC were detected together in one patient with UC. C.difficile and EAEC were detected in one patient with a diagnosis of UC. As a result of microscopic examination of the stool of a Crohn’s patient with EPEC, no signs of infection were found. Any acid-fast parasites could be detected in the KAF stain examination of the CD patient with C.parvum. The GI panel tests of three IBD patients with leukocytes in their stools were negative (Table 2). Some of the pathogens that were found positive by GI panel tests could not be identified by conventional methods.
Among patients with positive tests, 73 (60.3%) were positive for one pathogen, 24 (23.7%) were positive for two pathogens, three patients were positive for three pathogens and one patient was positive for four pathogens.
A total of 154 enteric pathogens were detected in 101 patients. E.coli species (22.8%) were the most common pathogen. The E.coli strains were ETEC, EAEC, and STEC stx1/stx2. Other detected enteric pathogens included C.difficile, Campylobacter spp, Salmonella spp, Yersinia enterocolitica, Norovirus, Rotavirus, Astrovirus, Sapovirus, and Human Adenovirus F40/F41. The most common viral and parasitic pathogens overall were Norovirus GI/GII (n = 12) and Cryptosporidium spp.(n = 5), respectively (Table 3). When we evaluated test positivity according to the pathogens, there was no statistical difference in the rate of positivity in patients with and without IBD (p>0.005) (Table 3).
Surgical procedures were performed on, 5 IBD patients with positive GI panel tests. Cutting seton was applied due to anal fistula, and segmental colonic resection was performed due to enterocutaneous fistula in one Crohn’s patient whose GI panel was positive out of 5 IBD patients. Two of 4 Crohn’s patients with negative GI panel underwent ileocecal resection due to obstruction. In one of these patients, a neuroendocrine tumor was detected in the ileum in the pathological examination of the specimen. In 4 ulcerative colitis patients with negative GI panel, cutting seton was applied in one patient due to anal fistula, palliative gastrojejunostomy was performed in one patient due to intra-abdominal Burkitt lymphoma, and total proctocolectomy and pouch ileoanal anastomosis were performed in one patient.
Discussion
Inflammatory bowel diseases are progressive, chronic, inflammatory disorders of the gastrointestinal tract. Genetic predisposition, imbalance or dysbiosis in the gut microbial community and immune response against these play a role in the development of IBD. The imbalance of gut microbiota is commonly caused by enteric pathogens, and they may act as environmental trigger in IBD patients [2]. So, our objective was to investigate the pathogens in the stools of patients with and without IBD by GI panel tests when they had diarrhea.
When the distribution of CD and UC among males and females is examined, it is observed that both genders are affected equally [6,7]. In our study, there was also no statistical difference in terms of gender in IBD and non-IBD patients (p>0.05).
The age distribution in IBD is thought to be bimodal. While the peak incidence of IBD occurs in people between the ages of 15 and 30, 10 to 15% of individuals aged over 65 years develop IBD creating a second peak. The incidence in the elderly decreases with increasing age [8]. The disease usually begins in adolescence, and about 25% of patients with IBD are younger than 20 years old. In our study, we divided the age ranges into two groups as 18-49 and 50-94 and found that pathogen positivity was higher in the younger IBD patients aged 18-49 compared to the older age group. There were statistically significant differences in terms of the age groups (p=0.0051).
Symptoms in IBD patients during the exacerbation period of the disease may be indistinguishable from gastrointestinal infections. Therefore, it is a common practice to evaluate patients with IBD for the presence of infection when their symptoms aggravate in order to make the proper diagnosis and provide effective therapy [9]. In the studies by Nobel et al. and Axelad et al., the rate of gastrointestinal pathogen positivity in IBD patients was found to be lower than that in patients without IBD [5,9]. Such a finding may be expected because IBD is a chronic and recurrent inflammatory disease, and non-infectious diarrhea can be seen frequently in IBD patients due to its nature [9]. In addition, antibiotics used in the treatment of IBD reduce the bacterial load and diversity in the guts [10]. In the analysis of our patients undergoing GI panel testing, the tests detected pathogenic agents in 38.4% (5/13) and 38% (96/253) of patients with and without IBD, respectively. We thought that similar rates between two groups were probably due to the limited number of IBD patients.
In our study, EPEC was the most frequent pathogen detected in both groups of patients. However, the rate of EPEC positivity was found to be higher in IBD patients than that in non-IBD patients. While EPEC positivity was 42.85% (3/7) in IBD patients, it was 21.8% (32/147) in patients without IBD. In similar studies, the rate of EPEC positivity was found to be higher in patients with IBD compared to those without IBD [5,9]. In addition, it is thought that E.coli species, especially EPEC, may be a predisposing factor for the development of IBD. Therefore, patients with positive GI panel tests, especially with microorganisms such as EPEC, should be followed closely if clinical suspicion for IBD is high [11].
It is observed that microbiome diversity is reduced in IBD patients compared to non-IBD patients [12]. Decreased microbiome diversity in the gut predisposes to C.difficile colonization. The PCR tests only detect the presence of nucleic acid, it is difficult to distinguish between active infection and colonization with PCR testing [12]. Therefore, it is recommended to perform the Toxin A/B EIA in PCR tests positive for C.difficile [13]. In a study conducted with patients similar to the population of our study, C.difficile rates by GI PCR panel test were found to be 11.5% and 10.1% in IBD and non-IBD patients, respectively [9]. We also detected similar positivity rates in IBD and non-IBD patients. In our study, the rate of C.difficile positivity was 14.3%(1/7) in IBD and 15%(22/147) in non-IBD. C.difficile was found in only one of our IBD patients in our study, and this patient was diagnosed with UC.
In many studies conducted with the GI panel test, Norovirus was identified as the most common viral pathogen in IBD patients [3,5,14,15]. It is well known that norovirus contributes to both the etiology and exacerbations of IBD. These researches indicated that mucosal immune response, particularly in CD, may be significantly modulated by norovirus and other viruses [5]. In studies similar to ours, the most detected virus was also norovirus, but virus positivity rates were considerably lower in IBD patients than those in non-IBD patients [5,9]. All Norovirus positivity in our study belonged to the patients without IBD. We considered that this finding was probably due to the insufficient number of IBD patients in our study.
In a study by Dizdar et al, they reported infectious bowel dysfunction in patients following Giardia infection, although its association with IBD was not specifically studied [16]. Some authors stated that helminths reduce the incidence of IBD [2,17]. In some studies with the GI panel test, almost no parasites were detected in IBD patients [3,5,9,14,15]. In our study, Cryptosporidium spp was detected in only one of 13 IBD patients.
The GI panel quickly investigates the presence of a wide variety of pathogens. It can detect pathogens that are difficult to isolate and identify in stool culture. Correct interpretation of GI panel test positivity is important, and it is also necessary to distinguish colonization from infection. It should also be kept in mind that misattribution of IBD symptoms to infections may lead to delay in treatment change, unnecessary days of isolation, excessive use of antibiotics, prolonged hospitalization and/or surgery [13]. GI panel test-negative results are also precious in IBD patient management. A negative GI panel test result is likely to modify IBD therapy; IBD medications are added or doses of the drugs already given are increased [5,15].
While the surgical treatment of CD has progressed predominantly on the management of complications, curative surgical procedures for UC have been identified [18]. In the context of UC surgery, CDI increases the required surgery in UC as well as increased postoperative complications [19]. The possibility of postoperative complications in UC can be assessed with GI panel testing.
The GI panel can offer useful data about the gut microbiome’s composition in addition to detecting pathogens. UC’s pathophysiology has been linked to changes in the microbiome, and studies have linked preoperative dysbiosis to less favorable surgical outcomes [20]. Prior to surgery, the GI panel can detect dysbiosis and provide data on the relative abundance of different bacterial taxa, enabling tailored therapies to enhance microbiome health.
However, the necessity of making a multidisciplinary decision in the surgical treatment of IBDs is the common point of all guidelines and studies [21]. With future studies, we think that pathogens and microbiota will be effective in the surgical decision and the selection of surgical procedures.
Limitations
This retrospective cohort study had limitations in documenting clinical symptoms consistently and assessing diarrhea severity, hindering comparisons. Further research is needed to establish a connection between pathogens and symptoms, determine their significance, and understand the impact on IBD progression. More prospective multicenter studies with larger patient populations are required.
Conclusions
This study found that patients with IBD had fewer bacterial and parasitic pathogens detected compared to those without IBD, potentially due to non-infectious causes of diarrhea and altered systemic immunity. Identifying any fecal pathogen is significant for treatment in IBD patients. PCR-based stool tests are advantageous over conventional methods in pathogen detection.
Acknowledgment
The authors thank the staff of the Gazi Hospital Medical Virology laboratory.
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 compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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