Supplement 1 2021
Ultrasonography in emergency service, evaluation of central venous catheterization
Dilay Satılmış 1, Oya Güven 2, Burcu Genc Yavuz 3, Mehmet Özgür Erdoğan 4, Şahin Çolak 3
1 Department of Emergency Medicine,University of Health Sciences Sultan, 2 Abdülhamid Han Training and Research Hospital, Istanbul, 2 Department of Emergency Medicine ,Rumeli University, Kırklareli, 3 Department of Emergency Medicine,University of Health Sciences Haydarpaşa Numune Training and Research Hospital, Istanbul, 4 Department of Emergency Medicine, Bahçeşehir University, Istanbul, Turkey
DOI: 10.4328/ACAM.20316 Received: 2020-08-21 Accepted: 2020-09-24 Published Online: 2020-09-28 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S1-4
Corresponding Author: Dilay Satılmış, Department of Emergency Medicine,University of Health Sciences Sultan 2 Abdülhamid Han Training and Research Hospital, Istanbul, Turkey. E-mail: firstname.lastname@example.org P: +90 (216) 542 20 00 F: +90 (216) 542 20 00 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3765-2208
Aim: In this study, we aimed to compare patients who underwent anatomic landmarks guided or ultrasound (USG) guided central venous catheterization (CVC) in terms of success rates and complications.
Material and Methods: A total of 220 patients were included in the study. Patients were divided into two groups as follows: Group U consisted of patients who underwent USG guided CVC procedure, and Group A consisted of patients who underwent CVC anatomic landmarks guided. Demographic data, CVC procedure technic, complications, and time to successful catheterization were recorded.
Results: The results showed a statistically significant difference; the length was less than 20 minutes in Group U. CVC-related complications and the mortality rate were significantly higher in Group A (p<0,01). In the analysis of all the CVCs independently from the location, the jugular vein was most preferred for the central cannulation in both landmarked and USG-guided techniques with a rate of approximately 94 % and 42 %, respectively (p<0,01).
Discussion: We found a significant increase in the success rate and a significant decrease in the complications rate and intervention duration when the USG- guided technique was preferred for central vein cannulation compared with the landmark technique. When USG is available, USG-guided procedure should become the standard for cannulation procedure in ED.
Keywords: Catheterization; Central venous; Emergency services; Ultrasonography
Central venous catheterization (CVC) is a widely used procedure in emergency departments to provide temporary or long-term vascular access. The most common indications for CVCs are as follows: hemodynamic monitoring, long-term fluid therapy, delivery of blood products or drugs (for example, chemotherapy and antibiotics), hemodialysis, an internal pacemaker need . Also, CVC is a life-saving procedure for patients with vascular access failure. Another reason to prefer CVC for peripheral veins is that CVCs are less likely to collapse or occlude with thrombus. Consequently, catheterization may provide a more long-term line.
CVC is an invasive procedure that is not without complication, the most common of which are air embolism, pneumothorax, arterial injury, arrhythmia, and infection . Complications of the central catheter are associated with many factors, such as patient-related factors, the side of intervention, the experience of the physician . The literature reports that ultrasound- guided cannulation increases the success of the procedure and reduces the complication [1, 3]. Average cost, lack of education, and experience to use ultrasounds are the common reasons for less use of ultrasound [1, 4].
Peripheral venous catheterization should not be performed if there is cellulitis or burns on the extremities, or if there is a severe acute injury to the distal or drainage site of the extremity . Hyperosmolar fluids and agents are known to cause chemical phlebitis, or sclerosis should not be administered by infusion through peripheral veins. In such cases, central venous catheterization is indispensable for treatment. The success of the central catheterization procedure depends on the anatomic region, the method applied, and the physician is performing the procedure. Complications may occur during or after the procedure. Mechanical, thrombotic, and infection-related complications may develop. Catheter malfunction, catheter breakage, air embolism, pneumothorax, arterial or nerve damage, arrhythmia, hemorrhage, sepsis are the most common .
The most common method used for catheter insertion is to follow the anatomical pathway, but the literature reports more serial USG-guided catheters interventions and fewer complications . In most cases,, many challenges arise during the anatomic landmarks guided procedure, such as short neck and suspected cervical trauma. In such situations, ultrasound- guided interventions are preferred to avoid patient movement and to achieve desired images. Besides, a portable USG device can be used to check whether the inserted catheter is in the vessel wall or at the bedside. Using this method in medical centers with USG devices reduces the number of interventions and, therefore, reduces the cost of follow-up and treatment of complications .
In this study, we aimed to compare patients who underwent anatomic landmarks guided or USG-guided central venous catheterization in terms of success rates and complications.
Material and Methods
Data extraction and the participants
Data were collected from the hospital database. Data of all the patients scheduled for central venous access in the ED during a year (January 01, 2012- March 30, 2013) were included. The patients with a lack of data, patients under 15 years of age, patients who were admitted from another hospital with already inserted CVC, patients who were referred to another hospital for further follow-up were excluded from the study.
Local ethics committee approval was obtained (number: HNEAH-KAEK 2013/70). Totally 220 patients out of 1300 were enrolled. The procedure selection was up to the physicians’ experience. Demographic data, number of interventions, CVC procedure technic, and complications were recorded. Data related to processes included vein preferred for the catheter placement (internal jugular, subclavian or femoral), measurement of the central venous diameter, number of attempts to successful catheterization, and time (minutes) to successful catheterization. Patients were divided into two groups as follows: Group U consisted of patients who underwent CVC procedure ultrasound-guided (B-mode USG), and Group A consisted of patients who underwent catheterization anatomic landmarks guided.
NCSS (Number Cruncher Statistical System), 2007 & PASS (Power Analysis and Sample Size), 2008 Statistical Software (Utah, USA) program was used for statistical analysis. Descriptive statistical methods (mean, standard deviation, median, frequency, ratio) were used to evaluate the data, and the Student t-test was used to compare normal distribution parameters. Pearson’s chi-square test, Yates Continuity Correction, and Fisher’s Exact test were used to analyze qualitative data. The results were evaluated with a 95% confidence interval and a significance level of p <0.05.
A total of 220 patients were included in the study. The ages of the patients were between 15 and 100 years; the average age was 67,29±20,16 years; %41,4 (n=91) of the patients were female, %58,6 (n=129) were male.
We investigated the ultrasound-guided and anatomic landmark guided catheter insertion attempts according to indications. The patients with hypovolemia, cardiopulmonary arrest, and the need for hemodynamic monitorization, significantly less underwent ultrasound-guided CVC (p<0,01). The patients with acute kidney injury and those who needed catheterization for hemodialysis significantly more underwent ultrasound-guided CVC (p<0,01).
We analyzed the preference of the central vein catheterization technique based on catheter localization. Ultrasound-guided central vein catheterization was significantly more preferred for jugular vein catheterizing (p<0,05). Table 1 shows the indications and the preferences of CVC technics according to the vein localization in detail.
We compared the durations for catheter insertion and the number of attempts, distinguished between the two groups. The results showed a statistically significant difference (p <0.05); the length was less than 20 minutes in Group U, and longer in Group A. Again, trial success was better in Group U compared to the Group A. Table 2 shows the duration of catheter insertion and the number of trials between the groups in detail.
We analyzed the catheter-related complications.
No pneumothorax, hemothorax, catheter embolism, air embolism, skin necrosis, pericardial tamponade was reported. All the rest complications were assigned in Group A.
The mortality rate was significantly higher in Group A (p<0,01). Catheter-related complications such as arrhythmia, vascular thrombosis infection, vein occlusion were detected in Group A, and were significantly higher (p <0.01). Table 3 shows the distribution of catheter-related complications according to the preferences of CVC techniques in detail.
CVC is a widely used procedure in emergency departments. To increase successful catheter placement and to reduce procedure-related complications, most guidelines recommend the use of the USG to guide the CVC placement [1-3]. CVC is a procedure that is most of the time is preferred for critical emergency cases: severe hypovolemia, trauma patients, hemorrhage. Some studies report preference of anatomic landmark guided catheterization of a rate of 41- 90 % [1, 4] and ultrasound-guided catheterization of a percentage of 8-32 % [3, 4]. Our rates were 77.72 % and 22.27 %, respectively. In our study, the urgent land-marked CVC indications were mostly patients with acute kidney injury, immediate preparation for hemodialysis, cardiac arrest patients, hypovolemia, and need for central monetarization. The results of our study are similar to the literature. Some studies reported that the main reasons for not using USG to guide the catheterizations were lack of training  and the absence of an ultrasound machine . We did not directly query the reason for the preference of the canulisation technique in our study. However, in our research, to understand why physicians prefer or do not prefer ultrasound guides during the central vein catheterization, we investigated the relationship between catheterization technique preference and indications for the central vein catheterization. In our study, we reported that the physicians preferred anatomic landmark guided catheterization for the emergent patients when there is shortness of time for the procedure: the patients such as hypovolemia patients, and to monitor hemodynamic of post- resuscitation patients. And when there is less urgency for the procedure, the ultrasound-guided catheterization was found preferred: e.g., in preparation for hemodialysis. Those results may suggest that physicians are tender to decide that the use of devices during urgency may cause time loss. Preference of the landmark procedure during emergencies (where you do not have the time to wait for the USG, cardiac arrest, for example) also was previously reported in some studies . To establish a decision mechanism for central venous catheterization technique preference, it is necessary to develop procedure algorithms based on time-positive outputs of USG use. Interestingly, some studies believe that physicians should still be able to perform CVC placement without the USG in case of an extremely urgent situation where the physician is unable to wait for the ultrasound machine [1-3]. Such conditions could justify teaching the landmark technique as a rescue technique. Our study and the results were not specific for certain central vein cannulation. We analyzed all the CVCs independently from the location. Nevertheless, we determined that the jugular vein was most preferred for the central cannulation in both landmarked and ultrasound-guided techniques with a rate of approximately 94% and 42%, respectively. The subclavian vein was the next preferred location for CVC. Miller et al. reported the femoral approach as most preferred in ED . Clinical trials and reports on central vein cannulation indicate different rates for the preferred vein [3, 4] unless they are not focused on the specific vein cannulation technique.
According to our results, we can argue that physicians seem to prefer immediate intervention to save time in crash emergency cases. However, when we compare and analyze durations of catheter insertion and numbers of attempts of interventions between the groups, we detected that the ultrasound-guided technique saves time: the procedure takes less time, and the intervention is more successful on the first attempt when the ultrasound guide is preferred. Our study reports show that more than 85 % of the patients’ intervention duration took less than 20 minutes when ultrasound was used to guide to venipuncture. In the landmark guided group (approximately 62 % of the patients), access and successful insertion took more than 20 minutes. In the ultrasound-guided group, only 14% of the procedures lasted over 20 minutes. Again vein catheterization attempts were made no more than twice using ultrasound, and 94 % of the patients were successfully catheterized at the first attempt, and there was no need for the third attempt when ultrasound is guiding the procedure. When the cannulation was performed landmarked, the success of the process on the first attempt was about 44 %, and more than 17 % of the processes needed more than three attempts. Previous studies report similar high rates (81.3-93.9 %) for a successful first attempt using ultrasonography and variable rates for success using the landmark technique (62-78.5 %) [4-6]. Again, some studies suggest that ultrasonographic guidance leads to a faster insertion time compared with the landmarked technique [1-3]. The possible complications of a technique are as significant as the success rates of the procedure. To compare the landmarked and the ultrasound-guided methods, we investigated the complications and the incidences. The overall complication rate in our study was 20.9% of the total number of cases (i.e. 46 cases out of 220). All complications (45 cases) were reported after landmarked cannulation. The most common complications we established in our study were catheter infection, arrhythmia, vein obstruction, and thrombosis. Most studies report fewer complications with ultrasound use [1, 4-7].
The anatomically guided technique may lead to more complications because an increase in the number of insertion attempts is associated with a higher complication rate. The incidence of complications in our study is relatively low.
Our study results will contribute to the literature, as there are only a few studies on central venous access techniques in the ED.
The current study has several limitations. First of all, the fact that the study was not multi-centered is an important limitation. However, it was performed in high-volume emergency departments and all consecutive patients meeting the criteria were included, thereby limiting selection bias. Secondly, the number of patients was limited; we think that further studies with a larger number of patients will add significance to this subject.
We found a significant increase in the success rate and a significant decrease in the complications rate and intervention duration, when the ultrasound-guided technique is preferred for central vein cannulation compared with the landmark technique. When ultrasonography is available, ultrasonographically- guided procedure should become the standard of cannulation procedure in ED.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
1. Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation. 1993; 87(5): 1557-62.
2. Mariantina F, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011; 39(7): 1607-12.
3. Maizel J, Bastide MA, Richecoeur J, Frenoy E, Lemaire C, Sauneuf B, et al. Practice of ultrasound-guided central venous catheter technique by the French intensivisits: a survey from the BoReal study group. Ann Intensive Care. 2016;6(1): 76.
4. Ullman AJ, Marsh N, Mihala G, Cooke M, Rickard CM.Complications of central venous Access devices: a systematic review. Pediatrics, 2015; 136(5):e1331-e44.
5. Calvache JA, Rodríguez MV, Trochez A, Klimek M, Stolker RJ, Lesaffre E. Incidence of mechanical complications of central venous catheterization using landmark technique: do not try more than 3 times. J Intensive Care Med. 2016;31(6): 397-402.
6. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006; 48(5):540-7.
7. Dudeck O, Teichgrager U, Podrabsky P, Haenninen EL, Soerensen R, Ricke J. A randomized trial assessing the value of ultrasound-guided puncture of the femoral artery for interventional investigations. Int J Cardiovasc Imaging. 2004;20 (5): 363-8.
Download attachments: 10.4328_ACAM.20316
Dilay Satılmış, Oya Güven, Burcu Genc Yavuz, Mehmet Özgür Erdoğan, Şahin Çolak. Ultrasonography in emergency service, evaluation of central venous catheterization. Ann Clin Anal Med 2021;12(Suppl 1): S1-4
Preferred career choice of medical students at a medical university in Vietnam
Nhat Ngo Minh
Vietnamese – German Faculty of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh city, Vietnam
DOI: 10.4328/ACAM.20317 Received: 2020-08-22 Accepted: 2020-09-22 Published Online: 2020-10-10 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S5-9
Corresponding Author: Nhat Ngo Minh, Vietnamese – German Faculty of Medicine, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung street, Ho Chi Minh city, Vietnam. E-mail: email@example.com P: +84982108108 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5060-1301
Aim: This research identifies the ratio of medical specializations among categories of career groups and analyses the differences between urban and suburban student backgrounds at a medical school in Ho Chi Minh City, South Vietnam.
Material and Method: A cross-sectional questionnaire survey was conducted at the beginning of 2019. Data and information collection for this study involved current (2019) medical students at the Pham Ngoc Thach University of Medicine in Ho Chi Minh City, South Vietnam. A total of 1,030 current medical students participated in this study that consisted of 240 third-year students, 256 fourth-year students, 276 fifth-year student, and 258 sixth-year students.
Results: The findings of this research show that students of PNTU tended to become medical specialists rather than medical practitioners. Those who pre- ferred family medicine to other disciplines were slightly older (23.8 > 22.95, p =0.046); fifth and sixth year students (31.6% and 50% respectively) and female students tended to choose family medicine more than males (63.1% vs 34.2%). Female students chose internal medicine (59% vs 38.7%) and medical science (62.6% vs 35.8%) more than males. A small number of suburban students wanted to become family physicians, while most students wanted to be specialists (2.7% vs 97.3%, p<0.001).
Discussion: This study has discovered that the number of medical students who prefer specialist training outnumbers those interested in becoming medical generalists. In Vietnam, less than 15% of the total participants considered family medicine or general internal medicine as an ideal career.
Keywords: Medical student; Specialist; Family medicine
Since the 19th century, studies have found that a higher ratio of primary care physicians in the population produces better health outcomes [1-3]; lowers the rate of all causes of mortality, such as low birth weight and lifestyle factors (obesity, alcohol use, and smoking); and improves sociodemographic measures (percentages of elderly, urban, and minorities; education; income; unemployment; and pollution) [4,5]. However, studies have also found that in low and middle- income countries, Universal Health Coverage (UHC) cannot be fully implemented because the number of primary care providers is relatively low .
A key problem in this circumstance was that family medicine practitioners are in extremely short supply. This lack of family physicians is a major issue for Vietnam in relation to the implementation of the PHC strategy and in the pursuit of UHC. Although the need for family physicians was mentioned in the plan Decision No. 935/QB-BYT, the total number of doctors of this type is currently small. In this case, it is necessary to innovate and develop a strategy to encourage medical students, who are the future health workforce, to follow family medicine training and practice to align with and suit the transition of the Vietnamese health system.
This research identifies the ratio of medical specialization among categories of career groups and analyses the differences between urban and suburban student backgrounds at a medical school in Ho Chi Minh City, South Vietnam.
Material and Methods
The main objective of this study is to explore the factors affecting students’ choice of career, identify the differences between the students who choose family medicine and other specializations, and identify factors that positively influence the selection of family medicine as the postgraduate training program.
To implement this investigation, a cross-sectional survey was applied in this research. A cross-sectional study design is a type of observational study design, in which the investigator simultaneously measures exposures and outcomes in the study participants .
Population and Criteria Selection
At Pham Ngoc Thach University of Medicine (PNTU), the general physician program encompasses 6 years of training: medical students acquire a learning foundation within the first 2 years of full time at the university.
A cross-sectional survey involving undergraduate medical students who have clinical experience was planned. Thus, first and second year students were excluded from the survey. Due to the previous recruitment policy of PNTU, only Vietnamese students with Ho Chi Minh citizenship are eligible to be enrolled in this medical program. Thus, international students and rural students who enrolled to follow the incorporation program (students who were sent from rural areas and will return back after finishing the program) are disregarded for this study. Consequently, the qualified population for this study was as follows: third-year, fourth-year, and sixth-year students, who have official citizenship in Ho Chi Minh city.
The data analyses were descriptively presented with frequency distributions and percentages. The Chi-square test was utilized to test the relationship between discrete variables. In the case of a small number in comparison, the Fisher test was applied to test the relationship of independent variables among the small size of the dependent variable. A χ2 level of 5% (p=0.05) was used to test for statistical significance.
This study received ethics approval from PNTU (Protocol 5732/ QD-TDHYKPNT). Informed consent was obtained from each student invited to participate in the research project, which was administered in the format of an electronic-based survey questionnaire. No personal identification was required during the data collection process.
A total of 1,030 (87%) respondents completed the survey in response to original invitations to participate in this study. The response rates were 80.8% (240 of 297), 85.5% (256 of 303), 93% (276 of 297) and 89.9% (258 of 287) for third-year, fourth-year, fifth-year, and sixth-year students, respectively (Table 1). Overall, the respondents were predominantly single (99.3%); 56.0% of respondents were female; most were living in an urban setting (89.2%); and they did not have parents (80.%) or relatives (57%) who were health workers.
In general, the overall mean age of respondents was 22.9 (SD=1.4) years. In addition, there was a significant difference in the mean age amongst each group (p=0.026) and between students who preferred FM and those who preferred a specialization (p=0.046). Students who preferred FM tended to have a higher age (23.8 vs. 22.9) (Table 1). In relation to parent’s education, 48.9% of respondents’ fathers had bachelor qualifications and 40.6% had mothers with high school/junior high school qualifications. However, the results showed no significant difference amongst groups or between the FM group and the combined group (Table 2).
In regard to social-economic status (as shown in Table 3), the income-earning per person index recorded that the majority (45%) of the household income of students was 2.5–10 million VND, 27.1%: 10–20 million VND, 18.2% earned over 20 million VND, and only 5% earned less than 2.5 million VND. The χ2 test revealed a significant difference between urban and suburban family earnings, demonstrating that urban families tend to have higher incomes compared with suburban families (p=0.014). After summarising the item list of respondent inputs, the wealth indexshowedthatthemajorityofstudents’familiesbelonged to the middle class (38.1%) and high-middle class (37.5%). Furthermore, about 74.1% of students declared that they were totally dependent on family income, and 17.7% of students had incomes of less than 2.5 million VND (approximately $US 100) per month. The index also confirmed that there was no difference in economic status affecting students’ choice of the medical profession. Based on the results, it can be concluded that the career choice did not depend on the demographic information of medical students, except for the mean age (students who preferred FM were slightly older than the rest of the students).
This study revealed a trend of career choice amongst the medical students of PNTU which demonstrates that internal medicine and surgical specialization were the two dominating groups, accounting for more than 80% of the total student preferences while less than 20% included emergency medicine, medical science, family medicine, and other groups. In general, the ratio among medical career groups reflected the present situation of the health workforce in Vietnam, following the disease pattern and the previous development trend of Vietnam’s health delivery system (hospital-centrism) . As the success of the Satellite Hospital project, which was designed to strengthen capacity for and quality of care at the lower level hospitals, progresses, more job opportunities are being created in that hospital workplace. The family doctor network project has met many difficulties and has had to manage with limited resources along with the distrust of the Vietnamese community. These issues help explain why most of the medical students tended to choose internal medicine and surgery: they have a greater chance of working in a hospital environment with better clinical conditions than CHC or in the university environment . To support this point, most of the students from internal medicine and surgery groups indicated a high preference for working in an urban center (more than 80%), and more than 80% of them confirmed that they chose the disciplines in order to secure more job opportunities to work in hospitals and achieve promotions. However, students who preferred family medicine and medical science also liked to work in the hospital, but there are limited positions available, and their working environment organized in the university, laboratory or CHCs setting usually has lower condition compared to hospitals. Therefore, the other ratio also shows that a limited number of students preferred family medicine (less than 6%) and medical sciences (about 8%). Overall, the hospital-centrism trend continues to influence the career choices of medical student, and this has resulted in a huge number of students who preferred jobs in urban hospitals. It is expected that the family doctor clinic model will continue to face more difficulties in providing primary care services under the principles of family medicine due to the low interest to the discipline.
Moreover, this study also observed a tendency to choose a profession in different learning groups. Our data show the decreasing trend of internal medicine and surgical specialization groups along with a significant increase in Family Medicine and Medical Science groups among the third-year to sixth- year students. Both internal medicine and surgery accounted for more than 90% of choices in the perception of third-year students. This can be explained by the first-year program, which merely focuses on internal medicine and surgical specialization. However, in the selection of fourth-year students, the percentage of surgery was significantly dropped. It could be argued that surgery is a difficult course that PNTU students usually struggle to complete. According to the clinical program, many courses are more related to internal medicine than surgery, and this explains why the percentage of choice for Surgery has dropped, while internal medicine has increased significantly this year. In the next two years of the training program, there was a balance between internal medicine and surgery, along with other courses such as family medicine, public health, and preventive medicine, providing students more options for future careers. Therefore, there was a decrease in the percentage of the two major groups along with a significant increase in family medicine and medical sciences choices. For example, students started to study family medicine in the fifth year of the program, and then the percentage of family medicine almost doubled in the choice of sixth year students (4.3% –7.4%). In short, the curriculum of the medical training program indirectly contributes to the career selection of students.
The results of this study identified the ratios amongst medical student career groups and found that more than 80% of students specified that they saw themselves in the internal medicine and surgery groups. Moreover, the findings highlighted the most favored medical careers among students, and these included disciplines such as pediatrics, family medicine, dermatology, general internal medicine, otolaryngology, neurology, obstetrics/ gynecology surgery, and imaging diagnosis.
We would like to thank Pham Ngoc Thach University of Medicine that supported the facilities to do this research.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
1. Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives. Soc Sci Med. 2010;70:904-11.
2. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38:831-65.
3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
4. Shi L. The relationship between primary care and life chances. J Health Care Poor Underserved. 1992;3:321-35.
5. Shi L. Primary care, specialty care, and life chances. Int J Health Serv. 1994;24:431-58.
6. Watkins DA, Jamison DT, Mills T, Atun T, Danforth K, Glassman A, et al., Universal Health Coverage and Essential Packages of Care, in Disease Control Priorities: Improving Health and Reducing Poverty, et al., editors, 3rd, Washington (DC): 2017.
7. Setia MS. Methodology Series Module 3: Cross-sectional Studies. Indian J Dermatol. 2016;61:261-4.
8. Takashima K, Wada K, Tra TT, Smith DR. A review of Vietnam’s healthcare reform through the Direction of Healthcare Activities (DOHA). Environ Health Prev Med. 2017;22:74.
9. Mosadeghrad AM. Factors Affecting Medical Service Quality. Iran J Public Health. 2014;43:210-20.
Download attachments: 10.4328_ACAM.20317
Nhat Ngo Minh. Preferred career choice of medical students at a medical university in Vietnam. Ann Clin Anal Med 2021;12(Suppl 1): S5-9
Mid-term and short-term efficacy of percutaneous pharmacomechanical thrombectomy in deep venous thrombosis
Ali Cemal Düzgün 1, Ekin İlkeli 2
1 Department of Cardiovascular surgery, Ankara Training and Research Hospital, Ankara, 2 Department of Cardiovascular surgery, Düzce State Hospital, Düzce, Turkey
DOI: 10.4328/ACAM.20318 Received: 2020-08-24 Accepted: 2020-09-24 Published Online: 2020-10-05 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S10-14
Corresponding Author: Ekin İlkeli, Department of Cardiovascular surgery, Düzce State Hospital, Düzce, Turkey. E-mail: firstname.lastname@example.org P: +90 380 529 13 00 GSM: +90 505 638 43 72 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0302-4721
Aim: In this study, we aimed to evaluate the success and clinical results of the Mantis XP pharmacomechanical thrombectomy catheter in 64 patients.
We evaluated the efficacy and results of pharmacomechanical thrombectomy treatment in acute and subacute deep vein thrombosis.
Material and Methods: Sixty-four patients with acute or subacute deep vein thrombosis of lower extremities underwent a single-session pharmacomechanical thrombectomy between 2015 and 2018. Leg circumferences and clinical outcomes were assessed 2 years after the procedure.
Results: Body mass index was 25-30 mg/kg2 in 51.6%, 30-40 mg/kg2 in 21.9% and >40 mg/kg2 in 2% of the patients.When leg circumferences were evaluated during and 2 years after the procedure, a significant reduction in circumference was found both at thigh and calf level (p<0.001).
Discussion: Pharmacomechanical thrombolytic treatment is based on interventional lysis of endovenous thrombosis and emerged as an alternative to open sur- gery, thrombectomy, and catheter-directed thrombolysis. Pharmacomechanical thrombectomy is safe and effective in the treatment of deep vein thrombosis.
Keywords: Venous thromboembolism; Thrombectomy; Thrombolysis; Mechanical thrombectomy
Venous thromboembolism has an annual incidence rate as high as 1-2 per 1000 and usually appears in the form of deep vein thrombosis (DVT). Approximately 20% of patients with symptomatic DVT develop “post-thrombotic syndrome (PTS)” with chronic leg pain, swelling, venous stasis, and leg ulcers . PTS is the main underlying reason of the high morbidity, poor quality of life, and socio-economic losses in the long term. The conventional treatments used for the prevention of PTS in patients with DVT are not yet considered sufficiently successful enough.
It has been demonstrated that DVT patients with iliofemoral segment involvement, in particular, have higher rates of PTS and lower quality of life when they are treated with anticoagulants alone .
The anticoagulants used in the standard treatment are known to reduce pulmonary embolism and mortality, while they were shown not to decrease the PTS risk since they do not reduce existing thrombus burden .
Some studies reported a PTS rate of 20-50% and a venous ulcer rate of 5-10% following standard anticoagulant treatment . Systemic thrombolytic agents have found no place in the treatment of DVT due to their side effects such as bleeding. Recently, catheter-mediated thrombolysis and pharmacomechanical thrombectomy devices have been used to reduce the high PTS rates. Thereby, the high bleeding risk associated with the use of thrombolytic agents is avoided by administering lower doses of these agents directly into the thrombus. It was shown that the reduction of thrombus burden with the use of catheter-mediated thrombolysis and other FMT devices can be effective in the prevention of permanent venous obstruction and venous valve damage [4,5]. Early reduction in thrombus load with this method is a promising strategy to decrease venous hypertension and the rate of PTS with the prevention of venous valvular damage.
Recently, endovenous catheter-mediated pharmacomechanical thrombolysis (PMT) procedures are being performed in an increasing number of centers and particularly as the first choice in the treatment of iliofemoral DVT in some clinics. Growing experience and favorable results with PMT have made it a more widely used method in the light of the high rate of PTS.
While the short-term results of PMT are favorable, there are limited studies on the long-term results.
In this study, we aimed to present the mid- to long-term results in terms of PTS in patients undergoing PMT. Moreover, the association between mid- to long-term results and various parameters, including etiology, gender, and body mass index were evaluated in this study.
Material and Methods
Sixty-four patients (32 males and 32 females) presenting with only acute or subacute iliofemoral DVT who were treated with PMT (Mantisxp Thrombectomy Device, İnvamed, TR) between 2015 and 2018 were included in the study.
All patients presented to the emergency service or outpatient clinic with complaints of leg pain and swelling and were hospitalized with the definitive diagnosis of DVT made using Doppler ultrasonography. All patients had high (femoral and/or
iliac vein) deep vein thrombosis. The mean age of the patients was 49.5 years (range 17-77 years).
Patients with recurrent DVT, DVT at a lower level, symptom duration of more than 2 weeks, life expectancy of less than 1 year, and/or additional risk factors for thrombolytic therapy were excluded.
Patients considered for PMT underwent the procedure under local anesthesia at the interventional radiology unit after providing informed consent. The vena cava filter was placed below the renal vein via the femoral vein with the patients in the supine position and then the patients were turned into the prone position (Figure 1). A 0.35-inch guidewire was inserted into the involved popliteal vein with percutaneous puncture under US guidance while the patients were in the prone position, and then a 7-Fr sheath was inserted into the popliteal vein via the guidewire. The occluded venous segments were assessed with venography performed through the sheath in the popliteal vein. The PMT thrombectomy procedure was then performed with tPA infusion by inserting a 6-F thrombectomy catheter (Mantisxp Thrombectomy devices) through the sheath in the popliteal vein and gradually advancing the catheter first to the inguinal level and then into the iliac veins (Figure 2). Optimal patency was tried to be achieved by applying the same procedure to the regions with inadequate patency on venograms performed after thrombectomy. The procedure was terminated in patients with adequate patency and these patients were followed up in the ward for potential complications.
In patients hospitalized for PMT, LMWH treatment (bemiparin sodium, 115 IU/kg, SC, once daily) was initiated immediately after the diagnosis and PMT was performed as soon as possible. In patients with no post-PMT complications, oral warfarin was initiated on top of LMWH treatment with regular INR measurements and LMWH treatment was stopped and oral warfarin treatment was continued when INR was >2. Patients who achieved effective INR levels were discharged on oral warfarin with advice to use compression stockings. Patients were followed up at 3-month intervals and remained on warfarin treatment for at least 6 months after discharge. Patients were advised to use compression stockings for 2 years. Calf and thigh circumferences of the patients were measured and patients were asked to assess their pain levels on the pain scale before and 24 hours after the procedure and every 6 months thereafter. Control Doppler US examination was performed at 6-month intervals.
Statistical analyses were performed using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA). The variables were evaluated using visual (histograms, probability plots) and analytic methods (Kolmogorov-Smirnov /Shapiro-Wilk test) to determine whether or not they are normally distributed. Descriptive analyses were presented using means and standard deviations for normally distributed variables. Frequencies and percentages were given for categorical and nominal variables. Repeated measures analysis of variance was used to explore the effect of the procedure (PMT) on the change in thigh and leg circumferences. The Chi-square test or Fisher’s exact test, where appropriate, was used to compare the proportions of Doppler US findings and pain scale categories and also to compare gender and thrombus status during follow-up. A p-value of less than 0.05 was considered to show a statistically significant result.
The mean follow-up was 24.38 months (range 3-40 months). All patients had thrombosis at the iliofemoral level with a symptom duration of less than 2 weeks. Twenty-eight patients (43.8%) had right and 36 patients (56.3%) had left lower extremity involvement. DVT etiologies are presented in Table 1. Thirty-one patients (48.4%) had history of smoking. Body mass index was 25-30 mg/kg2 in 51.6%, 30-40 mg/kg2 in 21.9% and >40 mg/kg2 in 2% of the patients.
After the PMT procedure, 5 patients developed hematoma in the popliteal region and only one of these patients required surgical exploration and vascular repair. In the remaining 4 patients, hematoma regressed with compression. One patient developed complaints similar to contrast allergy but these complaints were resolved in a short time without requiring any medication. None of the patients had severe bleeding. Almost all patients experienced a dramatically marked decrease in pre- and postprocedural pain. Pain scores measured before, after, and at 2 years after the procedure are presented in Figure 1. Significant differences were found between preprocedural, postprocedural, and 2-year measurements (p<0.001) (Figure 3a).
When preprocedural, post-procedural, and 2-year leg circumferences were evaluated, significant reductions in circumference were found both at thigh- and calf-levels (p<0.001) (Figure 3b). Control US examinations of the patients revealed that the patients with scores of 3-4 on the pain scale at 2 years had US findings consistent with thrombus and this relationship was statistically significant (p<0.001). Two of these patients developed stasis dermatitis during follow-up. No significant relation was found between control US findings and the etiological classification of DVT (p>0.05). Gender and age were not significantly related to control US findings and pain.
Early diagnosis and treatment of DVT complications are critical since they lead to high mortality and morbidity rates and long-term work loss and require long-term and expensive treatments. PMT should be used in patients with an active life, phlegmasia cerulea dolens, early diagnosis (acute or subacute), and iliofemoral involvement.
The short-term results of PMT, which is increasingly more commonly used in patients with high DVT, are pleasing, while its long-term results, particularly with respect to PTS, are still unclear. Many studies reported an unacceptable long-term PTS rate of 25-46% with classical anticoagulant treatment alone in iliofemoral DVT. There are studies showing that the PTS risk during 5-year follow-up periods is reduced by the use of PMT [6,7].
DVT is caused by immobilization, surgery, trauma, older age, malignity, factor deficiencies (protein c-protein s-antithrombin), factor V mutation and medications such as oral contraceptives. The American Venous Forum’s suggestion that ‘PMT should be performed within 14 days of symptom onset’ may explain the favorable results in terms of both PTS and venous patency [8,9]. Conventional treatment involves the use of warfarin, low-molecular-weight heparin or NOACs. Recently, PMT, thrombolysis, and similar methods have started to be used.
In our study, control US examinations and pain and leg circumference evaluations performed during mid- to long-term follow-ups after the PMT procedure revealed a rate of 10.9% for PTS findings. Two patients had stasis dermatitis. This suggests that this rate may increase even further with longer follow-up.
Pharmacomechanical thrombolytic treatment (PMT) is based on the interventional lysis of endovenous thrombosis and emerged as an alternative to open surgery, thrombectomy, and catheter- directed thrombolysis (CDT). Although the long-term effects of this treatment have not been reported in the multicenter randomized controlled studies published so far, observational studies have reported successful PMT practices .
There is consensus on the use of CTD or thrombolytic treatment in addition to PMT treatment in patients without contraindications [11-12].
Recent studies reported that IVC (inferior vena cava) filter reduces the risk of pulmonary embolism [13, 14]. In our study, all patients were successfully implanted with an IVC filter. Filters were removed from all except two patients. We believe that the IVC filter should be routinely used in all patients, despite the manual aspiration feature of the Mantis PMT catheter. The catheter aspirates blood clots near its lumen, but this is not sufficient in segments with higher thrombus loads, since it moves centripetally in the direction of the flow.
When PTS is evaluated in relation to the open vein hypothesis, venous patency was found in 92.1% of our patients. We believe that this resulted from the admission of the patients in acute- subacute phase and from the thrombus quality.
In general, symptom duration for more than 10 days was reported to reduce the rate of complete thrombus resolution [15,16].
Another conclusion of this study is that this procedure provides quite satisfactory thrombus resolution as well as significant symptomatic improvement.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
1. Ho WK, Hankey GJ, Lee CH, Eikelboom JW. Venous thromboembolism:diagnosis and management of deep venous thrombosis. Med J Aust 2005;182(9):476-81.
2. KahnS,ShrierI,JulianJ,DucruetT,ArsenaultL,MironM-J,etal.Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149(10):698-07.
3. Sharafuddin MJ, Sun S, Hoballah JJ, Youness FM, Sharp WJ, Roh BS, et al. Endovascular management of venous thrombotic and occlusive diseases of thelower extremities. J Vasc Interv Radiol. 2003;14:405-23.
4. Schulman S, Lindmarker P, Holmstrom M, Lärfars G, Carlsson A, Nicol P, et al. Post-thrombotic syndrome,recurrence, and death 10 years after the fi rst episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006; 4(4): 734–42.
5. Enden T, Wik HS, Kvam AK, Haig Y, Kløw NE, Sandset PM, et al . Health-related quality of life after catheter-directed thrombolysis for deep vein thrombosis: secondary outcomes of the randomised, non-blinded, parallel-group CaVenT study. BMJ Open. 2013;3(8):e002984.
6. Van Dongen CJJ, Prandoni P, Frulla M, Marchiori A, Prins MH, Hutten BA. Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome. J Thromb Haemost. 2005;3(5): 939-42.
7. Haig Y, Enden T, Grøtta O, Kløw N-E, Slagsvold C-E, Ghanima W, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. Lancet Haematol. 2016;3(2): 64-71.
8. Meissner, MH Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, et al. Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012;55(5):1449-62.
9. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et al. VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007; 98(4):756-64.
10. Köksoy C, Yılmaz MF, Başbuğ HS, Calik ES, Erkut B, Kaygın MA, et al. Pharmacomechanical Thrombolysis of Symptomatic Acute and Subacute Deep Vein Thrombosis with a Rotational Thrombectomy Device. J Vasc Interv Radiol. 2014; 25(12): 1895–900.
11. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999; 211(1): 39–49.
12. McLafferty RB. Endovascular management of deep venous thrombosis. Perspect Vasc Surg Endovasc Ther. 2008; 20(1): 87-91.
13. Sharifi M, Bay C, Skrocki L, Lawson D, Mazdeh S, et al. Role of IVC filters in endovenous therapy for deep venous thrombosis: the FILTER-PEVI (Filter Implantation to Lower Thromboembolic Risk in Percutaneous Endovenous Intervention) trial. Cardiovasc Intervent Radiol. 2012; 35(6): 1408–13.
14. Karthikesalingam A, Young EL, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJE. A Systematic Review of Percutaneous Mechanical Thrombectomy in the Treatment of Deep Venous Thrombosis. Eur J Vasc Endovasc Surg. 2011;41(4):554-65.
15. Park SI, Lee M, Lee MS, Kim MD, Won JY, Lee DY. Single-session aspiration thrombectomy of lower extremity deep vein thrombosis using large-size catheter without pharmacologic thrombolysis. Cardiovasc Intervent Radiol. 2014;37(2):412–19.
16. Rosfors S, Noren A. Venous Haemodynamics and Morphology in Relation to Recanalisation and Thrombus Resolution in Patients with Proximal Deep Venous Thrombosis. Phlebology. 1999;14:33-8.
Download attachments: 10.4328_ACAM.20318
Ali Cemal Düzgün, Ekin İlkeli. Mid-term and short-term efficacy of percutaneous pharmacomechanical thrombectomy in deep venous thrombosis. Ann Clin Anal Med 2021;12(Suppl 1): S10-14
Cobb angle measurement and pelvic inclination in children with spastic cerebral palsy: A cross-sectional study
Doaa Attia Gamil Hassan 1, Elham ElSaid Salim 2, Sherif N.G. Bishay 3, Mahmoud S. El Fakharany 4
1 Physiotherapist at Cairo University Specialized Pediatric Hospital (CUSPH), 2 Department of Physical Therapy for Pediatrics , Faculty of Physical Therapy, 3 Department of Orthopedic, National Institute of Neuro Motor System (NINMS, GOTHI), 4 Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
DOI: 10.4328/ACAM.20319 Received: 2020-08-27 Accepted: 2020-09-29 Published Online: 2020-10-28 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S15-19
Corresponding Author: Mahmoud S. El Fakharany, Lecturer of Pediatric Physical Therapy, Department of Physical Therapy for Pediatrics , Faculty of Physical Therapy, Cairo University, 11816, Cairo, Egypt. E-mail: Mahmoud.email@example.com P: 01067904792 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3943-4469
Aim: This study aimed to determine the correlation between pelvic inclinations and spinal alignment in children with cerebral palsy.
Material and Methods: Sixty children with spastic cerebral palsy from both sexes, aged 5 to 10 years, only with grade 1 or 1+ on the Ashworth scale, who can stand independently without assistive devices level I, II according to the Gross Motor Function Classification System (GMFCS)were selected. All children were assessed for measuring pelvic inclination using pelvic inclinometer and spinal alignment using radiological X-rays, and then measuringthe Cobb angle and correlation between the results.
Results: There was a significant moderate positive correlation between the right anterior pelvic tilt and theLordotic Cobb’s angle (r = 0.314, p = 0.01) and a significant weak positive correlation between left anterior pelvic tilt and Lordotic Cobb angle (r = 0.268, p = 0.03). However; there was a moderate negative significant correlation between the right anterior pelvic tilt and kyphotic Cobb’s angle (r = -0.313, p = 0.01) and a significant weak negative correlation between left anterior pelvic tilt and kyphotic Cobb angle (r = -0.27, p = 0.03).
Discussion: The extent of the lumbar Lordotic curve and the degree of pelvic inclination in a standing position are associated with the muscle lengths of the sagittal-plane pelvic rotators and the performance (strength) of the abdominal muscleswhich are affected in a patient with cerebral palsy (as they have weak- ness in core muscles). The rehabilitation program for children with cerebral palsy should include pelvic tilt correction and core stability exercise.
Keywords: Pelvic inclination; Spinal alignment; Pelvic inclinometer; Spastic cerebral palsy
Cerebral Palsy (CP) is described as a group of disorders of the development of movement and posture, causing activity limitation due to non-progressive disturbances that occurred in the developing fetal or infant brain . Spasticity is the most common motor disorder seen in CP defined as an abnormally increased resistance to externally imposed movement about a joint. Spasticity causes hypertonia that increases with increasing velocity of movement or causes a spastic catch. It can affect the entire body, including the trunk, face, and neck. It tends to be worse in the lower limbs in those with bilateral involvement, and in the upper limbs in those with unilateral involvement . Alignment to anatomical landmarks of the pelvis, most commonly the anterior superior iliac spines and the pelvic symphysis defines the anterior pelvic plane. The orientation of the anterior pelvic plane can differ considerably in the standing or lying position with respect to the frontal plane. This difference is defined as pelvic inclination. Zero pelvic inclination occurs when the anterior pelvic plane is parallel to the frontal plane . An inclinometer is a methodwhich was introduced for measurement of pelvic tilt of the anterior plane. These authors constructed an inclinometer that could be pressed firmly against the anterior pelvic spines and the symphysis . Children with CP have an increased risk of developing scoliosis compared to other patient populations. Muscle weakness, truncal imbalance, and asymmetric tone in paraspinal muscles have long been implicated in the onset of scoliosis in CP, but there is little literature to support this theory . The prevalence of spinal deformities in patients with cerebral palsy ranges from 10% of ambulatory patients with spastic hemiplegia to 65% of those with spastic quadriplegia . Neuromuscular scoliosis that occurs in CP is typically a C-shaped curve that is often kyphoscoliotic and associated with pelvic obliquity .
In the standing position, with the pelvis held in an anteriorly tilted position, the spinal column rests on the sacrum. The superior surface of the sacrum slopes forward. This is described as the “base angle” of the lumbar spine – the angle between the plane through the L5-S1 interspace and the horizontal. The greater the base angle, the more pronounced the lumbar lordosis .
Right anterior pelvic tilt is measured by using the pelvic inclinometer from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine on (PSIS) on the right side, and also the left anterior pelvic tilt is measured from the ASIS to the PSIS on the left side.
Material and Methods
This study was carried out on 60 childrenof both sexes with spastic cerebral palsy, aged 5 to 10 years, who were selected from the Outpatient clinic of Cairo university hospitals, Egypt (30 children with spastic hemiplegia, 30 children with spastic Diplegia). They were enrolled and assessed for their eligibility to participate in the study, as they were selected only with grade 1 or 1+ on the modified Ashworth scale and can stand independently without assistive devices level I, II in Gross Motor Function Classification System (GMFCS). The children were excluded if they had moderate or severe mental ability or if they had taken a Botox injection in the last 6 months or underwent orthopedic surgeries in the last 2 years. All children were assessed for pelvic inclination using pelvic inclinometer and for spinal alignment using radiological X-rays.
This study was approved by Cairo University Research Ethical Committee and written informed consent was obtained from the parents to participate in this study.
Measurement of pelvic tilting:
In a standing position, the child was asked to take the most erect position as much as possible, and stand barefoot, and with the hand-held pelvic inclinometer, pelvic inclinationcould be measuredby determining the angle formed by a horizontal line drawn between the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS). Each measurement was repeated two or three times so that the reliability of the measurements could be determined .
Measurement of Cobb’s angle:
For the lateral view, the child was asked to take the most erect position as much as possible, looking straight ahead with shoulders flexed and hands placedforward. This keeps the upper extremities from being superimposed over the spine on the lateral view. The most commonly used and most accurate measurement of spinal curvature is the Cobb angle. It is obtained by measuring the maximal angle from the superior endplate of the superior-end vertebra to the inferior endplate of the inferior- end vertebra. If endplates are difficult to visualize, the borders of the pedicles may be used. The measurements obtained using this method should be precise and reproducible .
Descriptive statistics were utilized in presenting the subjects demographic and clinical data. Quantitative variables were summarized using mean and standard deviation while categorical variables were summarized using frequencies and percentage. Pearson Correlation Coefficient was conducted to determine the correlation between pelvic tilt, lordotic Cobb angle and kyphotic Cobb angle. The level of significance for all statistical tests was set at p < 0.05. All statistical measures were performed through the statistical package for social sciences (SPSS) version 25 for Windows.
Sixty children with CP participated in this study. Participant characteristics are presented in Table 1. Twenty (33.3%) subjects had right-sided hemiplegia, 10 (16.7%) had left-side hemiplegia and 30 (50%) had Diplegia. Spasticity ranged from grade I to grade I+ and 47 (78.3%) subjects had grade I GMFCS and 13 (21.7%) had grade II.
Lordotic Cobb angle, kyphotic Cobb angle, right and left anterior pelvic tilt angles in the study group
The mean ± SD Lordotic cobb angle in the study group was 36.03 ± 14.67 degrees and kyphotic Cobb angle was 42.68 ± 13.77 degrees. The mean ± SD anterior pelvic tilt angle on the right side was 12.25 ± 5.39 degrees and that on the left side was 13.2 ± 5.41 degrees.
Correlation between pelvic tilt, Lordotic Cobb’s angle and kyphotic Cobb’s angle in the study group
There was a significant moderate positive correlation between right anterior pelvic tilt andLordotic Cobb angle (r = 0.314, p = 0.01) and a significant weak positive correlation between left anterior pelvic tilt and Lordotic Cobb angle (r = 0.268, p = 0.03). However, there was a moderate negative significant correlation between right anterior pelvic tilt and kyphotic Cobb’s angle (r = -0.313, p = 0.01) and a significant weak negative correlation between left anterior pelvic tilt and kyphotic Cobb angle (r = -0.27, p = 0.03) (Table 3, Figures 1-4).
The pelvis in the sagittal plane is commonly analyzed using 3 angular measurements: pelvic tilt, pelvic incidence, and sacral slope .
Pelvic tilt is defined by the line through midpointof the sacral plate and midpoint of the femoral heads axis, and the vertical ‘‘pelvic incidence’’, which was defined as the angle between the line perpendicular to the sacral plate at its midpoint, and the line connecting this point with the axis of the femoral heads . Sacral slope is defined as the angle between the horizontal and the sacral plate. It is hypothesized that the increased sacral slope creates greater lumbosacral lordosis .
It is a fact that the spine rests on top of the pelvis. It is unavoidable, therefore, that anything that affects the posture or stability of the pelvis of an upright human will also affect the spine. This applies to many postures and movements, although the standing and sitting postures are of most interest to ergonomists .
According to scientific studies, in a standing position with the pelvis held in an anteriorly tilted position, the spinal column rests on the sacrum. The superior surface of the sacrum slopes forward. This is described as the “base angle” of the lumbar spine – the angle between the plane through the L5-S1 interspace and the horizontal. The greater the base angle, the more pronounced the lumbar lordosis .There is never a lumbar curve if the base angle was less than 18 degrees. Conversely, a rounded back has never been seen if the base angle was greater than 10 degrees .The idea of this study corresponds to the study by Kendall et al who said that the extent of the lumbar Lordotic curve and the degree of pelvic inclination in the standing position are associated with the muscle lengths of the sagittal-plane pelvic rotators and the performance (strength) of the abdominal muscles. Such assumed relationships are based on the anatomy of the muscles and their potential for action on the pelvis. The abdominal muscles tilt the pelvis posteriorly, and the lumbar erector spinae muscles tilt it anteriorly . Thus, the lengths of the lumbar erector spinae and abdominal muscles, according to another theory, should also influence the size of the lumbar Lordotic curve and the degree of pelvic inclination in the standing position. For example, if the lumbar erector spinae muscles are shortened and the abdominal muscles are relatively lengthened, the degree of pelvic inclination and size of the lumbar lordosis would be expected to be greater than normal. Therefore, in a normal standing position, the degree of pelvic inclination is related to the lumbar curve, and both are related to the performance and length of the back and abdominal muscles . During posterior pelvic tilting, both the lower fibers of the rectus abdominis and the gluteals work, and reduce lumbar lordosis due to posterior pelvic tilting. The anterior pelvic tilt is actually a quite normal postural position. However, excessive anterior pelvic tilting beyond the “normal” range is a result of weakness in the abdominal muscles and tightness in the iliopsoas . Adopting a maximal anterior pelvic tilt increased lumbar lordosis by an average of10.8° and adopting a maximal posterior pelvic tilt decreased lumbar lordosis by an average of 9° in the standing position. Differences from Hyun Park’s study may be due to individual variables and the postures. The results of Levine’sstudy support the idea that pelvic tilting affects lumbar lordosis .
Muscle weakness is reported to be a common symptom in children with cerebral palsy , and spinal deformity is highly prevalent in patients with neuromusculardisorders. Furthermore, many of these children develop substantial pelvic obliquity, which leads to positionaldiscomfort, sitting intolerance, and complications such aspressure sores.Children with CP have poor trunk stability (weak core muscles) due to the low muscle tone of the trunk and proximal muscles and muscle weakness . Since in children with cerebral palsy, the abdominal and back muscles are more affected due to the weakness of the abdominal muscle and tightness of the erector spinae and iliopsoas muscles, which affect the pelvic tilting and lumbar lordosis (increase pelvic tilting anteriorly, that increaseslordotic curve).
According tothe study byJean-Luc Cle ́mentet al (2013), the proximal part of lordosis depends on the thoracic kyphosis, and the distal part depends on the pelvic incidence . Since the cervical, thoracic, and lumbar spinal regions are biomechanically related, any change in each arch might be due to the postural alteration in other arches . According to some studies,with an increase in lordosis, thoracic kyphosis also increases; however, some studies (supporting our results) have indicated that an increase in lordosis is accompanied by a decrease in kyphosis [20, 21].
There was a significant moderate positive correlation between right anterior pelvic tilt and Lordotic Cobb angle (r = 0.314, p = 0.01) and a significant weak positive correlation between left anterior pelvic tilt and Lordotic Cobb angle (r = 0.268, p = 0.03). However, there was a moderate negative significant correlation between right anterior pelvic tilt and kyphotic Cobb’s angle (r = -0.313, p = 0.01) and a significant weak negative correlation between left anterior pelvic tilt and kyphotic Cobb angle (r = -0.27, p = 0.03) (Table 3). Due to significant pelvic asymmetry, due to variations in pelvic morphology this is achieved by the ischial spine-pubic symphysis angle and the side-to-side difference in pelvic height. This latter finding is in agreement with Badii et al, who used radiographic techniques and defined a measure of innominate asymmetry. This makes anterior innominate rotation (asymmetrical anterior pelvic tilt) rotation between two sides of pelvis .
Regarding the relationship between thoracic kyphosis and lumbar lordosis, other studies  have shown a weak correlation between thoracic kyphosis and lumbar lordosis with. However, Yong  described a strong correlation between thoracic kyphosis and lumbar lordosis. In addition, Legaye J and Duval-Beaupere G (2005) have found a strong correlation between pelvic tilt angle and thoracic kyphosis and lumbar lordosis, assessing the onset of spinal deviation with pelvic evaluation (consistent with the results of our study) . In conclusion, the normal anatomy of the lumbar curve is lordosis due to theanatomical position of the lumbar spine rested on the sacrum by a certain angle, and also the normal anatomy of the pelvis is anterior pelvic tilting. Since the lumbar curve is biomechanically related to the pelvic region, any movement of the pelvis affects lumbar curve. The extent of the lumbar lordotic curve and the degree of pelvic inclination in the standing position are associated with the muscle lengths of the sagittal-plane pelvic rotators and the performance (strength) of the abdominal muscles.The abdominal muscles tilt the pelvis posteriorly, whereas the lumbar erector spinae muscles tilt it anteriorly. When the erector spinae muscle is shortened and the abdominal muscle is weakened, this increasesthe anterior pelvic tilting and also lumbar lordosis. Since in children with cerebral palsy abdominal and back muscles (core muscles) are more affected, this affects the pelvic tilting and lumbar lordosis (increases pelvic tilting anteriorly, which increasesthe lordotic curve). Since cervical, thoracic, and lumbar spinal regions are biomechanically related, any change in each arch can be associated with the postural alteration in other arches. Thus, an increase in lumbar lordosis may also affect the thoracic curve and increase thoracic kyphosis.
This study is important for children with cerebral palsy, when the core muscles are affected, ananterior pelvic tilt occurs which is most common, as this increases lumbar lordosis and may increase the thoracic curve (thoracic kyphosis).Therefore, correction of pelvic inclination by strengthening muscles around the pelvis, mainly pelvic extensors, and core stability exercises may decrease anterior pelvic tilt and decrease lumber lordosis. Thus these exercises should be integrated into the rehabilitation program for children with cerebral palsy, since there is a medium correlation between the pelvic inclination and lumbar lordosis.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Liao H, Liu Y, Liu W, Lin Y. Effectiveness of Loaded Sit-to-Stand Resistance Exercise for Children with Mild Spastic Diplegia: A Randomized Clinical Trial. Arch Phys Med Rehabil. 2007; 88 (1): 25-31.
2. Sakrewski L, Ziyiani J, Boyd R. Systematic review and meta-analysis of therapeutic management of upper limb dysfunction in children with congenital hemiplegia. Pediatrics. 2009; 123 (6):e1111–22.
3. Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup navigation inaccurate. Acta Orthop. 2005; 76(4):517-23.
4. McCarthy J, D’Andrea L, Betz R, Clements DH. Scoliosis in the child with cerebral palsy. J Am AcadOrthopSurg. 2006; 14(6):367–75.
5.Brayda-Bruno MCinnella P, Vincitorio F, Lovi A, Grava G, Brayda-Bruno M. Spinal Fusion With Cotrel-Dubousset Instrumentation for Neuropathic Scoliosis in Patients With Cerebral Palsy. Spine. 2006; 31(14):E441-7.
6. Mandal AC. The correct height of school furniture. Human Factors.1982; 24: 257-69.
7. Mayston MJ. People with cerebral palsy: effects of and perspectives for therapy. Neural Plast. 2001; 8(1-2):51-69.
8. Cobb JR. Outline for the study of scoliosis. Am Acad Orthop Surg Instr Course Lect. 1948;5:61–75.
9. Labelle H, Roussouly P, Berthonnaud E, Dimnet J, O’BrienM. The importance of spino-pelvic balance in L5-s1 developmentalspondylolisthesis: a review of pertinent radiologicmeasurements. Spine (Phila Pa 1976). 2005; 30 (Suppl.6):S27–34.
10. Boulay C, Tardieu C, Hecquet J, Be ́naim C, Mitulescu A, Marty C, et al. Anatomical reliability of two fundamental radiological andclinical pelvic parameters: incidence and thickness. Eur J Orthop Surg Traumatol. 2005; 15(3):197-204.
11. Lim JK, Kim SM: Difference of sagittal spinopelvic alignments between degenerative spondylolisthesis and isthmic spondylolisthesis. J Korean Neurosurg Soc. 2013; 53:96–101.
12. Schoberth H. Seating: Posture, injuries and furniture. Berlin: Springer Verlag; 1962.
13. Kendall FP, McCreary EK, Provance PG, Rodgers M, Romani WA. Muscles, testing and function: with posture and pain. Baltimore, MD: Williams & Wilkins; 1993.
14. Youdas JW, Garrett TR, Harmsen S, Suman VJ, Carey JR. Lumbar lordosis and pelvic inclination of asymptomatic adults. Phys Ther. 1996 76(10):1066-81.
15. Lau KT, Cheung KY, Chan KB, Chan MH, Lo KY, Chiu TT. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther. 2010;15(5):457-62.
16. Levine D, Whittle MW. The effects of pelvic movement on lumbar lordosis in the standing position. J Orthop Sports PhysTher. 1996; 24(3):130-5.
17. Toner LV, Cook K, Elder GC. Improved ankle function in children with cerebral palsy after computer-assisted motor learning. Dev Med Child Neurol. 1998; 40(12): 82935.
18. Pehrsson K, Larsson S, Oden A, Nachemson A. Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms. Spine (Phila Pa 1976). 1992;17(9):1091-6.
19. Cle ́ment J-L, Geoffray A, Yagoubi F, Chau E, SollaF, Oborocianu I, et al. Relationship between thoracic hypokyphosis, lumbar lordosis and sagittal pelvic parameters in adolescent idiopathic scoliosis. 2013; 22(11): 2414–20.
20. Roussouly P, Nnadi C. Sagittal plane deformity: an overview of interpretation and management. Eur Spine J. 2010;19(11):1824-36.
21. Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity- postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010; 35(25):2224-31.
22. Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson P, Munk PL, et al. Pelvicbone asymmetry in 323 study participantsreceiving abdominal CT scans. Spine. 2003; 28(12):1335–9.
23. Upasani VV, Tis J, Bastrom T, Pawelek J, Marks M, Lonner B, et al . Analysis of sagittal alignment in thoracic and thoracolumbar curves in adolescent Eur Spine J (2013) 22:2414–2420 2419 123 idiopathic scoliosis. How do these two curve types differ? Spine. 2007; 32(12):13559.
24. Yong Q, Zhen L, Zezhang Z, Bangping Q, Feng Z, Tao W, et al Comparison of sagittal spinopelvic alignment in Chinese adolescents with and without idiopathic thoracic scoliosis. Spine. 2012 37(12):E714-20.
25. Legaye J, Duval-Beaupere G. Sagittal plane alignment of the spine and gravity: a radiological and clinical evaluation. Acta Orthop Belg. 2005; 71(2):213–20.
Download attachments: 10.4328_ACAM.20319
Doaa Attia Gamil Hassan, Elham ElSaid Salim, Sherif N.G. Bishay, Mahmoud S. El Fakharany. Cobb angle measurement and pelvic inclination in children with spastic cerebral palsy: A cross-sectional study. Ann Clin Anal Med 2021;12(Suppl 1): S15-19
Factors affecting fear of breast cancer recurrence in a developing country
Noha Yehia Ibrahim, Soha Mohamed Talima, Dalia Omar Darwish
Department of Clinical Oncology (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Egypt
DOI: 10.4328/ACAM.20320 Received: 2020-08-26 Accepted: 2020-10-16 Published Online: 2020-10-18 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S20-24
Corresponding Author: Noha Yehia Ibrahim, Kasr Alainy School of Medicine. Kasr Al-Ainy Center of Clinical Oncology and Nuclear Medicine (NEMROCK). Cairo University, PO Box 99, Manial El-Roda, Cairo 11553, Egypt. E-mail: firstname.lastname@example.org GSM: 01223234407 P: 00 02 3626246 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3291-0036
Aim: The survival and treatment outcomes of breast cancer patients have improved dramatically in the last decades. In this study, we aimed to study Fear of cancer recurrence (FOCR) in breast cancer.
Material and Method: This is a descriptive correlational study on 313 non-metastatic breast cancer patients. The questionnaire consisted of a demographic checklist and a short form of fear of progression questionnaire. The five-point Likert scale was used to score responses to 12 items. A score of 34 or above indicates a dysfunctional level of FoP-Q-12.
Results: The mean age of the patients was 52.63 years ±10.65 with a mean time of follow-up of 50.7 ±35.19 months. The mean total score was low 30.78 ± 30.78; 95%CI: 29.64-31.91. The highest score was for “Being afraid of the possibility that children could contract cancer” (3.24 ± 1.706; 95% CI: 3.24-3.05), and the lowest score was for ‘Fear of becoming less productive at work’’ (1.75 ± 1.285; 95% CI: 1.6-1.89). FOCR was affected by the mean age of both the patient and the children (p- value = < 0.001), reaching a high statistical significance; whereas FOCR was higher in patients without a university degree and not living with spouse and children (p-value: 0.005 and 0.063). On multivariate analysis, FOCR was only associated with a higher university degree (OR 0.301, 95% CI: 0.115-785, P value: 0.014).
Discussion: Studying FOCR is important to improve the quality of life of cancer survivors. Egyptian breast cancer patients experienced a low level of fear of cancer recurrence. This may be related to strong religious beliefs among this population. FOCR was only associated with not having a high University degree.
Keywords: Breast cancer; Fear of recurrence; Fear of progression; Egypt
The survival and treatment outcomes of breast cancer patients have improved dramatically in the last decades . This may be due to better risk stratification according to biomarkers, tailoring hormonal therapy along with combination chemotherapy, targeted therapy and immunotherapy .
There is a growing interest in the quality of life of surviving patients, as they may experience symptoms related to side effects of treatment. They may also suffer from emotional distress as well as impairment of physical and psychological wellbeing ; these factors may lead the patient to worry about cancer recurrence .
Fear of cancer recurrence (FOCR) was defined as “the worry or anxiety of the patient about the recurrence of the tumor in the same part of the body or spread to other organs” . Factors affecting FOCR included age, sex, time since diagnosis, quality of life, anxiety, and depression [6, 7]. This fear is one of the major concerns and unmet needs of breast cancer patients . The 12-item questionnaire FoP-Q-12 is one of the instruments for measuring FoP. It has been successfully applied to samples of breast cancer patients or samples dominated by breast cancer patients . Personalized Medicine, maintenance therapy and screening of cancer recurrence are very important as they are accompanied by relevant psychological disturbance [10, 11]. FOCR has not been well studied in the Middle East and only a few studies have been conducted . In Egypt, depression and anxiety were higher in cancer patients when compared to control on the Psychological Distress using the Hospital Anxiety and Depression Scale . To our knowledge, FOCR has not been previously studied in either Egypt or other Arab countries. The aim of this work is to investigate FOCR and its predictive factors among Egyptian cancer patients.
Material and Methods
This is a descriptive correlational cross-sectional study on 313 non-metastatic breast cancer patients. Patients were recruited from March to June 2017. The study was approved by the clinical oncology department ethical committee as well as the Faculty of Medicine Cairo University ethical committee (03-05- 17). Informed consent was obtained from all participants prior to participation in the study.
The study included all non-metastatic breast cancer patients aged ≥18 years attending the follow up out-patient clinic. Patients should have completed active treatment including chemotherapy and radiotherapy; however, they may be still on hormonal treatment. The time interval from diagnosis was at least 6 months. The participants must have been aware of their diagnosis and should have been under the normal physical and psychological conditions to participate in the survey.
The questionnaire consisted of a demographic checklist and a short form of fear of progression questionnaire , which was translated into Arabic and back- translated by two independent English translators. This was then revised by 18 academic members affiliated to Cairo University. The internal consistency was calculated on a sample of 20 pilot patients. The α Cronbach coefficient was 0.83. The five-point Likert scale was used to score the response of the 12 items of the questionnaire. It ranged from one (never) to 5 (very often).
The final score was a sum of all items. A score of 34 or above indicatesadysfunctionallevelofFoP-Q-12(Herschbachetal., 2010; Hinz et al., 2015) [14,15].
The data collection was done by two oncologists inviting 320 out-patients using a private face to face interview. Most of the patients, (97.8 %, 313 patients) accepted to participate and only 7 patients refused. The aim of the study was explained to all patients, and only those accepting to give informed consent were included in the study. The extraction of medical data was done by the researchers from the medical records. This included staging, time from diagnosis and treatment received. Statistical analysis
All data were statistically studied using descriptive analysis as well as FOCR in relation to different clinico-epidemiological factors. Univariate and multivariate analyzes using the COX regression module were performed to test the power of the relationship between the independent variables and FOCR. A probability value (p value) less than 0.05 was considered significant. The statistical calculations were done using Microsoft Excel version 7 and SPSS statistical software (Statistical Package for Social Sciences).
The study included 313 breast cancer patients. The mean age was 52.63 ±10.65 years, and the mean follow-up time was 50.7 ±35.19 months. Most of the cases were married (73%, 229), housewife (80.8%, 253), and living with spouse and children (57.8%, 181). The majority of participants (63.9%) had some kind of education either a diploma degree (28.8%), primary education (23%), or university degree (12.1%). The rest of them were illiterate (36.1%, 113). Patients presented as staged I, II, III (9.9%, 50.5%, and 39.6% respectively). The Socio-demographic and medical characteristics of the participants are shown in Table 1.
All patients accepting to take the questionnaire gave informed consent. The responses of the participants to all items of the fear of progression questionnaire had a mean total score of 30.78 ± 30.78; 95%CI: 29.64-31.91. The highest score was for “Being afraid of the possibility that the children could contract cancer” (3.24 ± 1.706; 95% CI: 3.24-3.05), followed by Anxiety about what will happen to the family if something happens to the patient (3.22 ± 1.667, CI 3.03-3.4) and “Being afraid of pain” (3.15± 1.539, 95% CI: 2.98-3.32). The lowest score was for ‘’Fear of becoming less productive at work’’ (1.75 ± 1.285; 95% CI: 1.6-1.89) and ‘’Fear of no longer being able to pursue hobbies’’ (1.8 ± 1.26; 95%CI: 1.66-1.94). Responses of the participants to all items of fear of progression questionnaire are shown in Table 2.
According to demographic and disease characteristics of the patients by fear score, the patients were divided according to whether they have a high or low score for FOCR with a cut off value of 34. The majority of these patients had a low score (59.1% vs 40.9%, p-value: < 0.001). FOCR was affected by the mean age of the patient and the mean age of children (p-value= < 0.001), reaching a high statistical significance. Whereas FOCR was higher in patients without a university degree and not living with a spouse and children (p-value: 0.005 and 0.063).
Factors affecting FOCR are shown in Table 3.
In multivariate logistic regression analysis, FOCR was not associated with patient age, living condition, age of children, or treatment received. It was only associated with a higher university degree (OR 0.301, 95% CI: 0.115-785, p-value: 0.014).
After an extensive review of the literature, this is the first study to investigate FOCR and the factors affecting it among cancer patients in Egypt and Arab countries. Also, it included the largest number of breast cancer patients among the few studies in the Middle East.
The study showed that most of the participants had a low score <34 (59.1% vs. 40.9%, p value = < 0.001), with a mean total score of 30.78. The highest score was for “Being afraid of the possibility that the children could contract cancer” followed by “Worrying about what will happen to the family if something happens to the patient”, and “Being afraid of pain”. The lowest score was for “Fear of becoming less productive at work” and
“Fear of no longer being able to pursue hobbies”. FOCR was only associated with a lack of a high University degree.
The incidence of moderate to high fear was 40.9%. This was in accordance with the results (49%) found in Simard, 2013, a systematic review to identify quantitative studies associated with FOC and different types of cancer . The mean score was 30.78. This was close to the mean (24.9) recorded by Hinz et al. in 2014. In their study, they found only 16.7 % of the participant scoring above the cut-off score. It showed the reliability of the short form of the fear of progression questionnaire with a Cronbach’s alpha of 0.9. The study included 2059 cancer patients six months after completion of their rehabilitation program. Females and younger patients showed higher scores .
This low score was in accordance with a meta-analysis done by six German registries including 2671 breast cancer patients. They used the short form of fear of the progression questionnaire. The majority (82%) had a low level of fear. Patients with moderate and high levels of fear accounted for 11% and 6%, respectively. However, the number of these patients was lower than in the present study (17% vs. 40.9%) . Another study showed low to moderate levels of fear in African Americans with breast cancer . Moreover, a study conducted on patients with colon cancer found that only 38% of them suffer from high fear .
Time since the initial diagnosis did not show statistical significance in our study. This was contradictory to many other studies showing that FOCR decreases with time elapsed since the diagnosis [17, 19, 20]. A Belgium study showed a significant interaction effect between age and 18 month follow-up (P < .02). This interaction suggests that the course of FCR over time depends on the age of the participants with older breast cancer survivors reported decreasing levels of FCR .
FOCR was affected by the mean age of the patients with high statistical significance (p-value: < 0.001). This is in accordance with a big study from the USA including a 2010 survey among breast cancer patients. The study included 2,668,697 survivors. In univariate analysis, worry about recurrence was positively correlated with the present age and radiotherapy (p-value 0.03 and 0.04, respectively) .
Younger Age significantly affected FOCR < 0.001 in the present study, and this was similar to other studies [15, 17]. There was a great association with young age and considering oneself as a cancer patient with moderate and high FOCR in a German meta-analysis. (Odds ratio = 3.00, confidence intervals = 1.91- 4.73 and odds ratio=3.36, confidence intervals=2.66-4.25 respectively) .
The age of children affected the FOCR in many studies. Having younger children raises the burden on the mother as a primary caregiver. This increases her worry about what will happen to her children if she gets recurrence, and increases the sense of fear . Other studies showed that motherhood increases the fear of leaving children, regardless of their age . In the present study, the mean age of children affected the score of FOCR, reaching high statistical significance (p-value: < 0.001). Our study showed that FOCR was lower among patients with a university degree and living with spouse and children (p-value: 0.005 and 0.063), and in multivariate analysis, a higher score of FOCR was only correlated with patients without university degree. This was comparable to a descriptive and correlational study done in the Middle East by Aghdam et al. in 2014 on 129 cancer patients of both sexes and different diagnoses, showing that FOCR was associated with a lower level of education and not living with spouse and children. Multivariate analysis in this Iranian study showed the highest association with female sex, being breast cancer, not having a university degree, and receiving radiotherapy (p-value= 0.021, 0.044, 0.008 and 0.094, respectively) .
In the present study, the Egyptian patients experienced a low level of fear of cancer recurrence. This may be related to strong religious beliefs among such patient populations.
The limitation of the study is that only breast cancer patients were included. These were only female, out-patients with no consideration for hospitalization. Also, the study was cross- sectional, including every patient only once in the questionnaire. The study design did not include quality of life or any psychological assessment. This was considered as a screening study as it was the first to address this issue in the region. Future perspectives
Further studies should include patients with different types of cancer in the Middle East. Male sex should be included. Also, the future studies should include patients from different cultures and regions. Studies should be longitudinal evaluating the fear of the same patient several times since the diagnosis to determine whether it affected the extent of fear. This should include early and late assessment. Also, there should be a correlation between the quality of life and any associated psychological disturbance, especially anxiety and depression. Conclusion
This study conducted in Egypt showed a low score of FOCR. Higher level was associated with patients without university education. The short form of FOCQ proved to be a rapid and reliable method to screen breast cancer patients under follow- up. This can provide high risk survivors with psychological support and assistant programs.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Bodai BI, Tuso P. Breast Cancer Survivorship: A Comprehensive Review of Long- Term Medical Issues and Lifestyle Recommendations. Perm J. 2015; 19(2): 48–79.
2. Vorobiof DA. Recent Advances in the Medical Treatment of Breast Cancer. F1000Research. 2016; 5: 2786. DOI: 10.12688/f1000research.9619.1
3. Arndt V , Koch-Gallenkamp L, Jansen L , Bertram H, Eberle A, Holleczek B, et al. Quality of life in long-term and very long-term cancer survivors versus population controls in Germany. Acta Oncologica. 2017; 56(2):190-7. DOI: 10.1080/0284186X.2016.1266089.
4. Koch L, Bertram H, Eberle A, Holleczek B, Schmid-Höpfner S, Waldmann A, et al. Fear of recurrence in long-term breast cancer survivors— still an issue. Results on prevalence, determinants, and the association with quality of life and depression from the Cancer Survivorship—a multi-regional populationbased study. Psycho-Oncology. 2014; 23(5): 547–54.
5. Vickberg SM. The Concerns About Recurrence Scale (CARS): A systematic measure ofwomen’sfears about the possibility of breast cancer recurrence. Ann Behav Med. 2003; 25(1):16-24.
6. Simard S, Thewes B, Humphris G, Dixon M, Hayden C, Mireskandari S, et al. Fear of cancer recurrence in adult cancer survivors: a systematic review of quantitative studies. J Cancer Surviv. 2013;7(3):300–22.
7. Koch L, Jansen L, Brenner H, Arndt V. Fear of recurrence and disease progression in long-term (>/=5 years) cancer survivors-a systematic review of quantitative studies. Psychooncology. 2013; 22(1):1–11.
8. Ellegaard MB, Grau C, Zachariae R , Jensen A.B. Fear of cancer recurrence and unmet needs among breast cancer survivors in the first five years. A cross- sectional study. Acta Oncol. 2017; 56(2):314–20.
9. Mehnert A, Herschbach P, Berg P, Henrich G, Koch U. Fear of progression in breast cancer patients – validation of the short form of the fear of progression questionnaire (FoP-Q-SF). Z Psychosom Med Psychother. 2006;52(3):274–88.
10. Thewes B, Husson O, Poort H, Custers J, Butow PN, McLachlan S-A, et al. Fear of Cancer Recurrence in an Era of Personalized Medicine. J Clin Oncol. 2017; 35(29):3275-8.
11. Simard S, Savard J. Screening and comorbidity of clinical levels of fear of cancer recurrence. J Cancer Surviv. 2015; 9(3):481-91.
12. Aghdam AM, Rahmani A, Nejad ZK, Ferguson C, Mohammadpoorasl A, Sanaat Z. Indian Journal of Palliative Care. 2014; 20 (2):128-33.
13. Hussein Gaballa H, Erfan S, El-Sayed M, Ali Eldin N, Abdel Gawad W. Psychological Distress in Egyptian Patients with Cancer. Egypt J. Psychiatry. 2009; 29(2): 71-8.
14. Herschbach P, Berg P, Waadt S, Duran G, Engst-Hastreiter U, Henrich G, et al. Group Psychotherapy of Dysfunctional Fear of Progression in Patients with Chronic Arthritis or Cancer. Psychother Psychosom. 2010; 79(1):31–8.
15. Hinz A, Mehnert A, Ernst J, Herschbach P, Schulte T. Fear of progression in patients 6 months after cancer rehabilitation—a validation study of the fear of progression questionnaire FoP-Q-12. Support Care Cancer. 2014; DOI 10.1007/ s00520-014-2516-5.
16. Koch L, Bertram H, Eberle A, Holleczek B, Schmid-Höpfner S, Waldmann A, et al. Fear of recurrence in long-term breast cancer survivors-still an issue. Results on prevalence, determinants, and the association with quality of life and depression from the cancer survivorship–a multi-regional population-based study. Psychooncology. 2014; 23(5):547-54.
17. Taylor TR, Edward D, Huntley ED, Sween J, Makambi K, Mellman TA, Williams C, et al. An Exploratory Analysis of Fear of Recurrence among African- American Breast Cancer Survivors. Int J Behav Med. 2012; 19(3): 280–7.
18. Custers J, Gielissen M, Janssen S, de Wilt JHW, Prins JB. Fear of cancer recurrence in colorectal cancer survivors. Support Care Cancer. 2016; 24(2):555– 62.
19. Mehnert A, Koch U, Sundermann C, Dinkel A. Predictors of fear of recurrence in patients one year after cancer rehabilitation: A prospective study. Acta Oncol. 2013; 52(6):1102-9.
20. Wan C, Silverstein K, Arès I, Bielajew C. Predictors of Fear of Recurrence in Breast Cancer Survivors. Cancer Studies and therapeutics. Can Stu The J. 2016; 1(1): 1–8.
21. Starreveld DEJ, Markovitz SE, van Breukelen G, Peters M. The course of fear of cancer recurrence: Different patterns by age in breast cancer survivors. Psychooncology. 2017; Jul 20. doi: 10.1002/pon.4505.
22. Tewari A, Chagpar AB. Worry about breast cancer recurrence: a population- based analysis. Am Surg. 2014; 80 (7): 640-5.
23. Lebel S, Beattie S, Arès I, Bielajew C. Young and worried: Age and fear of recurrence in breast cancer survivors. Health Psychol. 2013; 32: 695-705.
Download attachments: 10.4328_ACAM.20320
Noha Yehia Ibrahim, Soha Mohamed Talima, Dalia Omar Darwish. Factors affecting fear of breast cancer recurrence in a developing country. Ann Clin Anal Med 2021;12(Suppl 1): S20-24
Prognostic significance of systemic inflammatory markers in laryngeal squamous cell carcinoma
Orhan Tunç, Burhanettin Gönüldaş, Berkay Güzel, Muzaffer Kanlıkama
Department of Otorhinolaryngology, Gaziantep University, Gaziantep, Turkey
DOI: 10.4328/ACAM.20321 Received: 2020-08-28 Accepted: 2020-10-15 Published Online: 2020-10-17 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S25-30
Corresponding Author: Orhan Tunç, Gaziantep University, Otorhinolaryngology, Gaziantep, Turkey. E-mail: email@example.com , firstname.lastname@example.org P: +90 555 391 99 06 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7764-1138
Aim: The aim of this study is to reveal the relationship between neutrophil-lymphocyte ratio (NLR), Mean platelet volume (MPV), Platelet- lymphocyte ratio (PLR), MPV-platelet ratio (MPVPR) and systemic inflammatory index (SII) levels in laryngeal Squamous cell carcinoma.
Material and Methods: One hundred twenty patients diagnosed with larynx cancer between 2014 and 2019 were evaluated retrospectively. In addition, 30 patients without cancer were included in the study as a control group. The patients ‘ages, genders and preoperative blood tests, pathology results (tumor stage and lymph node metastasis) were obtained from the patients’ files. In addition, NLR, PLR, MPVPR, Systemic inflammatory index (SII) values were calculated and recorded.
Results: There was a significant positive correlation between stage and NLR, PLR and SII values, and a significant negative correlation between MPVPR (p=0,001, r: 0,292, p=0,009, r: 0,238, p=0,000, r: 0,384, p=0,004, r: -0,259, respectively). There was a significant positive correlation between metastasis status and NLR, PLR and SII values (p=0,013, r: 0,226, p=0,032, r: 0,196, p=0,003, r: 0,268, respectively). In terms of metastasis, sensitivity 63,2%, and specificity 58,5% for NLR (p=0,014), sensitivity 63,2% and specificity 58,5% for PLR (p=0,033), sensitivity 68,4% and specificity 65,2% for SII (p=0,001) were found. The cut-off point for these values was >2.33, >113.7, and >646.28, respectively.
Discussion: Our study is the first study to assess that WBC, NLR, PLR, and SII parameters can be used as a potential prognosis factor in patients with laryngeal tumors in predicting tumor stage and evaluating metastasis status.
Keywords: Laryngeal cancer; Prognostic factor; Neutrophil-Lymphocyte ratio; Platelet- Lymphocyte ratio; MPV-Platelet ratio; Systemic inflammatory index
Laryngeal cancer accounts for 2.4% of all newly diagnosed malignancies each year in the world . Laryngeal cancer is the second most common head and neck cancer other than skin cancer and accounts for 25% of all head and neck cancers . Almost all (95%) are squamous cell carcinomas. Laryngeal cancers are more common in middle-aged men. Risk factors include smoking, tobacco, alcohol use, air pollution and occupational factors . This type of head and neck cancer responds best to treatment when appropriate diagnosis and adequate treatment approaches are applied.
The TNM classification and histological rating system provide guidance for determining tumor behavior and treatment method for larynx cancer. The general condition and profession of the patient are other important parameters that determine which treatment method will be applied and how much of the larynx functions can be maintained. However, despite the application of the same treatment method in patients with similar features, obtaining different results shows that all these parameters are not sufficient, and direct us to investigate different prognostic factors. The purpose of investigating different tumor markers in larynx cancer is to improve cancer preventive treatments, increase the knowledge about cancer and the biological behavior of the host, predict the recurrence and secondary cancers encountered in larynx cancer, and plan the treatments more effectively [1-3].
The relationship between inflammation and cancer has been known since ancient times . Inflammatory cells, together with the cytokines and chemokines they produce in the early stages of the neoplastic process, increase genomic instability and angiogenesis, facilitate tumor cell migration, increase DNA damage, and thus become a strong tumor promoter . In recent studies, it has been shown that pre-treatment peripheral leukocyte (neutrophil, lymphocyte monocyte) and platelet levels are related to diagnosis and prognosis in various cancers [5- 7]. Besides, it is also an inexpensive and convenient biomarker. The pre-treatment neutrophil/lymphocyte ratio (NLR) has been shown to be a poor prognostic factor in patients with renal cell cancer, small and non-small cell lung cancer . However, NLR was shown to be related with many malignancies such as nasopharyngeal, gastric, hepatocellular, pancreatic and epithelial ovarian cancer [8, 9]. In addition, mean platelet volume (MPV), platelet/lymphocyte ratio (PLR), MPV-platelet ratio (MPVPR) and systemic inflammatory index (SII) levels have been shown to vary in various tumors and are associated with prognosis [10, 11]. However, there are a limited number of studies on larynx cancer in the literature.
The aim of this study is to reveal the relationship between NLR, MPV, PLR, MPVPR and systemic inflammatory index (SII) levels and squamous cell cancer of the larynx.
Material and Methods
The study was carried out after receiving the approval of the institutional Ethics Committee. In our study we conducted a retrospective analysis of 120 patients who applied to the Otorhinolaryngology Clinic of the Gaziantep University Research Hospital and underwent partial or total laryngectomy for laryngeal cancer between 2014 and 2019. In addition, 30 patients without cancer were included in the study as a control group. Patients with active infection, hematological diseases, second primary cancer, and chronic inflammatory diseases such as systemic lupus erythematosus (SLE) and missing data were excluded from the study.
The patients ‘ages, genders and preoperative blood tests, pathology results (tumor stage and lymph node metastasis) were obtained from the patients’ files. In addition, NLR, PLR, MPVPR, Systemic inflammatory index (SII) values were calculated and recorded. The following parameters were calculated from the hemogram results performed at the preoperative stage: NLR was found by dividing the neutrophil count by the lymphocyte count; PLR was found by dividing platelet count by lymphocyte count; MPVPR was found by dividing the number of MPV by the number of platelets; Systemic inflammatory index (SII) was found by multiplying neutrophil count and PLR value.
The tumor classification of the patients was made according to the TNM classification determined by The American Joint Committee on Cancer (AJCC), which was modified in 2017. The stage of the tumor and lymph node involvement were evaluated based on histopathological evaluation. Analyzes of all samples were performed on Sysmex XN-9100TM (Kobe, Japan) hematological auto analyzer devices.
The normality control of the data was done with the Shapiro Wilk test. The Student’s t- test was used for comparing the means of normally distributed parameters, and the Mann- Whitney U test was used for the comparison of parameters that did not conform to normal distribution. In multiple comparisons, the Kruskal-Wallis variance analysis was used. Descriptive statistics were expressed with Odds ratio and 95% confidence intervals. ROC analysis was used to determine the cut-off point, the area under the curve (AUC), the sensitivity (sensitivity) and the specificity (specificity) of the data. P <0.05 was considered statistically significant.
The comparison of laboratory and socio-demographic findings between the groups of patients and control is shown in Table 1. The average age of the patients was 62.00 (34.0-79.0) years, and the number of males was 112 (93.3%). In the control group, the mean age was 53.00 (36.0-65.0) years, and the number of males was 112 (93.3%). There was a statistically significant difference between the groups in terms of age and gender (p=0,000). Compared to the control group, WBC, RBC and Neutrophil levels were statistically significantly higher in the patient group (p=0,004, p=0,000, p=0,003, respectively). Hemoglobin and Hematocrit levels were statistically significantly lower in the patient group compared to the control group (p=0,010, p=0,000, respectively). Compared to the control group, NLR, PLR and SII values were statistically significantly higher in the patient group (p=0,006, p=0,030, p=0,042, respectively). No statistical significance was found between the groups in terms of other parameters (Table 1). The comparison of laboratory results according to the cancer stage is shown in Table 2. There was a statistically significant difference between groups in terms of WBC, platelet, and neutrophil levels (p=0,001, p=0,020, and p=0,009, respectively).
WBC, platelet and neutrophil levels increased as the stage increased. There was a statistically significant difference between the groups in terms of hemoglobin and hematocrit levels (p=0,020, p=0,031, respectively). It was found that hemoglobin and hematocrit levels decreased as the stage increased. However, statistical significance was found between the groups in terms of NLR, PLR, MPVPR, and SII parameters (p=0,017, p=0,038, p=0,010 and p=0,000, respectively). In addition, as the stage increased, it was determined that NLR, PLR and SII levels increased and MPVPR level decreased (Table 2).
In the comparison of laboratory results and treatment methods applied according to metastasis status in patients, WBC and Neutrophil levels were found to be statistically significantly higher in patients with metastasis compared to patients without metastasis (p=0,006, p=0,010, respectively). Compared to the group without metastasis, NLR, PLR, SII values were statistically significantly higher in the group with metastasis (p=0,014, p=0,033, and p=0,003, respectively). No statistical significance was found between the groups in terms of other biochemical parameters (p = 0,863). Partial laryngectomy in 43 (35.8%), radiotherapy in 27 (22.5%) and total laryngectomy in 50 (41.7%) cancer patients were performed. Partial laryngectomy in 28 (34.1%), radiotherapy treatment in 27 (32.9%) and total laryngectomy in 27 (32.9%) patients without metastasis were performed. Partial laryngectomy in 15 (39.5%) and total laryngectomy in 23 (60.5%) patients with metastasis were performed. Statistical significance was found in terms of treatments applied to patients with and without metastasis (p=0,000).
In correlation analysis of results according to the stage and metastasis, there was a significant positive correlation between stage and metastasis, WBC, platelet, neutrophil values (p=0,000, r: 0,481, p=0,000, r: 0,370, p=0,002, r: 0,275, p=0,000, r: 0,446, respectively). However, there was a significant positive correlation between stage and NLR, PLR and SII values and a negative correlation with MPVPR (p=0,001, r: 0,292, p=0,009, r: 0,238, p=0,000, r: 0,384, p=0,004, r: -0,259, respectively). There was a significant positive correlation between metastasis status and WBC and neutrophil values (p=0,006, r: 0,252, p=0,009, r: 0,237, respectively). However, there was a significant positive correlation between metastasis status and NLR, PLR and SII values (p=0,013, r: 0,226, p=0,032, r: 0,196, p=0,003, r: 0,268, respectively).
According to the results of ROC analysis in patients with metastasis, sensitivity 68,4%, and specificity 63,4% for WBC (p=0,001), sensitivity 63,2%, and specificity 58,9% for neutrophil (p=0,001), sensitivity 63,2%, and specificity 59,8% for NLR (p=0,003), sensitivity 63,2% and specificity 58,5% for PLR (p=0,023), sensitivity 68,4% and specificity 65,2% for SII (p=0,001) were found. The cut-off point for these values were >9.32, >5.75, >2.36, >113.7, and >646.28, respectively. As a result, according to ROC analysis for metastasis, platelet and MPVPR were not found to be prognostic factors, although the WBC, Neutrophil, NLR, PLR and SII were significant prognostic factors (Figure 1).
Logistic regression analysis of factors used for differentiating malign tumors from benign tumors is shown in Table 3. Risk factors that were found to be significantly associated with differentiation in the regression analysis included WBC, NLR, PLR, and SII (Table 3).
In our study, a statistically significant relationship was found between the stage of cancer and the platelet, neutrophil, NLR, PLR, MPVPR and systemic inflammatory index (SII) levels in patients with laryngeal squamous cell carcinoma. In our study, however, a statistically significant relationship was found between metastasis and especially NLR, PLR and SII levels in patients with laryngeal cancer metastasized.
The relationship between cancer and chronic inflammation began about a hundred years ago, when Rudolf Virchow first identified leukocytes in tumor tissue [12, 13]. Since then, many studies have been conducted showing that chronic inflammation in tumor tissue as a host response is effective in tumor development, metastasis, prognosis and response to treatment. In recent studies, the relationship between systemic inflammation degree and cancer has been shown by evaluating parameters such as NLO, PLR and SII, which are systemic inflammatory markers [5, 14]. While neutrophils and platelets contain and secrete inflammatory factors that inhibit apoptosis in tumor cells, directly contribute to the proliferation and metastasis of tumor cells, lymphocytes release protective inflammatory factors that prevent proliferation and metastasis [5, 12, 13, 15, 16]. Lymphocytopenia, which occurs in the tumor tissue, also causes the immune response to be interrupted by the host . NLR, PLR and SII will be higher and MPVPR will be lower due to the increase in the number of neutrophil- platelets and decreased lymphocyte systemically [18-20]. In our study, neutrophil, NLR, PLR and SII values were found to be statistically significantly higher in patients with laryngeal cancer. In addition, although the platelet, MPV and lymphocyte values were high and the MPVPR value was low in the patient group, it was not statistically significant.
In a study by Murat et al., elevated NLR might be an inflammatory marker to differentiate low- from high-grade malignant parotid gland tumors . In another study, it is stated that NLR and PLR parameters can be used in the differential diagnosis of benign and malignant masses in patients with parotid gland tumors . Rachidi et al. reported that neutrophil, lymphocyte and NLR have prognostic significance in these cancers in large cohort studies involving all head and neck cancers (oral, pharyngeal and laryngeal cancers . In studies on tongue squamous cell cancers, Öztürk et al. reported that NLR and PLR values are valuable markers in predicting local recurrence, and Deveci et al. reported that high SII values were associated with increased perineural/lymphovascular invasion and extranodal involvement [14, 22]. Chen et al. reported that PLR is superior to NLR in predicting disease-free survival and overall survival in oral squamous cell cancers . In a study by Mori et al., it was stated that NLR may be a prognostic factor in patients with gastric cancer . In the same study, no significant correlation was found between PLR and gastric cancer patients as prognostic factors . In our study, as tumor stage increased, WBC, platelet, Neutrophil, NLR, PLR and SII levels increased and MPVPR level decreased. However, WBC, Neutrophil, NLR, PLR and SII values were statistically significantly higher in patients with metastasis. Furthermore, according to ROC analysis for metastasis, platelet and MPVPR were not found to be prognostic factors, although the WBC, Neutrophil, NLR, PLR and SII were significant prognostic factors.
In the literature, studies examining the relationship of laryngeal tumors with inflammatory markers are limited. Studies on patients with larynx cancer have also reported that NLR, MPV and PLR are independent prognostic inflammatory markers. In a study conducted by Fu et al., MPV level was found to be decreased in patients with laryngeal cancer, and was reported to be a prognostic factor . In our study, no significant relationship was detected between the groups in terms of MPV level. However, there was no significant relationship in terms of tumor stage and metastasis in the patient group. Kum et al. reported that in patients with laryngeal squamous cell carcinoma and precancerous laryngeal lesions, the NLR levels were significantly higher than in patients with benign laryngeal lesions . In a study by Chen et al., the elevated preop PLR and NLR were significantly related with cancer progression and worse survival . In the same study, it was stated that the preoperative NLR could be independent prognostic markers of overall survival (OS) and progression-free survival (PFS) in laryngeal squamous cell carcinoma patients undergoing surgical resection . In a study by Kara et al. on 81 patients with laryngeal cancer, the mean PLR in the T4 stage tumors were significantly higher than the T1 and T2 stage, and according to ROC analysis for mortality, although the PLR and RDW were significant prognostic factors, NLR was not found to be a prognostic factor . In the study conducted by Erdis et al., it was seen that high SII value may be an indicator of shorter overall survival and disease-free survival in patients with oral cavity cancer . In our study, NLR, PLR and SII values were found statistically significantly higher in 120 patients with laryngeal cancer. However, a significant positive correlation was found between tumor stage and NLR, PLR and SII values, and a negative correlation with MPVPR. In addition, there was a significant positive correlation between the presence of metastasis and NLR, PLR and SII values. Moreover, according to the results of ROC analysis in patients with metastasis, sensitivity 68,4% and specificity 63,4% for WBC (p=0,001), sensitivity 63,2% and specificity 58,9% for neutrophil (p=0,001), sensitivity 63,2% and specificity 59,8% for NLR (p=0,003), sensitivity 63,2% and specificity 58,5% for PLR (p=0,023), sensitivity 68,4% and specificity 65,2% for SII (p=0,001) were found. The cut-off point for these values were >9.32, >5.75, >2.36, >113.7, and >646.28, respectively. As a result, according to ROC analysis for metastasis, platelet and MPVPR were not found to be prognostic factors, although the WBC, Neutrophil, NLR, PLR and SII were significant prognostic factors. However, as a result of logistic regression analysis of factors used for differentiating malign tumor from benign tumor, the risk factors found to be significantly associated with differentiation in the regression analysis included WBC, NLR, PLR, and SII. Thus, we determined that WBC, NLR, PLR, and SII were significant prognostic factors for metastasis.
Our study has some limitations. First, our study is a single-center and retrospective study. The small patient sample size was the second limitation. Moreover, multi-center and prospective studies should be planned to support these preliminary results. Conclusion
Our study is the first study to assess WBC, NLR, PLR, and SII parameters can be used as potential prognosis factors in patients with laryngeal tumors, in predicting tumor stage and evaluating metastasis status. These cheap and easy parameters can be used as potential prognosis factors in patients with laryngeal tumors to predict tumor stage and evaluate metastasis status. We think that these values should be defined in laboratory devices and added to blood results in order to facilitate the clinician’s work. However, new prospective studies with a larger group of patients are needed to determine the reference intervals of these values and to use them as prognostic factors.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Lin HW, Bhattacharyya N. Staging and survival analysis for nonsquamous cell carcinomas of the larynx. Laryngoscope. 2008;118(6):1003-13.
2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics. CA Cancer J Clin. 2005;55(2):74-108.
3. Hashibe M, Boffetta P, Zaridze D, Shangina O, Szeszenia-Dabrowska N, Mates D, et al. Contribution of tobacco and alcohol to the high rates of squamous cell carcinoma of the supraglottis and glottis in Central Europe. Am J Epidemiol. 2007;165(7):814-20.
4. Coussens LM, Werb Z. Inflammation and cancer. Nature. 2002;420(6917):860- 7.
5. Damar M, Dinç AE, Erdem D, Aydil U, Kizil Y, Eravcı FC, et al. Pretreatment neutrophil-lymphocyte ratio in salivary gland tumors is associated with malignancy. Otolaryngol Head Neck Surg. 2016;155(6):988-96.
6. He JR, Shen GP, Ren ZF, Qin H, Cui C, Zhang Y, et al. Pretreatment levels of peripheral neutrophils and lymphocytes as independent prognostic factors in patients with nasopharyngeal carcinoma. Head neck. 2012;34(12):1769-76.
7. Zeren S, Özbay İ, Bayhan Z, Koçak FE, Ucar BI, Kahraman C, et al. The neutrophil-to-lymphocyte ratio as a diagnostic marker for malignant thyroid diseases. Turkish Journal of Biochemistry. 2017;42(5):559-63.
8. An X, Ding P-R, Wang F-H, Jiang W-Q, Li Y-H. Elevated neutrophil to lymphocyte ratio predicts poor prognosis in nasopharyngeal carcinoma. Tumor Biology. 2011;32(2):317-24.
9. Cho H, Hur HW, Kim SW, Kim SH, Kim JH, Kim YT, et al. Pre-treatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment. Cancer Immunol Immunother. 2009;58(1):15-23.
10. Ekici NY, Kuran G. The Significance of Systemic Inflammatory Markers In The Differential Dıagnosıs of Benign And Malign Masses In Patients With Parotid Gland Tumors. KBB-Forum. 2019;18(2):100-6.
11. Fu S, Liu L, Zhang X, Liu Z-P, Wang R-T. Platelet indices in laryngeal cancer. Cancer Biomarkers. 2018;21(3):675-80.
12. Moore MM, Chua W, Charles KA, Clarke SJ. Inflammation and cancer: causes and consequences. Clin Pharmacol Ther. 2010;87(4):504-8.
13. Hussain SP, Harris CC. Inflammation and cancer: an ancient link with novel potentials. Int J Cancer. 2007;121(11):2373-80.
14. Deveci İ, Sürmeli M. Correlation of Systemic Immune-Inflammation Index and Neutrophil-to-Lymphocyte Ratio with Histopathological Findings in Patients with Tongue Cancer. Haydarpasa Numune Med J. 2018;58(3):122-7.
15. Chen L, Zeng H, Yang J, Lu Y, Zhang D, Wang J, et al. Survival and prognostic analysis of preoperative inflammatory markers in patients undergoing surgical resection for laryngeal squamous cell carcinoma. BMC Cancer. 2018;18(1):816.
16. Jaiswal M, LaRusso NF, Burgart LJ, Gores GJ. Inflammatory cytokines induce DNA damage and inhibit DNA repair in cholangiocarcinoma cells by a nitric oxide- dependent mechanism. Cancer Res. 2000;60(1):184-90.
17. Waldner M, Schimanski CC, Neurath MF. Colon cancer and the immune system: the role of tumor invading T cells. World J Gastroenterol. 2006;12(45):7233-8.
18. Omar M, Tanriverdi O, Cokmert S, Oktay E, Yersal O, Pilanci KN, et al. Role of increased mean platelet volume (MPV) and decreased MPV/platelet count ratio as poor prognostic factors in lung cancer. Clin Respir J. 2018;12(3):922-9.
19. Sefil F, Ulutas KT, Dokuyucu R, Sumbul AT, Yengil E, Yagiz AE, et al. Investigation of neutrophil lymphocyte ratio and blood glucose regulation in patients with type 2 diabetes mellitus. J Int Med Res. 2014;42(2):581-8.
20. Takeuchi H, Abe M, Takumi Y, Hashimoto T, Kobayashi R, Osoegawa A, et al. The prognostic impact of the platelet distribution width-to-platelet count ratio in patients with breast cancer. PLoS One. 2017;12(12):e0189166. DOI:10.1371/ journal.pone.0189166
21. Rachidi S, Wallace K, Wrangle JM, Day TA, Alberg AJ, Li Z. Neutrophil-to- lymphocyte ratio and overall survival in all sites of head and neck squamous cell carcinoma. Head Neck. 2016;38 (Suppl. 1):E1068-74. DOI: 10.1002/hed.24159
22. Ozturk K, Akyildiz NS, Uslu M, Gode S, Uluoz U. The effect of preoperative neutrophil, platelet and lymphocyte counts on local recurrence and survival in early-stage tongue cancer. Eur Arch Otorhinolaryngol. 2016;273(12):4425-9.
23. Mori M, Shuto K, Kosugi C, Narushima K, Hayashi H, Matsubara H, et al. An increase in the neutrophil-to-lymphocyte ratio during adjuvant chemotherapy indicates a poor prognosis in patients with stage II or III gastric cancer. BMC Cancer. 2018;18(1):1261.
24. Kum RO, Ozcan M, Baklaci D, Kum NY, Yilmaz YF, Gungor V, et al. Elevated neutrophil-to-lymphocyte ratio in squamous cell carcinoma of larynx compared to benign and precancerous laryngeal lesions. Asian Pac J Cancer Prev. 2014;15(17):7351-5.
25. Kara M, Uysal S, Altinişik U, Cevizci S, Güçlü O, Dereköy FS. The pre- treatment neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and red cell distribution width predict prognosis in patients with laryngeal carcinoma. Eur Arch Otorhinolaryngol. 2017;274(1):535-42.
Download attachments: 10.4328_ACAM.20321
Orhan Tunç, Burhanettin Gönüldaş, Berkay Güzel, Muzaffer Kanlıkama. Prognostic significance of systemic inflammatory markers in laryngeal squamous cell carcinoma. Ann Clin Anal Med 2021;12(Suppl 1): S25-30
The assessment of deep learning computer vision algorithms for the diagnosis of prostatic adenocarcinoma
Syed Usama Khalid Bukhari 1, Ubeer Mehtab 2, Syed Shahzad Hussain 3, Asmara Syed 4, Syed Umar Armaghan 5 , Syed Sajid Hussain Shah 4
1 Department of Computer Science, The University of Lahore, Islamabad, Pakistan, 2 Bahawal Victoria Hospital, Quaid e Azam Medical College, Bahawalpur, Pakistan, 3 Electrical Engineering Department., National University of Technology (NUTECH), Islamabad, Pakistan, 4 Faculty of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia, 5 Biomedical Engineering, Riphah International University, Islamabad, Pakistan
DOI: 10.4328/ACAM.20322 Received: 2020-08-28 Accepted: 2020-09-30 Published Online: 2020-10-08 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S31-34
Corresponding Author: Syed Usama Khalid Bukhari, Assistant Professor, Department of Computer Science, The University of Lahore, Islamabad, Pakistan. E-mail: email@example.com P: +92 349 1050449 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1581-8609
Aim: In this study, we aimed to evaluate the effectiveness of artificial intelligence for the histopathological diagnosis of prostatic adenocarcinoma by analyzing the digitized pathology slides.
Materials and Methods: After the approval of the research project by the Ethics Committee of the University of Lahore – Islamabad Campus, a total of eight hundred and two (802) images were obtained from the anonymized slides stained with hematoxylin and eosin, which included 337 anonymized images of pros- tatic adenocarcinoma and 465 anonymized images of nodular hyperplasia of prostate. Eighty percent (80%) of the total digital images were used for training and 20% for testing. Three ResNet architectures ResNet-18, ResNet-34, and ResNet-50 were employed for the analysis of these images.
Results: In the present study, the analysis of pathology images by convolutional neural network architecture ResNet-50 has revealed the diagnostic accuracy of 99.5 %, while the other convolutional neural network architectures ResNet-18 and ResNet-34 showed the diagnostic accuracy of 97.1% and 98 %, respectively.
Discussion: The findings of the present study suggest that an intelligent vision system is possibly a worthwhile tool for the histopathological evaluation of prostatic tissue to differentiate between benign and malignant disorders. The application of deep learning for the histological diagnosis of malignant tumors could be quite a helpful tool for better patient care.
Keywords: Prostate; Adenocarcinoma; Deep learning; Computer vision
Prostatic carcinoma is the second most prevalent type of malignant tumor diagnosed in males all over the world . In 2018, more than one million (1,276106) patients have been diagnosed as a case of prostatic cancer around the globe, and this malignant tumor caused 358989 deaths during that time period .
Variation in the prevalence of cancers exists among the different geographic regions . Some tumors are more prevalent in one region and less common in other. The prostatic cancer is the most frequent malignant tumor of the male population in one hundred and five countries, which mainly include the countries from the continents of Europe, Africa, North and South America . The geographic variation in the prevalence of prostatic cancer has been attributed to genetic and environmental factors. Higher consumption of meat has been linked to a higher risk of development of prostatic carcinoma [4,5].
The incidence of prostatic malignancy rises with an increase in age. The prostatic malignancy is more common in the 7th decade with a mean age of sixty-six years . An increased incidence of prostatic adenocarcinoma has been observed in the younger population. This rising trend in the incidence of prostate cancer in the younger age group has been attributed to improved diagnostic techniques and environmental factors including the rising incidence of obesity among the adolescent and younger age groups .
The prostatic carcinoma causes urinary tract symptoms due to the enlargement of the prostrate. The spread of prostatic adenocarcinoma to the vertebral column causes backache. The common symptoms with which these patients present usually include urinary obstruction, urgency, hesitancy, discomfort, frequency, and hematuria [7-9]. The suspected cases of prostatic malignancy are tested for a prostate-specific antigen. There is an increased suspicion of prostatic carcinoma in case of elevated blood PSA level . But the definitive diagnosis of prostatic malignant tumor is confirmed by the histopathological examination of a tissue specimen from the prostate. The rising number of prostatic biopsies for the histopathological examination will increase the stress on the histopathologists in the future, as more than two million cases of prostatic cancer are expected by the year 2040 .
The application of artificial intelligence and the development of Computer-aided diagnostic programs may be instrumental in enhancing laboratory efficiency by reducing turnaround time, cost, and the likelihood of human errors. Artificial intelligence is yielding very good results in the interpretation of digital images by analyzing them using Deep learning architecture.
The main focus of this study is to assess the usefulness of machine learning for the histological diagnosis of prostatic adenocarcinoma.
Material and Methods
The research project has been approved by the Ethics Committee of the University of Lahore – Islamabad Campus. Eight hundred and two (802) digital anonymized images were collected, which included 337 images of prostatic adenocarcinoma and 465 images of prostatic hyperplasia. We have used three ResNet convolutional neural network architectures, ResNet -18, ResNet -34 and ResNet-50. Due to dataset limitation, the transfer learning approach has been employed to train the models using the ImageNet dataset .
A total of 337 images of prostatic adenocarcinoma and 465 images of nodular hyperplasia of the prostate were used in the present research project. These images have been reviewed and labeled by two histopathologists.
A random approach of FastAI API (available at: https://www. fast.ai/) was used to load the data into train and test sets, to avoid the likelihood of selecting images of the same class for a mini-batch input, that could impact the performance of model validation.
Two sets (training set and test set) were made from the whole dataset. The training set was comprised of 80% of the total dataset, while the Testing set made up 20% of the total dataset. For image, we used data augmentation for regulation.
A total of eight hundred and two (802) images were collected of which, three hundred and thirty-seven digital images (337) of adenocarcinoma of prostate and four hundred and sixty- five (465) images of prostatic hyperplasia. Six hundred and forty (640) images, randomly chosen from both carcinoma and prostatic hyperplasia images accounting for 80% of the total data set, were employed for training data set. One hundred and sixty-two (162) images were randomly chosen from both carcinoma and hyperplasia images that is 20% of the total data set, were employed in the test data set.
Three ResNet architecture models (ResNet-18, ResNet-34 and ResNet-50) were used to classify the input image. The results of training data set and test data set are shown in Table 1 and Figure 1. The diagnostic accuracy of 97.1%, 98 %, and 99.5 % have been achieved with ResNet-18, ResNet-34, and ResNet-50, respectively. The results are depicted in Table 2.
The convolutional neural network has been applied in this research project to diagnose prostatic adenocarcinoma by analyzing the digital pathology images which revealed excellent results. The other published series that assessed the accuracy of deep learning for the diagnosis of cancers of lung, breast and prostate also showed very encouraging results [12-15]. In the present study, we applied three architectures of deep leaning (ResNet-18, ResNet-34 and ResNet-150) for the prostatic tissue image analysis to diagnose prostatic adenocarcinoma and to differentiate it from nodular hyperplasia. The ResNet-50 architecture revealed the highest diagnostic accuracy (99.5 %) which is followed by ResNet-34 (98%) and ResNet-18 ( 97.1%), respectively. A study conducted by Pantanowitz L et al. in which they applied convolutional neural network revealed that the disagreement between the histopathologists and artificial intelligence algorithm for the diagnosis of prostatic carcinoma was only in nine percent of biopsy parts .
The rapid advancement in field of artificial intelligence in the recent past has drawn the attention of health care providers to apply this technology for the solution of complex medical problems. The artificial intelligence is characterized by development of machines which have the capability to do cognitive assignments for the achievement of desirable output based on given input. The application of artificial intelligence has been expected to revolutionize the patient care by improving the diagnostic accuracy and reducing the cost with better choices for the management of diseases . An important sub group of artificial intelligence is deep learning. The application of deep learning revealed very encouraging results in the field of radiology for image interpretation. A study conducted by Pasa F et al. showed very encouraging results of Convolutional neural network (CNN) for analysing X-ray images. They used convolutional neural network to diagnose tuberculosis . The histopathological assessment is a quite subjective matter which may be a possible reason of the inter-observer discrepancies. The advancement in the computational image technology may be able to make the histopathology more objective and quantitative .
The histopathological diagnosis of malignant tumors is based upon certain specific microscopic features such as pleomorphism, hyperchromasia, high nucleus to cytoplasmic ratio, atypical mitosis, necrosis, multinucleated giant cells and pattern of arrangement of neoplastic cells. The assessment of digital pathology images with machine learning may provide valuable assistance in the interpretation and differentiation of neoplastic and non-neoplastic lesions.
The application of a computer-based diagnostic system in histopathology will be a great help to the histopathologists in the current scenario of a rising trend in the incidence of neoplastic lesions leading to an increase in the number of biopsies.
Adenocarcinoma of the prostate is a quite prevalent tumor in the majority of the countries of the world. More than one million cases of prostate cancer are diagnosed every year around the globe. By 2040, approximately two million persons may become victims of prostatic malignancy every year . The rising number of prostatic biopsies for the purpose of histopathological diagnosis will increase the burden on the diagnostic laboratories and increase the stress on the histopathologists. In order to overcome this situation, the application of smart technology such as artificial intelligence may be very helpful.
The application of digital pathology could be a good substitute for the glass slides for diagnostic purposes in histopathology . The data sets of digital pathology images which have been labeled by histopathologists are employed as training data sets for the convolutional networks. These online available datasets could be used as a training and complementary leaning for the residents .
One of the limitations of the present study is the non- segmentation of the image, as architecture is not employed to mark or circle the site of carcinoma on the digital image. Further studies are suggested in which the computer vision system should encircle the segment containing cancerous areas in the digital image, as it would be more helpful for histopathologists to concentrate on that specific site to review it for the diagnosis of malignancy, particularly in the whole digitalized slides. Conclusion:
1. The findings of the present research project favor the potential application of computer vision-based systems as a valuable tool for the histopathological evaluation of prostatic tissue in differentiating benign from malignant disorders.
2. The use of intelligent vision system in the field of histopathology for the diagnosis of malignant disorders may also lessen the risk of human errors.
3. The application of artificial intelligence in the field of histopathology will reduce the stress and decrease the workload on histopathologists.
4. The application of convolutional neural network architecture may provide the second opinion to the histopathologists.
5. Collections of pathology images datasets may be made available online and these could be used as training and complementary learning resources for the residents.
The authors are grateful to Dr. Hassan Bokhari and Faran Mazhar for their valuable assistance.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394424.
2. Idrees R, Fatima S, Abdul-Ghafar J, Raheem A, Ahmad Z. Cancer prevalence in Pakistan: meta-analysis of various published studies to determine variation in cancer figures resulting from marked population heterogeneity in different parts of the country. World J Surg Oncol. 2018;16:129. DOI:10.1186/s12957- 018-1429-z.
3. Rawla P. Epidemiology of Prostate Cancer. World J Oncol. 2019;10(2):63-89. DOI:10.14740/wjon1191.
4. Gibson TM, Ferrucci LM, Tangrea JA, Schatzkin A. Epidemiological and clinical studies of nutrition. Semin Oncol. 2010;37(3):282-96.
5. Rohrmann S, Platz EA, Kavanaugh CJ, Thuita L, Hoffman SC, Helzlsouer KJ. Meat and dairy consumption and subsequent risk of prostate cancer in a US cohort study. Cancer Causes Control. 2007;18(1):41-50. DOI: 10.1007/s10552- 006-0082-y.
6. Bleyer A, Spreafico F, Barr R. Prostate cancer in young men: An emerging young adult and older adolescent challenge. Cancer. 2020;126(1):46-57. DOI:10.1002/ cncr.32498.
7. Estebanez J, Teyrouz A, Gutierrez MA, Linazasoro I, Belloso J, Cano C, et al. Natural history of prostate cancer. Arch Esp Urol. 2014;67(5):383-7.
8. Hamilton W, Sharp D. Symptomatic diagnosis of prostate cancer in primary care: a structured review. Br J Gen Pract. 2004;54(505):617-21.
9. Tabassum T, Imtiaz A, Jabeen R. A Study to Evaluate α-Methylacyl Co-A Racemase Expression in Hyperplasia and Different Grades of Adenocarcinoma of Prostate. Pakistan Journal of Medical and Health Sciences. 2017;11(3):909-14.
10. Özsoya O, Fiorettab G , Aresa C , Miralbella R. Incidental detection of synchronous primary tumours during staging workup for prostate cancer. Swiss Med Wkly.2010;140(15–16):233–6
11. Russakovsky O, Deng J, Su H, Krause J, Satheesh S, Ma S, et al. ImageNet Large Scale Visual Recognition Challenge. Int J Comput Vis. 2015;115:211-52. DOI:10.1007/s11263-015-0816-y.
12. Ehteshami Bejnordi B, Veta M, Johannes van Diest P, van Ginneken B, Karssemeijer N, Litjens G et al. Diagnostic assessment of deep learning algorithms for detection of lymph node metastases in women with breast cancer. JAMA. 2017;318(22):2199-210. DOI: 10.1001/jama.2017.14585.
13. Campanella G, Hanna MG, Geneslaw L, Miraflor A, Silva VWK, Busam KJ, et al. Clinical-grade computational pathology using weakly supervised deep learning on whole slide images. Nat Med. 2019; 25: 1301–9. DOI: 10.1038/ s41591-019-0508-1.
14. Coudray N, Ocampo PS, Sakellaropoulos T, Narula N, Snuderl M, Fenyo D, et al. Classification and mutation prediction from non-small cell lung cancer histopathology images using deep learning. Nat Med. 2018; 24: 1559–67. DOI: 10.1038/s41591-018-0177-5.
15. Litjens G, Sánchez CI, Timofeeva N, Hermsen M, Nagtegaal I, Kovacs I, et al. Deep learning as a tool for increased accuracy and efficiency of histopathological diagnosis. Sci Rep. 2016;6:26286. DOI: 10.1038/srep26286.
16. Pantanowitz L, Quiroga-Garza GM, Bien L, Heled R, Laifenfeld D, Linhart C, et al. An artificial intelligence algorithm for prostate cancer diagnosis in whole slide images of core needle biopsies: a blinded clinical validation and deployment study. The Lancet Digital Health. 2020; 2(8): e407–16. DOI:10.1016/S2589- 7500(20)30159-X.
17. Goldenberg S, Nir G, Salcudean SE. A new era: artificial intelligence and machine learning in prostate cancer. Nat Rev Urol.2019; 16: 391–403. DOI:10.1038/s41585-019-0193-3.
18. Pasa F, Golkov V, Pfeiffer F, Cremers D, Pfeiffer D. Efficient deep network architectures for fast chest X-ray tuberculosis screening and visualization. Scientific Reports. 2019; 9:6268. DOI: 10.1038/s41598-019-42557-4.
19. Madabhushi A, Lee G. Image analysis and machine learning in digital pathology: Challenges and opportunities. Med Image Anal. 2016; 33:170-5. DOI:10.1016/j.media.2016.06.037.
20. Griffin J, Kitsanta P, Perunovic B, Suvarna SK, Bury J. Digital pathology for intraoperative frozen section diagnosis of thoracic specimens: an evaluation of a system using remote sampling and whole slide imaging diagnosis. J Clin Pathol. 2020;73 (8):503-6. DOI: 10.1136/jclinpath-2019-206236.
21. Roy SF, Cecchini MJ. Implementing a structured digital-based online pathology curriculum for trainees at the time of COVID-19. J Clin Pathol. 2020;73:444. DOI:10.1136/jclinpath-2020-206682.
Download attachments: 10.4328_ACAM.20322
Syed Usama Khalid Bukhari, Ubeer Mehtab, Syed Shahzad Hussain, Asmara Syed, Syed Umar Armaghan, Syed Sajid Hussain Shah. The assessment of deep learning computer vision algorithms for the diagnosis of prostatic adenocarcinoma. Ann Clin Anal Med 2021;12(Suppl 1): S31-34
Electrodiagnostic effect of Armeo® Robotic Therapy versus Conventional Therapy in Erb’s Palsy Children
Abdel Aziz A Sherief 1, Ahmed S Abdelfattah 2, Mahmoud S. Elfakharany 3
1 Department of physical therapy for Pediatrics, Faculty of Physical Therapy, Kafer El Sheikh University, 2 Department of physical therapy for Basic science, Faculty of Physical Therapy, Cairo University, 3 Department of physical therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
DOI: 10.4328/ACAM.20324 Received: 2020-08-29 Accepted: 2020-09-29 Published Online: 2020-10-28 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S35-40
Corresponding Author: Mahmoud S. El Fakharany, Lecturer of Pediatric Physical Therapy, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 11816, Cairo, Egypt. E-mail: Mahmoud.firstname.lastname@example.org P: 01067904792 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3943-4469
Aim: This study aimed to examine the efficacy of Armeo robotic therapy versus conventional therapy for upper limb function in children with Erb’s palsy. Material and Methods: Thirty children with Erb’s palsy, aged 3 to 5 years, were selected for this randomized controlled study and randomly assigned into two equal groups. The control group (A) received conventional therapy and the study group (B) received Armeo robotic therapy. Intervention for both groups contin- ued 45 minutes, 3 days/week for 12 successive weeks. The range of motion (ROM) of wrist extension using a digital electro-goniometer and the percentages of deltoid and biceps muscle degeneration using Electroneurography (ENoG) were evaluated for both groups before and after the intervention.
Result: A substantial decrease in the percentage of degeneration occurred in the biceps and deltoid in Group (B) compared with that of Group (A) post treat- ment (p > 0.001), and a significant increase occurred in wrist extension ROM in Group (B) compared with that of Group (A) post treatment (p > 0.001). The findings obtained clearly endorse the implementation of Armeo ® Robotic Therapy as an alternative to care program for children with Erb’s palsy.
Discussion: Children with motor dysfunction could be improved using targeted functional training. Variations in repeated movements and enriched environ- ments play an important role in motivating children, thereby enhancing training intensity and effectiveness. The use of robotic machines as a possible rehabili- tation strategy for achieving motor recovery may be justified by the beneficial effects on motor learning and therapeutic effects, since robotic training prolongs the duration and increases the training intensity.
Keywords: Erb’s Palsy; Armeo®; Robotic therapy; Robot
Brachial plexus birth palsy (BPBP) refers to upper extremity paralysis secondary to traction or compression injury sustained during birth into the brachial plexus. The incidence of BPBP is roughly 0.9 to 2.0 out of 1,000 live births [1, 2]. Erb’s palsy is a brachial plexus palsy affecting the upper trunk with nerve root C5-C6 causing loss of balance and arms weakness with internal shoulder twist deformity and hanging arm in limply with wrist and finger flexion typical of the tip of the waiter. Risk factors include dystocia of neck, macrosomia, rough or instrumented delivery, and breech presentation. BPBP varies in intensity and degree of plexus involvement, ranging from acute neuropraxia to the completion of some or all of the brachial plexus root cervical nerve avulsion. BPBP’s evolutionary history remains largely unknown due to the lack of research from birth to maturity of affected patients. Historically, 80 to 90 percent of patients were thought to show spontaneous recovery within the first 2 months of life, with normal upper extremity function afterwards [2, 6]. Additional studies have shown a much lower rate of recovery, with just 66 percent of affected children fully recovered, and 10 percent to 30 percent with severe lasting loss . Patients with chronic neurological disorders are at high risk of permanent neurological dysfunction between the ages of 3 to 6 months [2, 3, 6, 10, 11]. For infants who display limited spontaneous neurological recovery, microsurgical reconstruction with nerve grafting or transfers is indicated. The restoration of antigravity biceps activity by 3 to 6 months of age has historically been used to predict long-term neurological recovery. Michelow et al. reported in a small retrospective series that the use of biceps function alone wrongly predicted recovery in 12.8 % of cases . When elbow flexion and elbow, wrist, thumb, and finger extension were combined into a single test score (the Toronto Test score) at 3 months, the proportion of patients whose recovery was wrongly estimated was reduced to 5.2 percent . Researchers explored immersive video games in virtual reality (VR) with stroke individuals and children with CP. The overall results confirm that VR systems enhance upper limb recovery and habilitation. It is proposed that the use of constant massive practice in conjunction with the motivational features integrated in immersive VR games leads to this enhancement [6, 8, 9]. Sensory displays and gaming technologies developed especially for children can provide variety and entertainment value that cannot be accomplished in a typical clinical context . Other authors cite VR as a mean of achieving extended practice times for motor-impaired children, fulfilling one of the key tenants of mass practice [8, 10]. Additionally, exploratory research supporting VR’s ability to target specific neural networks can provide potential neuroanatomic treatment strategies for CP rehabilitation . Robotic interfaces allow the shaping of movement patterns with various methods including the actual human-computer interface, haptically rendered obstacles, and global forces such as anti-gravity or damping. Additionally, Fasoli et al.  identified a study in which a group of 5–12-year-old children with hemiplegia secondary to CP performed 16, 60-minute practice sessions in a simple virtual environment, with assistance over an 8-week span as required for robotic facilitation. Subjects showed average changes (percentage change from baseline) of 7.49 (13%) in the Upper Extremity Test Performance and 8 (42%) in the Upper Extremity Fugl-Meyer Evaluation ratings, along with anecdotal accounts of increased real-world parental use. A similar pilot study was described by Frascarelli et al . Twelve children with upper limb motor function impairments due to brain lesions completed 18 1-hour sessions to meet specific targets using controlled and unguided movements facilitated by the same robotic device used by Fasoliet al. in the previous study , the subjects on average showed an improvement of 3.33 points (9 percent) and an improvement of 6.71 points (12 percent) in the Unilateral Upper Limb Function score in Melbourne evaluation (UEFMA) score. These changes in clinical research were followed by smoothness enhancements of 63 %and trajectory speed enhancements of 40 % assessed during the training . Armeo® spring is a system used for upper limb rehabilitation ; it is an exoskeleton that provides gravitational support for the affected upper limb by means of a spring mechanism and magnifies any residual active movement of the hemiparetic arm. As an orthosis with seven degrees of freedom and built-in position sensors, it gives information about specific movement parameters (resistance, strength, range of motion, and coordination), with a possibility to adjust the system sensitivity depending on the patient’s condition. In its distal region, the system includes a pressure-sensitive handgripwhichallowsagradedperformanceduringgraspand release exercises. This system enables participants to practice independent, task-oriented and repetitive movements in a virtual three-dimensional (3D) learning environment, involving central neural pathways related to proprioceptive and visual feedback processing [14,15].
Material and Methods
This study included 30 patients with a diagnosis of unilateral obstetric brachial plexus palsy that involves C5–6, as well as positive electroneurography results, suggesting disruption of the innervation in the affected limb for the deltoid and biceps brachii muscles. Children with any other problems than Erb’s paralysis were excluded, such as contractures, suffering from fixed limitations in the affected upper limb, musculoskeletal problems, neuromuscular problems or hypersensitivity to latex and adhesive bands.
1. Electroneurography (ENoG) used to measure percentages of deltoid and biceps brachii muscle degeneration.
2. Armeo robotic therapy (Figure 1) is a passive upper limb orthosis, which lightens the weight of the upper limb in 3D space, using an ergonomic and adjustable backrest (antigravity effect), and allows natural movement in the workspace. This makes it easier for users with moderate to severe disabilities to achieve a greater range of motion .
3. Digital electro-goniometer is used to determine the range of wrist extension.
A randomized study included thirty children with Erb’s palsy selected from the out-patient clinic, Faculty of Physical Therapy, Cairo University (males and females, aged 3 to 5 years).
Those meeting the criteria of inclusion were divided into two groups as follows: Group (A) (control) and Group (B) (study). Children in Group (A) received 12 successive weeks of conventional therapy, and group (B) received 12 successive weeks of Armeo robotic therapy.
This study was approved by the Cairo University Research Ethics Committee, and written informed consent was obtained from the parents of each subject to participate in this study. Participant recruitment
All children were randomly assigned equally in two groups using the closed envelopes procedure (30 children each).
A. Evaluation procedure
• Electroneurography (ENoG)
For measuring the percentages of degeneration of the deltoid and the biceps brachii muscles, a computerized electromyography device (Neuroscreen plus – four channels – version 1.59 produced by TOENNIES, 97204 Hochberg, Germany) was used with surface electrodes. To prepare the patient and measure his temperature, he was asked to lie on the examination table in a supine position, per skin from waist- up and the sites required for stimulation and registration were washed with alcohol-damped medical cotton to minimize skin impedance. He was asked to maintain his head in mid position to prevent manifestation of any primitive reflexes that could alter the distribution of tone in his body. ENoG was first performed on the safe side and then replicated on the affected one. The site of the bipolar stimulator was above the Erb’s point and the determination of the best position to generate the compound muscle action potential (CMAP) was manually adjusted. For the deltoid, the active recording electrode was placed in the motor point of the posterior deltoid muscle fibers with the reference recording electrode placed farther distally at a relatively quiet point, and the active electrode was placed in the motor point of the biceps muscle with the reference recording electrode placed farther distally at a relatively quiet point for the biceps muscle. The ground electrode was placed under the clavicle’s lateral 1/3. A rectangular pulse was developed, with a time base of 5 ms and a frequency of 1 Hz. The intensity of the current stimulation was increased step by step until the amplitude of the diphasic myogenic CAP had not increased further. To be sure of supramaximal stimulation we added about 10 percent of current. The range of stimulation intensity was 15 to 40 mA. For measuring the peak-to-peak amplitude, the software included with the Neuroscreen plus system was used.
• Digital electro-goniometer was used to determine the range of wrist extension.
1. Conventional Therapy
The Group (A) received conventional therapy for 45 min/session, 3 times/week, for 12 successive weeks. This program included: 1. Passive stretching exercises for elbow and wrist flexors.
2. Weight-bearing exercises for the upper limbs.
3. Stimulation of the protective reactions of the upper limbs in all directions.
4. Exercises facilitating hand skills, such as reaching, grasping, carrying, releasing, in-hand manipulation, and bilateral hand use.
The children performed these exercises while satting on a chair, while the therapist sat beside to guide and assist them in performing the exercises correctly.
2. Armeo robotic therapy
The Group (B) received practice in a virtual environment, using Armeo® spring (Hocoma, AG, Switzerland). The Armeo® system is a novel tool that combines robotic assistance and virtual reality to provide a unique way to engage children in the repetitive motions required for motor learning. This exoskeleton device provides an engaging environment to help achieve the repetitive practice that the upper extremities need to improve their function. The Armeo system is highly adjustable, allowing the therapist to customize the device to the needs of each child. Armeo equipment is based on the product “T-WREX” . This product is a passive upper limb orthosis, which lightens the weight of the upper limb in 3D space, using an ergonomic and adjustable backrest (antigravity effect), and allows natural movement in the workspace. This makes it easier for users with moderate to severe disabilities to achieve a greater range of motion . The Armeo has five different degrees of freedom: shoulder flexion/extension, shoulder abduction/adduction, elbow flexion/extension, forearm pronation/supination, and grip strength. The therapist can choose to lock out different motions or work on all motions at the same time, depending on the needs of each child. In addition, adjustments can be made to the amount of gravity assistance provided by the exoskeleton, depending on the strength of the upper extremities. The therapist adjusts the electric lifting column according to the child’s height while sitting, and the length of the orthosis for upper arm and forearm to avoid compensatory movement. The 3D workspace is then adjusted with the amount of weight support. After feeding the data from each patient into the device, the therapist selects the appropriate program according to the difficulty level; the computer senses the movement of the joint angle and uses the information to provide visual feedback and track the entire process. Patients practiced the Armeo therapy for 45 min/ session, 3 times/week, for 12 successive weeks. This provided the high level of repetition required to facilitate changes in the upper extremities [18, 19]. During each 45-minute session, the patients performed a gamut of exercises customized for each patient, under the supervision of a physiotherapist. This study used the standard game and difficulty settings assigned by the Armeo software. The exercises were chosen in order to provide an engaging and gradual training with increasing difficulty (very easy, easy, moderate, and difficult). The exercises involved different joints (shoulder, elbow, and wrist), defined movements (flexion-extension, abduction-adduction, and pronation- supination, separated or in combination); the movement was to be performed in a 1D, 2D, or 3D environment, with increasing demand for accuracy and/or speed. The system automatically recorded information about the exercise during each training session (such as difficulty level, work area, and weight support), the score obtained by the subject and the time required for the exercise. The games were cognitively engaging and functionally relevant; they visually guided the patient’s performance and provided him/her with feedback. As in common video games, a score lets the patient follow his/her performance and improvement over time. The therapist verbally reinforced positive efforts, furnished suggestions, increased the difficulty gradually, and selected the task .
The characteristics of the subjects were compared using the t-test for both groups, for comparison of sex and affected side distribution between groups, the chi-squared test was used. For all variables, the normal data distribution was tested using the Shapiro-Wilk method. To test the homogeneity between groups, Levene’s test for homogeneity of variances was carried out. Mixed MANOVA was performed to compare the effects of treatment on the percentage of degeneration of the biceps and deltoid and wrist extension ROM between the group A and B as between-group comparison and between pre and post treatment in each group as within-group comparison. Post- hoc tests were carried out using the Bonferroni correction for subsequent multiple comparisons. The level of significance for all statistical tests was set at p ≤ 0.05. All statistical analyses were conducted using the statistical package for social studies (SPSS) version 25 for Windows (IBM SPSS, Chicago, IL, USA).
Table 1 shows the subject characteristics of both groups. There was no significant difference between both groups regarding age, sex or the affected side (p > 0.05).
Effect of treatment on the percentage of degeneration of biceps and deltoid and wrist extension ROM:
Mixed MANOVA revealed that there was a significant interaction of treatment and time (F = 80.81, p = 0.001). There was a significant main effect of time (F = 1028.67, p = 0.001). There was a significant main effect of treatment (F = 113.12, p = 0.001).
Both groups showed a significant decrease in the percentage of degeneration of the biceps and deltoid post treatment compared with that pretreatment (p < 0.001). Also, both groups showed a significant increase in wrist extension ROM post- treatment compared with that pretreatment (p < 0.001) (Table 2).
There was no significant difference between groups A and B in all variables pre-treatment (p > 0.05). There was a significant decrease in the percentage of degeneration of the biceps and deltoid in Group B compared with that in Group A post treatment (p > 0.001); and a significant increase in wrist extension ROM in Group B compared with that in Group A post treatment (p > 0.001). (Table 2).
The study showed that there was a significant decrease in the percentage of degeneration of the biceps and deltoid, which reveals that this kind of therapy is recommended in these cases. History has shown that the vast majority (95.7%) of obstetric brachial plexus paralysis resolved spontaneously, with 92% of recovery over the first three months . In some patients, contractures and deformities can occur rapidly, regardless of the incidence of spontaneous recovery and the transient quality of the paralysis. One should not expect spontaneous recovery, as, despite the complete return of muscle power, limitation of motion and deformity may persist if therapy is delayed . Long- term residual deficits can include progressive bony deformities, muscle atrophy, joint contractures, potential impaired limb growth, shoulder girdle weakness, and/or “Erb’s Engram’ (elbow flexion accompanied by shoulder abduction) . The findings of this study indicate that Armeo® Robotic Therapy is significantly more effective in improving the upper limb function in children with Erb’s palsy than conventional therapy. New technologies allow and promote active involvement, leading directly to functional changes that are far beyond those obtained with conventional therapy . The main objective of this study on rehabilitating children with Erb’s palsy was to restore the basic functional abilities of their arms. Recovery from neural damage usually depends on different factors, such as the nature and extent of rehabilitation. Conventional rehabilitation programs that provide optimum therapeutic results are shorter and less intensive. Children with motor dysfunction could be improved using targeted functional training. Variations in repeated movements and enriched environments play an important role in motivating children, thereby enhancing training intensity and effectiveness. . The use of robotic machines as a possible rehabilitation strategy for achieving motor recovery may be justified by the beneficial impact on motor learning and the therapeutic effect, since robotic training prolongs the duration and increases the training intensity . By using the Armeo system in this study, the therapist was able to manipulate all parameters of exercise, such as duration, intensity and type of feedback, based on treatment goals and individual ability. Therefore children can regularly and with increased enthusiasm perform the necessary tasks. Furthermore, the therapists can track the effects of their gestures and correct them if necessary . During the robotic therapy used in this study, sensorimotor, visual, and auditory input was provided simultaneously with exercise, or at the end of the practice period. The findings of this study are in agreement with those of Glavić et al., who showed that the Armeo spring system is a useful method to improve the quality of movement of the upper limb. To achieve the best possible outcomes for children with Erb’s palsy, it is advisable to supplement conventional therapy with robotic therapy . Improving the consistency of the movement of the study group’s upper extremities is associated with vigorous motor activity that can restore and improve neuronal pathways, and increase neuronal plasticity in children with motor deficits triggered by central or peripheral nervous system disorders. In addition to intensive motor training, a goal-oriented and task- specific training program is another requirement for successful rehabilitation. .
We would like to emphasize not only the positive effect of Armeo® robotic therapy, but also the successful motivation of patients at this age. Armeo®Robotic Therapy is significantly more effective than conventional therapy in improving the quality of movement of the upper limb in children with Erb’s palsy.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Chater M, Camfield P, Camfield C. Erb’s palsy – Who is to blame and what will happen? Paediatr Child Health. 2004; 9(8):556-60.
2. Okafor U, Akinbo S, Sokunbi O, Okanlawon A, Noronha C. Comparison of electrical stimulation and conventional physiotherapy in functional rehabilitation in Erb’s palsy. Nig Q J Hosp Med. 2008; 18(4):202-5.
3. Terzis JK, Kostopoulos E. Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy. Plast ReconstrSurg. 2010; 126(3):951-63.
4. Raiss P, Rettig O, Wolf S, Loew M, Kasten P. Range of motion of shoulder and elbow in activities of daily life in 3D motion analysis. Zeitschrift fur Orthopadie und Unfallchirurgie. 2007;145(4):493-8.
5. Chomiak J, Dungl P, Ošťádal M, Frydrychová M, Burian M. Muscle transfers in children and adults improve external rotation in cases of obstetrical brachial plexus paralysis: a comparative study. Int Orthop. 2014;38(4):803-10.
6. Snider L, Majnemer A, Darsaklis V. Virtual reality as a therapeutic modality for children with cerebral palsy. Dev Neurorehabil. 2010; 13(2):120–128.
7. Adamovich SV, Fluet GG, Tunik E, Merians AS. Sensorimotor training in virtual reality: A review. Neurorehabilitation. 2009; 25:29–44.
8. Rizzo A, Kim G. A SWOT analysis of the field of virtual reality rehabilitation and therapy. Presence. 2005; 14:1–28.
9. Reid DT. Benefits of a virtual play rehabilitation environment for children with cerebral palsy on perceptions of self-efficacy: A pilot study. Pediatr Rehabil. 2002; 5(3):141–8.
10. Parsons TD, Rizzo AA, Rogers S, York P. Virtual reality in paediatric rehabilitation: A review. Dev Neurorehabil. 2009; 12(4):224–38.
11. Fasoli SE, Fragala-Pinkham M, Hughes R, Krebs HI, Hogan N, Stein J. Robotic therapy and botulinum toxin type A: A novel intervention approach for cerebral palsy. Am J Phys Med Rehabil. 2008; 87(12): 1022-5.
12. Frascarelli F, Masia L, Di Rosa G, Cappa P, Petrarca M, Castelli E,et al. . The impact of robotic rehabilitation in children with acquired or congenital movement disorders. EurJ Phys Rehabil Med. 2009; 45(1):135–41.
13. Turconi AC, Biffi E, Maghini C, Peri E, ServodioIammarone F, Gagliardi C. Can new technologies improve upper limb performance in grown-up diplegic children? Eur J Phys Rehabil Med. 2016; 52(5):672-81.
14. Bartolo M, De Nunzio AM, Sebastiano F, Spicciato F, Tortola P, Nilsson J,et al. . Arm weight support training improves functional motor outcome and movement smoothness after stroke. Funct Neurol. 2014; 29(1):15-21.
15. Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia. 2013; 28(5):261-7.
16. Qiu Q, Ramirez DA, Saleh S, Fluet GG, Parikh HD, Kelly D, et al. The New Jersey Institute of Technology Robot-Assisted Virtual Rehabilitation (NJIT-RAVR) system for children with cerebral palsy: A feasibility study. Journal of Neuroengineering and Rehabilitation. 2009; 6:40.
17. Valvano J. Activity-focused motor interventions for children with neurological conditions. Phys Occup Ther Pediatr. 2004; 24(1-2):79–107.
18. Volman MJ, Wijnroks A, Vermeer A. Effect of task context on reaching performance in children with spastic hemiparesis. Clin Rehabil. 2002; 16:684–92.
19. Trefler E, Taylor SJ. Prescription and positioning: Evaluating the physically disabled individual for wheelchair seating. Prosthet OrthotInt. 1991; 15(3):217– 24.
20. Turconi AC, Biffi E, Maghini C, Peri E, ServodioIammarone F, Gagliardi C. Can newtechnologies improve upper limb performance in grown-up diplegic children? Eur J PhysRehabil Med. 2016; 52(5):672-81.
21. Magill R, Anderson R. Motor Learning and Control: Concepts and Applications. 10th ed. North Ryde: NSW McGraw-Hill; 2014. p. 325-30.
22. Kempermann G, Van Praag H, Gage FH. Activity-dependent regulation of neuronal plasticity and self-repair. Prog Brain Res. 2000; 127:35-48.
23. You SH, Jang SH, Kim YH, Kwon YH, Barrow I, Hallett M. Cortical reorganization induced by virtual reality therapy in a child with hemiparetic cerebral palsy. Dev Med Child Neurol. 2005; 47(9):628-35.
24. Glavić J, Rutović S, Cvitanović NK, Burić P, Petrović A. Technology- enhanced upper limb physical rehabilitation in hemiplegic cerebral palsy. Int J Neurorehabilitation. 2016; 3:225. DOI: 10.4172/2376-0281.1000225.
25. Damiano D. Activity, activity, activity: Rethinking our physical therapy approach to cerebral palsy. Phys Ther. 2006; 86(11):1534-40.
Download attachments: 10.4328_ACAM.20324
Abdel Aziz A Sherief, Ahmed S Abdelfattah, Mahmoud S. Elfakharany. Electrodiagnostic effect of Armeo® Robotic Therapy versus Conventional Therapy in Erb’s Palsy Children. Ann Clin Anal Med 2021;12(Suppl 1): S35-40
Perception of some ethical issues by clinical medical students, physicians and nurses, faculty of medicine, Alexandria university, Egypt
Amal A. Mashali, Heba A. Hussein
Department of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt
DOI: 10.4328/ACAM.20326 Received: 2020-08-31 Accepted: 2020-11-10 Published Online: 2020-11-21 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S41-48
Corresponding Author: Heba Abdel Samie Mohamed Huseein, Lecturer of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt. E-mail: Hebaforensic@gmail.com P: 01002957439 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0022-4640
Aim: Today the practice of good medicine raises both ethical and legal issues that affect doctors. This is developed through education and later from practical experience. A cross-sectional study was conducted in Alexandria University hospitals to gauge the extent of knowledge, awareness and attitude of undergradu- ate medical students, physicians and nurses towards medical ethics.
Materials and Methods: A structured questionnaire including awareness of principles of medical ethics and attitudes towards ethical issues and medical errors was distributed to participants. Three-point Likert scale (agree, disagree, and do not know) was used to assess the attitudes.
Results: The majority of the participating nurses (84.8%), 74% and 56.5% of the participating physicians and students, respectively divulged that their clinical teachers encouraged them to raise ethical issues. More than half of all respondents denied witnessing a physician treating patients differently because of their backgrounds or beliefs; 67.5% of all responding participants denied observing a physician discussing confidential information in an inappropriate setting. Nearly three- quarters of research respondents denied witnessing a physician who did not take informed consent before any invasive intimate examination or before performing any interventional procedure. Among the responding physicians and nurses, 54% and 46.6% respectively affirmed observing a medical error by one of their physicians; 40.1% of the responders attributed medical errors to load of work due to a low number of caregivers, while 51.9% of them suggested training in preventing errors and encouraging hospitals to report medical errors.
Discussion: Different related studies revealed similar responses from participants of their research. They confirmed that the majority of participants had posi- tive attitudes towards autonomy, paternalism, justice and confidentiality. In addition, medical errors have been reported by participants in some studies. We can conclude that participants had a reasonable knowledge and positive attitude towards medical ethics.
Keywords: Ethical issues; Attitude; Perception; Confidentiality; Consent; Medical errors
The term ‘Medical Ethics’ is attributed to the English physician Thomas Percival, who in the year 1803 first published the expectations and requirements of a member of the medical profession. It is based on a set of values that healthcare professionals can lean on in case of conflict or confusion and includes the four main principles . Health ethics as applied to medical practice date back to the ancient civilization by the symbolic adherence to the Hippocratic Oath, codes of conduct and laws regulating the profession are devised and updated from time to time .
Over the last 3 decades, medical practice has been increasingly complicated by the emergence of moral conflicts in medical care and an increased emphasis on patient-centeredness in the doctor-patient relationship, the development of sophisticated medical technology, and the influence of legal and health system factors on clinical care. For these reasons, medical ethics is now considered a key foundational component of the essential knowledge and skills required for good clinical practice . The practice of good medicine raises both ethical and legal issues that affect doctors. This is developed through education . After graduating and entering into a practical field, the exposure to various challenges makes it difficult to take decisions encompassing the broader aspect of both scientific knowledge and human values. Medicine is holistic in nature and the patient- physician relationship is its backbone [5, 6]. The disciplines of law and ethics in medical practice overlap in many areas, and yet each has its unique parameters and distinct focus . Medical ethics has been founded on the framework of four moral principles of autonomy, beneficence, nonmaleficence, and justice. The first of these principles, autonomy, is the respect for the patient’s right to self-governance, choice in care, and the right to accept or refuse treatment . In recent years, interest in understanding the ethical environment faced by students, physicians and nurses has increased . The importance of culture as a part of medical education has been raised, and ethical views have become an issue with an increase in research on these issues [8, 9].
In today’s society, with the complexity of medical treatment and decisions surrounding health care, it is important for health- care providers, to be knowledgeable and aware of the laws and ethics that govern patient care. Not only to preserve the patient’s right to competent, compassionate health care, but also to avoid legal problems that can threaten their ability to earn a living [10, 11].
The objectives of the present work were to assess medical students’, nurses’ and physicians’ perceptions of the ethical environment, to gather information about any ethical issue they witnessed or experienced during their clinical rotations, to evaluate ethical conduct among healthcare providers in different ethical dilemmas.
Material and Methods
A descriptive cross-sectional survey was carried out on 340 study participants divided into 100 physicians of different specialities and different categories, house-officers, residents, and clinical staff members, 115 medical students (in the clinical phase) and 125 nurses of different specialities at the three University Hospitals of Alexandria University, Egypt from March 2019 to January 2020.
An anonymous self-administered structured questionnaire was designed, based on appraisal of literature, and distributed by the authors of the research. It was designed to examine the perception of research participants (physicians, students in the clinical phase, and nurses) of different ethical issues encountered during day-to-day practice, preserving the confidentiality of patients, obtaining informed consent from patients, and medical errors, through a four-section design. At the same time, an Arabic version of the questionnaire was prepared for distribution to nurses in order to be more understandable. Some questions of no relevance to nurses were omitted from this version [12,13].
At the same time, the questionnaire included an explanation of the objectives of the research and ended with a space where subjects of research could write their personal experience of ethical issues that they have witnessed. Participation was voluntary and did not involve the collection of personally identifiable information.
On purpose, the subjects included in the research did not receive any definition of what was considered unethical behavior in the questionnaire. This is done in order to assess their knowledge and what they perceived as unethical in their own conduct and the conduct of the healthcare givers.
Before the beginning of the study, a small-scale trial was conducted to identify potential methodological problems. The following aspects were evaluated: the reaction of the study participants to the research procedures, the data collection tools like sequence and clarity of questions, and the time needed to fill the questions, sampling procedures, and supervision and administration of fieldwork activities. Its reliability was confirmed by carrying out a Cronbach’s alpha coefficient equal to 0.872. Moreover, the validity of the questionnaire was tested. Ethical considerations
Ethical approval was obtained from The Ethics Committee of Alexandria Faculty of Medicine (IRB No: 00012098, FWA No: 00018699) before starting the research. Informed consent was obtained from each research participant before participating in the study.
No personally identifiable information was obtained or linked to participants’ responses, except for the class of students and for the specialty of physicians and nurses. Moreover, confidentiality was observed and ensured by the researchers.
Statistical analysis of the data
Data were introduced to the computer and processed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). Qualitative data were defined using number and percent. The significance of the acquired results was judged at the 5% level. The Chi-square test for categorical variables, to compare between different groups, and Monte Carlo correction (correction for chi-square when more than 20% of the cells have expected count less than 5) were used.
The current study included 340 respondents divided into 100 physicians of different specialties, 115 medical students in the preclinical phase and 125 nurses of different specialties. Participants’ general characteristics are shown in Table 1. Professional Conduct of physicians, nurses, and students Table 2 demonstrates that the majority of the participating nurses (84.8%), 74% and 56.5% of participating physicians and students, respectively, stated that their clinical teachers encourage them to raise ethical issues. A significant difference was noted between the given answers, where X2=27.326 and mcp=0.001. Among the participated physicians, students, and nurses, 53%, 47%, and 77.6%, respectively, declared that they reported to the authorities if they noticed that any of their fellows impaired or had a lack of professional responsibility, with significant difference noted between them (X2=29.213 and p<0.001).
More than half of participated physicians (54%) and (49.6%) nurses in the current research observed a colleague or a physician who was not putting patient’s interest first (X2=18.155 and mcp=0.001). On the other hand, 58.3% of contributing students did not notice such a behavior. At the same time, 53%, 47% and 77.6% of participated physicians, students and nurses, respectively, declared reporting to authorities if they noticed any of their fellows impaired or lacking professional responsibility, with a significant difference noted between them (X2=29.213 and p<0.001).
A significant difference was observed between respondents’ answers regarding whether they had previously observed a physician who gave a medical certificate of sick leave to a person who was not ill (X2=l40.238 and p<0.001), and less than half of the participating physicians and students (46% and 48.7%), respectively, declared such behavior.
Only 22% and 28% of responding physicians confirmed being asked to do something unethical for fear of receiving a poor evaluation or to fit in the group. A significant difference was noted with X2 =22.307 and 28.574, p<0.001, respectively.
At the same time, 49%, 46.1% and 38.5% of responding physicians, students and nurses, respectively, watched a medical teacher manifesting unethical behavior towards a patient. Moreover, the present study shows that the majority of participating physicians and students (90% and 87.8%) affirmed that they saw a physician making fun of a patient. Only 24% of responding nurses witnessed such behavior. In addition, the responses of the attendees reported by physicians and students were laughing (42.2% and 32.7%) or additional joking (28.9% and 28.7%), respectively.
At the same time 87%, 83.5% and 12.2% of responding physicians, students and nurses declared that they observed how a nurse made fun of a patient before. However, 76%, 83.5% and only 5.7% of contributing physicians, students and nurses, respectively, perceived a student made fun of a patient before.
The highest percentages (79.6%, 73.9% and 70.2%) of participating physicians, students and nurses, respectively, denied watching a physician made fun of a psychiatric patient, with a significant difference (X2=16.936 and p=0.002). Similarly, more than two thirds (68.1%) of all responding research participants declared they had never seen a physician making fun of an obese patient before. Moreover, 66%, 67.8% and 67.8% of responding physicians, students and nurses, respectively, did not witness a physician describing a patient or his family in an insulting manner.
In addition, the current research describes that more than half (55.6%) of all responding research participants denied witnessing a physician treating patients differently because of their backgrounds or beliefs (X2=13.599 and p=0.009). On the other hand, 10.9% of them signed this question as “don’t know”. In addition, 53.4% of the total respondents declared not perceiving a physician treating a patient in a disrespectful manner, while 41.9% of them confirmed watching such a behavior, with non-significant difference between them, (X2=6.338 and p=0.175).
Among all respondents, 45.9% stated that they witnessed a physician before describing other clinical services or other physicians in a derogatory manner. Among all the research participants, 43.5% denied having seen such a scene before. Non-significant difference was noted between the three groups (X2= 7.557 and p=0.109).
In the present study, 54.9% of all responding participants had witnessed rude behavior from a physician before, with a significant difference between them (X2=20.973 and p<0.001). At the same time, 55.8% of all responding participants declared observing an inappropriate behavior from a physician, with non-significant difference between obtained responses (X2= 6.366 and MCp= 0.167).
Moreover, the majority of all responding participants (80.2) denied watching a patient in distress upon examination during clinical rotation, with a significant difference (X2= 89.177 and p<0.001). According to the nurses’ responses, the physician’s empathic attitude towards the patient accounted for 42.5% and aggressive attitude accounted for 27.5%.
The present work shows that 57.8% of all respondents denied the fact of observing a physician who wrote an inappropriate prescription, with a significant difference (X2=11.362 and p=0.023). Moreover, 55.5% of all responding participants negated that they had witnessed a case of fraud before, with a significant difference noted between the attained responses (X2=15.214 and p=0.004). In addition, 61.7% of them did not witness any unlicensed activity (X2=22.323 and p<0.001). Among responding physicians, students and nurses, 73%, 75.7% and 68%, respectively, did not watch a physician using drugs or alcohol, with a significant difference observed between responses (X2=9.863 and p=0.043). In addition, 57%, 38.3% and 73.4% of responding physicians, students and nurses, respectively, confirmed perceiving a case of medical negligence, with a significant difference attained (X2=33.514 and p<0.001).
Table 3 shows that regarding confidentiality related issues, 62.6%, 45.2% and 45.1% of responding physicians, students and nurses, respectively, affirmed witnessing a physician discussing a patient’s condition in a public place such as a lift, corridor, waiting room, coffee shop. A significant difference was noticed between the three groups (X2=14.691 and p=0.005).
On the other hand, more than half (54.1%) of the total respondents confirmed that they had not seen the disclosure of information to family members without the patient’s permission before, with a significant difference between the responses received (X2=36.274 and p<0.001).
Among the responding physicians, students and nurses, 67%, 50% and 36.9%, respectively, heard a physician commenting on a patient, but not in the patient’s presence, with a significant difference between them (X2= 23.567 and p<0.001).
In the present research, 67.5% of responding participants denied having observed a physician discussing confidential information in an inappropriate setting. A significant difference was detected with X2=37.846 and p <0.001. Furthermore, 75.1% of all respondents did not saw a physician give false information to a patient or his/her family before, with a non- significant difference obtained (X2= 2.961 and p=0.564). On the other hand, about three quarters of the responding participants (73.6%) did not observe that a physician withheld information from a patient without proper reasons, with a significance between them (X2=19.205 and p=0.001).
In the present research, only about two-thirds (63.2%) of responding physicians and students confirmed that they were introduced to the patients or their families as students by their seniors, with a non-significant difference between them (X2=1.694 and p=0.429), while only 36.3% of them stated that they were introduced as a junior physician to the patients or their families by their seniors. A significant difference was observed between the answers (X2= 23.141 and p<0.001).
On the other hand, 66.7% of all respondents negated having watching a physician not taking verbal consent before interviewing or examining a patient. A significant difference was noted between the answers (X2=12.118 and p=0.016). At the same time, near three-fourths (72.3%) of research respondents denied witnessing a physician who did not take informed consent before any invasive intimate examination, such as rectal or vaginal while under anesthesia. In the current work, 76.9% of respondents did not see a physician not taking informed consent before performing any interventional procedure. In addition, 68% of them did not witness a case where the key components of informed consent before performing any interventional procedure were not fulfilled, with a significant difference between the obtained responses (X2=28.517 and p<0.001); 70% of all respondents did not observe a physician not taking informed consent about the type of anesthesia before performing any interventional procedure. Furthermore, 75.6% of research respondents did not watch a physician not taking informed consent from parents of child patients before performing any interventional procedure, with a significant difference observed (X2=22.030 and p<0.001).
At the same time, 75.9% of responding research participants of the current work negated perceiving a physician not taking informed consent from a caregiver of an incompetent patient before performing any interventional procedure, with a significant difference between them (X2=16.626 and p=0.002); 59.7% of them denied witnessing a physician not taking consent for blood sampling with significant difference noticed X2=16.835 and p=0.002; 64.4% of all respondents in the present study did not observed a physician not taking consent for suturing of a patient. In addition, 68.5% of the research respondents did not watch a physician not taking informed consent for tissue sampling; 58.4% of them did not saw that the necessary procedures were performed against the patient’s wish.
Regarding the previous experience of a medical error, more than half of the total respondents (52.2%) in the present work declared that one of their family members had been subjected to a medical error before, with a non-significant difference noticed between the three groups (X2= 8.117 and p=0.087). Furthermore, the highest percentage of responding physicians (63%) confirmed witnessing a medical error done by one of their colleagues. On the contrary, the higher percentage of participating students and nurses (69.3%) and (47.5%) respectively, negated watching this before, with a significant difference between the obtained answers (X2=43.775 and p<0.001).
In addition, 54% and 46.6% of responding physicians and nurses, respectively affirmed observing a medical error by one of their physicians, while the highest percentage of responding students (63.2%) negated watching this, with a significant difference between the answers gained (X2=45.892 and p<0.001).
When the research participants were asked about how serious this problem was, the highest percentage of responding physicians (54.6%) signed as none, while the highest percentage of responding students and nurses (46.8%) and (54.2%), respectively, answered it was minor problem. Only 20.5% of all respondents stated that it was a major problem. A significant difference was noted (X2= 29.321 and p<0.001) (Figure 1).
Regarding the consequences of this observed medical error, serious pain was stated by 30.8% of all respondents, followed by temporary disability (28%), then loss of time from work or school (21.7%). The least percentage was given to permanent disability in 9.8% of answers (Figure 2).
Moreover, concerning who was responsible for the observed medical error, it was a physician in 47.9% of all respondents’ answers, followed by a nurse in 24.1%, then a clinic in 13.6%. The least percentage was given to the hospital, accounting for 10.1% of all obtained answers.
On the other hand, when the participated research subjects were asked about the possible cause of the observed medical error, 40.1% of them mentioned the workload due to a low number of caregivers, while insufficient training was mentioned by 38.3%. Only 12.5% of respondents revealed stress as the cause of medical error.
Furthermore, the current study shows the measures that were recommended by the study participants in order to reduce medical errors. About two thirds (64.5%) of them recommended developing a system for preventing error, followed by 51.9% of them who suggested training in preventing errors, and finally, encouraging hospitals to report medical errors (45.3%). The least percentage (10%) of respondents proposed suspending the license of a medical institution.
Knowledge and practice of medical ethics by healthcare professionals is an extremely important issue in today’s highly sophisticated and expensive medical treatment .
The current study included 340 respondents to a self- administered structured questionnaire divided into 100 physicians of different specialties, 115 medical students in the preclinical phase and 125 nurses of different specialties. The questionnaire was for mainly four ethical issues.
Professional misconduct extends to any behavior affecting the clinician in his professional capacity, which may properly be regarded as dishonorable or disgraceful by his colleague in the light of the accepted ethical standards of the profession, whether written or unwritten. Improper delegation, abuse of confidentiality and exercising of undue influence over a patient’s affairs are other serious overconfidence mistakes. Further instances of professional misconduct include drunkenness, treatment in return for financial inducements from the suppliers, incorrect certification with regards to sick notes, or insulting patient .
In the present study the majority of participating nurses (84.8%), 74% and 56.5% of participating physicians and students, respectively, divulged that their clinical teachers encouraged them to raise ethical issues. More than half of the participated physicians (54%) and 49.6% of nurses observed a colleague or a physician who was not putting patient’s interest first, whereas 58.3% of the participating students did not notice such behavior. At the same time, 53%, 47% and 77.6% of participated physicians, students and nurses, respectively, declared that they reported to the authorities if they noticed that any of their fellows impaired or had a lack of professional responsibility, with a significant difference noted between them.
To evaluate the awareness and attitudes of medical ethics amongst medical students in Malaysia, the response rate was 84.3% reflecting positive attitudes of students towards medical ethics . Similar findings were observed by Chatterjee and Sarkar  and Walrond et al. , while in the study by Acharya and Shakya , 91.3% of the medical interns considered medical ethics to be important.
In the work of Mohamed et al., a significant difference was observed between respondents’ answers regarding previously watching a physician who gave a medical certificate of sick leave to a person who was not ill .
Among the responding physicians, students and nurses, 87%, 83.5% and 12.2%, respectively, declared that they had previously observed a nurse making fun of a patient before. However, 76%, 83.5% and only 5.7% of the participating physicians, students and nurses, respectively, perceived a student making fun of a patient.
More than half of all respondents denied witnessing a physician treating patients differently because of their backgrounds or beliefs, or treating a patient in a disrespectful manner, while 41.9% of them confirmed watching such behavior and witnessed rude or inappropriate behavior from a physician. However, the majority of all responding participants denied watching a patient in distress upon examination during clinical rotation.
Medical students confirmed that occasionally they might do what they consider unethical but necessary for their survival or success, while at the same time believing that they are main training.
Kunda observed that medical students are motivated to justify reasonably their observation and participation in unethical behavior .
Testerman et al. concluded that some medical students struggle to develop coping skills in the complex and challenging medical environment, but that this cynicism decreases as residents and then as practicing physicians when they become more knowledgeable, skillful, and adept at dealing with ambiguous and challenging medical and ethical situations. These two studies were conducted in the nineties of the twentieth century before medical ethics was included in curricula and when ethical issues were not mostly concerned in practice .
In the present work, 73%, 75.7% and 68% of responding physicians, students and nurses did not watch a physician using drugs or alcohol. In addition, 57%, 38.3% and 73.4% of responding physicians, students and nurses respectively confirmed perceiving a case of medical negligence. Nearly similar results were observed in other works [16-18].
The rule of confidentiality is nonetheless subject to a number of important limitations both legal and moral in clinical practice .
In the present study, 62.6%, 45.2% and 45.1% of responding physicians, students and nurses, respectively, affirmed witnessing a physician discussing a patient’s condition in a public place.
However, 67.5% of all responding participants denied observing a physician discussing confidential information in an inappropriate setting. Furthermore, 75.1% of all respondents did not see a physician giving false information to a patient or his/her family or withheld information from a patient without proper reasons.
Similar results were reported in a study by Singh et al. (2016) regarding the respect of patient wishes informing close relatives. However, a small percentage of their respondents considered confidentiality an unimportant aspect of treatment .
Consent is the act of giving approval or acceptance of something done or proposed to be done, and an act exact conduct flowing from the person giving the consent. In recent years, informed consent before an interventional procedure is mandatory to ensure that one’s autonomy is respected, letting patients to carefully consider their choices .
In Achaya and Shakya work, the majority of the participants had positive attitudes towards autonomy, paternalism, justice, and confidentiality . Similar findings were reported by Chatterjee and Sarkar and others [16, 17].
Medical errors are accepted as a human factor and are recorded in the literature everywhere in the world . More than half of the total respondents (52.2%) in the present work declared exposure of one of their family members to a medical error before.
Among the responding physicians and nurses, 54% and 46.6%, respectively, affirmed observing a medical error by one of their physicians, while the highest percentage of responding students (63.2%) negated watching similar incidents. The consequences were serious only as stated by 20.5% of all respondents. The consequences included severe pain, as stated by 30.8% of all respondents, followed by temporary disability (28%), and then loss of time from work or school (21.7%). The least percentage was given to permanent disability in 9.8% of responses.
The responsible personnel was a physician in 47.9% of answers of the responses, followed by a nurse in 24.1%, and then a clinic in 13.6%. The least percentage was given to the hospital with 10.1% of all obtained answers.
This is in contrast to results found in a study in Africa that showed that 42% of respondents agreed that ethics is important only for legal purpose indicating that there is very little knowledge regarding health care ethics in these settings .
There was some discrepancy in our study population between doctors and nurses. This could be attributed to personalized judgment in the absence of knowledge on ethics. On the other hand, 40.1% of the responders attributed the errors to load of work due to a small number of caregivers, while insufficient training was mentioned by 38.3% of them, and 12.5% of respondents revealed stress as a cause of medical error.
About two thirds of respondents in the present work recommended developing system for preventing error, while 51.9% of them suggested training in preventing errors and 45.3% suggested encouraging hospitals to report medical errors.
In Adhikari et al’s work, the preference of the resident doctors and nurses were consultation regarding ethical and legal problem they observe . Similarly, the majority (67.2 %) of doctors preferred to consult a lawyer, while majority of the nurses (80.7 %) prefer consulting their supervisors.
Our study elucidates that doctors and nurses differ in their attitudes pertaining to practical ethical issues such as informing close relatives, consenting to treating, adherence to confidentiality and consent. The attitude towards medical ethics including core values for the guidance of doctors, physician’s duties towards patients including respect, and confidentiality and consent among the students of our medical college was satisfactory.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Beauchamp TL, Childress JF. Principles of Biomedical ethics. 7th ed. Oxford: Oxford University Press; 2013.
2. Baldwin Jr D, Daugherty SR, Rowley BD. Unethical and unprofessional conduct observed by residents during their first year of training. Acad Med. 1998;73(11):1195–200.
3. Manson H. The Need for Medical Ethics Education in Family Medicine. Fam Med. 2008; 40 (9):658-64.
4. Elger BS, Harding TW. Terminally ill patients and Jehovah’s witnesses: teaching acceptance of patients’ refusals to vital treatments. Med Educ. 2002; 36: 479-88.
5. Tauber AI. Confessions of a Medicine Man. An Essay in Popular Philosophy. Cambridge MA: MIT Press; 1999.
6. Tauber AI. The ethical imperative of holism in medicine. In: Promises and Limits of Reductionism in the Biomedical Sciences. West Sussex: John Wiley & Sons; 2002.
7. RaiJ J, Acharya RV, Dave D. Knowledge and Awareness among Interns and Residents about Medical Law and Negligence in a Medical College in Vadodara. IOSR J of Dental and Medical Sciences.2013; 3 (4):32-8.
8. Bickel J. Proceedings of the AAMC Conference on Students’ perception of their ethical environment and personal development. Acad Med.1996;69:670-9.
9. Satterwhite WM, Satterwhite RC, Enarson CE. Medical Students’ Perception of Unethical Conduct at One Medical School. Acad Med. 1998;73(5): 529-31.
10. Kovatz S, Shenkman L. Unethical Behaviour Witnessed by Medical Students During Their Medical Studies. The Open Ethics J. 2008; 2: 26-8.
11. Studdert DM, Bismark MM, Mello MM, Harnam Singh, Spittal MJ. Prevalence and characteristics of physicians prone to malpractice claims. N Engl J Med. 2016;374(4):354-62.
12. Jatana1 S K, Soe HHK, Phyu1 KL, Lwin H, Than NN. A Survey on Knowledge and Attitudes towards Medical Ethics among Undergraduate Medical Students. Education. 2018; 8(3): 48-53
13. Adhikari NS, Paudel K, Aro R, Adhikari TB, Adhikari B, Mishra SR. Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting. BMC Med Ethics. 2016; 17(1):68
14. Hariharan S, Jonnalagadda R, Walrond E, Moseley H. Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. BMC Med Ethics. 2006;7: E7.
15. Tukur B, Buk LLB, Lagos BL, Nkanta CA. Medico – Legal Issues in Clinical Practice: An Overview. Dala Journal of Orthopaedics (DJO). 2017; 1(1): 89-98.
16. Chatterjee B, Sarkar J. Awareness of medical ethics among undergraduates in a West Bengal medical college. Indian J Med Ethics. 2012; 9(2): 93-100.
17. Walrond ER, Jonnalagadda R, Hariharan S, Moseley HSL. Knowledge, Attitudes and Practice of Medical Students at the Cave Hill Campus in relation to ethics and law in healthcare. West Indian Med J. 2006; 55(1): 42-7.
18. Acharya RP, Shakya YL. Knowledge, attitude and practice of medical ethics among medical intern students in a Medical College in Kathmandu. Bangladesh J Bioethics. 2015; 6(3). DOI: 10.3329/bioethics.v6i3.27613.
19. Mohammad M, Ahmad F , Rahman S Z , V Gupta V , Salman T. Knowledge, Attitudes and Practices of Bioethics among Doctors in a Tertiary Care Government Teaching Hospital in India. J Clinic Res Bioeth. 2001; 2:6.
20. Kunda Z. The case for motivated reasoning. Psychological Bulletin; 1990;108:480-98.
21. Testerman JK, Morton KR, Loo LK, Worthley JS, Lamberton HH. The natural history of cynicism in physicians. Acad Med. 1996;71(Suppl. 1): S43-5.
22. Singh S, Sharma P K, Bhandar B, Kaur R. Knowledge, awareness and ethical practiceswerecomparedamongconsultantsandSRs.IndianjofPharmacology. 2016; 48;7:89-93.
23. Cocanour CS. Informed consent – It’s more than a signature on a piece of paper. Am J Surg. 2017;214(6):993-7.
24. Bonetti M, Cirillo P, Musile Tanzi P, Trinchero E. An Analysis of the Number of Medical Malpractice Claims and Their Amounts. PLoS ONE. 2016; 11(4): e0153362.
25. Monsudi KF, Oladele TO, Nasir AA, Ayanniyi AA. Medical ethics in sub-Sahara Africa: closing the gaps. African Health Sciences. 2015;15 (2): 673- 81.
Download attachments: 10.4328_ACAM.20326
Amal A. Mashali, Heba A. Hussein. Perception of some ethical issues by clinical medical students, physicians and nurses, faculty of medicine, xxx university. Ann Clin Anal Med 2021;12(Suppl 1): S41-48
The effect of proprioceptive exercises on static and dynamic balance in professional athletes
Muharrem Gokhan Beydagı 1, Burcu Talu 2
1 Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, 2 Inonu University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Malatya, Turkey
DOI: 10.4328/ACAM.20327 Received: 2020-08-31 Accepted: 2020-10-19 Published Online: 2020-10-24 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S49-53
Corresponding Author: Burcu Talu, Inonu University, Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Malatya, Turkey. E-mail: email@example.com P: +90 5317910984 F: +90 4223410220 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5623-8291
Aim: In this study, we aimed to evaluate the effect of proprioceptive exercises on static and dynamic balance in professional athletes.
Material and Method: The study was designed with a matched-group using a pre-post design. Twenty professional male athletes (mean age: 20.55±3.55 years, Body Mass Index: 22.45±1.46 kg/m2) participated in the study. Proprioceptive exercises were performed 3 days per week with a physiotherapist and at home on the remaining days for the 6-week training period. After obtaining demographic information, static and dynamic balance parameters were evaluated using the KorebalanceTM balance assessment equipment. Static and dynamic balance evaluation was performed while they were in the positions of eyes open, double/ single-leg stance, and hands on-off; in addition, for static balance in the positions with closed eyes.
Results: Comparing balance parameters before and after proprioceptive exercise training, a statistically significant difference was found in all static balance parameters (p<0.05). In addition, a statistically significant difference was found in the dynamic balance parameters in a double-leg stance position (p<0.05), whereas no statistically significant difference was found in the dynamic balance parameters in a single-leg stance position (p>0.05).
Discussion: The research results showed that proprioceptive exercises effectively improved static and dynamic balance in professional athletes. Thus, due to the integration of balance and the proprioceptive system, exercises will positively contribute to athletes’ postural control capabilities by improving their bal- ance performance. But, there was no effect on dynamic balance in one-leg stance position, so it would be beneficial to include in the training program exercises, which increase the dynamic balance in one-leg stance position.
Keywords: Proprioception; Balance; Exercise
Football is a type of sport that requires technical skills as well as static and dynamic balance. Most of these technical skills, such as juggling the ball in the air and passing, receiving, or dribbling the ball, require standing and balancing on one leg. Balance plays a crucial role during difficult conditions such as moving on slippery grass, changing the ball’s orbit, pushing opponents, and facing footballers during a football game . Balance is a highly integrated dynamic process involving multiple neurological pathways that require proprioceptive feedback. Many sports require superior balancing ability to achieve the highest level of competition . Improvement in balance control is thought to be important for footballers and is based on a combination of mobility, power, and proprioception. Therefore, improvements in balance may lead to a better performance during football games . Some research results suggest that proprioceptive ability is important for achieving higher balance skills in athletes . Proprioceptive senses are related to the physical condition of the body and include stative, tendon, and muscle senses and pressure senses from the plantar. Therefore, the proprioceptive mechanism is necessary for proper joint functioning in sports, daily life activities, and some occupational skills [5, 6].
The purpose of a proprioceptive exercise program is to train the afferent pathways to increase the sense of movement and to make sure complicated movements are performed correctly without any hesitation or thought. Therefore, open and closed kinetic chain exercises should be added to the exercise program in an orderly manner . Athletes would continue to perform balance exercises in proprioceptive exercise programs to increase motor function at the brain stem level. These programs should be implemented with standard progression, both with and without visual system input, and be specific to the activities and capabilities that the athlete needs .
Proprioception, a complex part of the neuromuscular system, is provided by afferent and efferent stimuli that allow both body balance and orientation to be sustained [9-11]. These stimuli are transported and interpreted under the control of the central nervous system, allowing the formation and maintenance of proprioception in sports activities. Previous studies have shown that improvement in balance performance, which plays an important role in sports physical fitness parameters, significantly improves footballers’ body posture stability, increases performance, and protects against injuries [12-14]. Therefore, an improvement of proprioception in lower extremity joints through special exercises will lead to balance development in athletes, and thus will significantly affect their performances .
We hypothesize that proprioceptive exercises affect static and dynamic balance in professional athletes.
Material and Methods
This study is an experimental study using a matched-group and a pre-post design investigating the effect of proprioceptive exercises on static and dynamic balance in professional athletes. Twenty professional male footballers from the Yeni Malatyaspor football club competing in the Turkish Super
League participated in the study.
The study population consisted of the athletes aged 15-29 of the football club Yeni Malatyaspor. All of the athletes who agreed to participate in the survey and met research inclusion criteria were included in the study sample without using any sample selection method. Assuming that the difference between pre-treatment (190.1 ± 42.1) and post-treatment (145.5 ± 25.7) double-leg stance static balance scores was determined as 44.6 in the power analysis with α = 0.05 and 1-β (power) = 0.80 , it was calculated that at least 10 participants should be included in the study. The NCSS PASS 13 program was used to calculate the sample size.
Prior to participation in the present study, all individuals provided their informed consent. The experimental protocol was approved based on the ethical standards of the Declaration of Helsinki. In order to conduct this study, the required permission and consent was obtained from the Malatya clinical research ethics committee (Approval number=2016/177, Approval date =23/11/2016).
Following permission from the ethics committee, the research data were collected in the application laboratory of the Physiotherapy and Rehabilitation Department in the Faculty of Health Sciences at Inonu University and the Yeni Malatyaspor football club.
The individuals aged 15-29 years, licensed, able to adapt to the training program, volunteered to participate in the study, did not suffer from ankle instability, and signed the informed consent form were allowed to participate in the study. The athletes who suffered from systemic disease, experienced an injury in the last 6 months, refused to perform exercises, or had previous surgery were excluded from the study.
Participants’ demographic information including age, height, body weight, Body Mass Index (BMI), dominant side, and football experience were obtained. Following the pre-application evaluation, athletes were assigned two proprioceptive exercise sets 3 days per week for a 6-week training period under the supervision of a physiotherapist. They were asked to perform these exercises as at-home exercise on the remaining days. The athletes performed the exercises individually following the warm-up exercises before their regular training program. The athletes were carefully instructed to complete the warm- up process before starting the exercises. The exercises were carried out under the supervision of a physiotherapist from the Yeni Malatyaspor football club. Five different exercises lasting 10-15 minutes were assigned to each athlete. The exercises were carried out using a balance board, soccer ball, bosu ball, and small shuttle balance system.
The exercises were used moderately for the first 2 weeks, and as time progressed (Exercises were applied for 6 weeks; in the first 3 weeks- 2 sets of 15 repetitions; 4th week- 2 sets of 20 repetitions; 5th week- 2 sets of 25 repetitions; 6th week- 2 sets of 30 repetitions), the exercise program proceeded by exercising the ankle, knee, and hip joints at different joint angles. The participants performed proprioceptive exercises for a 6-week period to gradually improve the sensitivity and sensation of joint position in their trained joints. They also practiced these exercises as at-home exercises.
Static and dynamic balance parameters were evaluated before starting proprioceptive exercises and 6 weeks after the exercises using the KorebalanceTM balance assessment and training equipment (Korebalance Premier-19 Systems Inc., USA) (Figure 1). The device calculates the total score, which includes deviations caused by impairment of postural balance. A higher total Korebalance score indicates poorer balance, while a lower total score indicates better balance . Static balance evaluation was performed while participants were in the positions of eyes open-closed, double-leg/single-leg stance, and hands on-off, whereas dynamic balance evaluation was performed while they were in the positions of eyes open, double-leg/single-leg stance, and hands on-off.
For analysis of the data, SPSS for Windows, Version 16, was used, and the mean ± standard deviation value for the variables was calculated. Because the data did not show a normal distribution, analyses were conducted using non-parametric tests. The Wilcoxon Signed Ranks Test was used because the repeated measurements were tested over the same sample. The significance level was set as p<0.05 in the analyses.
Twenty professional male athletes from the football club Yeni Malatyaspor participated in this study. The majority of athletes were right dominant (75%). Table 1 shows their demographic characteristics.
Comparing balance parameters before and after proprioceptive exercise training, a statistically significant difference was determined for all parameters of static balance (p<0.05). In addition, a statistically significant difference was found in the dynamic balance parameters in a double-leg stance position (p<0.05), whereas no statistically significant difference was found in the dynamic balance parameters in a single-leg stance position (p>0.05) (Table 2).
The results showed that proprioceptive exercises positively contributed to the static and dynamic balance of professional athletes.
Proprioceptive loss and decrease in neuromuscular control cause functional instability in joints . Proprioceptive exercises provide small but positive improvements in motor skills . The ability to remain in balance during a single-leg or double- leg stance requires visual, neural, and vestibular integrity . In the presence of an intact vestibular system, it is easy for people with closed eyes to stand due to the normal functioning of various proprioceptive receptors, such as mechanoreceptors in ligaments, Golgi tendon organ, and the muscle spindle . Ankle proprioception is closely related to balance , however, there is a controversy regarding which balance parameters are affected by ankle proprioception . A neuroimaging study reported that the central processing of proprioceptive signals from the foot and ankle complexes, beyond the peripheral reflex mechanisms, is essential for balance and postural control . Footballers are known to have superior single-leg straight stance skills . In the present study, the participants’ low scores for static and dynamic balance in a single-leg stance are related to their high single-leg balance. The further development of this ability is an important factor for achieving greater success by footballers. The proprioceptive exercises carried out by athletes should be somewhat challenging to further develop these abilities . The present study results indicated that even elite athletes’ static and dynamic balance scores in the single-leg stance position improved due to proprioceptive exercise training. The difference between the pre- and post-training static balance scores in the single- leg stance was significant, whereas this difference for the single-leg dynamic balance parameters was not significant. Similar to the present study, Karakaya et al. found that ankle proprioceptive exercises positively affected static body balance parameters in healthy young college students . Khuman et al. stated that footballers had better static and dynamic balance than other athletes, and they found no significant difference between static and dynamic balance in terms of lower extremity dominance . The present study supports this result. Another study dynamically assessed balance using a single-plane balance platform and investigated the effects of a 6-week strength and proprioception training program on clinical balance in patients who had previously experienced a first-degree lateral ankle sprain. They found that the strength and proprioceptive training program improved participants’ balance .
Han et al. stated that since the central processing of ankle proprioceptive information together with other sensory information ensures the integration of posture and balance control, ankle proprioception plays an important role in balance control . In line with the literature, the present study results indicated that a 6-week proprioception exercise program improved both dynamic balance parameters (22% when eyes open and hands off; 39% when eyes open and hands on) and static balance parameters (33% with eyes open and hands off; 38% with eyes open and hands on; 28% with eyes closed and hands off). Similarly, Arslan et al. (2010) found that an 8-week proprioception training program improved dynamic postural control in taekwondo athletes .
A limitation of the study is that there is no standardization of proprioceptive exercises in the literature. This is an important limitation for studies in this area. However, we attempted to overcome this limitation by using proprioceptive exercises with predetermined efficacy from similar previous studies. Further studies that examine the efficacy of proprioception exercises, standardize them, and add dual task exercises are needed to improve single-leg dynamic balance.
Based on the results, the present study is the first study evaluating, in detail, all parameters of both dynamic and static balance in athletes before and after proprioceptive exercise training. The need for this study in the literature has been mentioned in the research limitation sections of previous studies [15, 23]. A lack or deterioration of the balance mechanism may adversely affect performance in athletes. The research results showed that proprioceptive exercises effectively improved static and dynamic balance in professional athletes. Thus, due to the integration of balance and the proprioceptive system, exercises will positively contribute to athletes’ postural control capabilities by improving their balance performance. But, there was no effect on dynamic balance in one leg stance, thus it would be beneficial to include exercises, which increase the dynamic balance in one leg stance in the training program.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Evangelos B, Georgios K, Konstantinos A, Gissis I, Papadopoulos C, Aristomenis S. Proprioception and balance training can improve amateur soccer players’ technical skills. J Phys Educ Sport. 2012;12(1):81.
2. Han J, Anson J, Waddington G, Adams R, Liu Y. The role of ankle proprioception for balance control in relation to sports performance and injury. Biomed Res Int. 2015;2015:842804. DOI: 10.1155/2015/842804.
3. Butler RJ, Southers C, Gorman PP, Kiesel KB, Plisky PJ. Differences in soccer players’ dynamic balance across levels of competition. J Athl Train. 2012;47(6):616-20.
4. Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D. Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc. 2001;9(3):128- 36.
5. Suner-Keklik S, Cobanoglu-Seven G, Kafa N, Ugurlu M, Guzel NA. The Validity and Reliability of Knee Proprioception Measurement Performed with Inclinometer in Different Positions. J Sport Rehabil. 2017:1-18.
6. Coskun G, Talu B, Cools A. Proprioceptive force-reproduction of the rotator cuff in healthy subjects before and after muscle fatigue. Isokinet Exerc Sci. 2018;26(3):175-81.
7. Li JX, Xu DQ, Hoshizaki B. Proprioception of foot and ankle complex in young regular practitioners of ice hockey, ballet dancing and running. Res Sports Med. 2009;17(4):205-16.
8. Yong MS, Lee YS. Effect of ankle proprioceptive exercise on static and dynamic balance in normal adults. J Phys Ther Sci. 2017;29(2):242-4.
9. Bruhn S, Gollhofer A, Gruber M. Proprioception training for prevention and rehabilitation of knee joint injuries. Eur J Sports Traumatol Rel Res. 2001;23(2):82-9.
10. Snyder N, Cinelli M. Comparing Balance Control Between Soccer Players and Non-Athletes During a Dynamic Lower Limb Reaching Task. Res Q Exercise Sport. 2020;91(1):166-71.
11. Robertson S, Elliott D. Specificity of learning and dynamic balance. Res Q Exercise Sport. 1996;67(1):69-75.
12. Myer GD, Ford KR, Palumbo JP, Hewett TE. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. J Strength Cond Res. 2005;19(1):51-60.
13. Panics G, Tallay A, Pavlik A, Berkes I. Effect of proprioception training on knee joint position sense in female team handball players. Br J Sports Med. 2008;42(6):472-6.
14. Adlerton AK, Moritz U, Moe-Nilssen R. Forceplate and accelerometer measures for evaluating the effect of muscle fatigue on postural control during one-legged stance. Physiother Res Int. 2003;8(4):187-99.
15. Karakaya MG, RutbIl H, Akpinar E, Yildirim A, Karakaya IC. Effect of ankle proprioceptive training on static body balance. J Phys Ther Sci. 2015;27(10):3299- 302.
16. Talu B, Bazancir Z. The effect of different ankle and knee supports on balance in early ambulation of post-stroke hemiplegic patients. Neurol Sci. 2017;38(10):1811-6.
17. Shields RK, Madhavan S, Cole KR, Brostad JD, Demeulenaere JL, Eggers CD, et al. Proprioceptive coordination of movement sequences in humans. Clin Neurophysiol. 2005;116(1):87-92.
18. Chtara M, Rouissi M, Bragazzi NL, Owen AL, Haddad M, Chamari K. Dynamic balance ability in young elite soccer players: implication of isometric strength. J Sports Med Phys Fitness. 2018;58(4):414-20.
19. Isakov E, Mizrahi J. Is balance impaired by recurrent sprained ankle? Br J Sports Med. 1997;31(1):65-7.
20. Powers ME, Buckley BD, Kaminski TW, Hubbard TJ, Ortiz C. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. J Sport Rehabil. 2004;13(3):201-27.
21. Goble DJ, Coxon JP, Van Impe A, Geurts M, Doumas M, Wenderoth N, et al. Brain activity during ankle proprioceptive stimulation predicts balance performance in young and older adults. J Neurosci. 2011;31(45):16344-52.
22. Matsuda S, Demura S, Uchiyama M. Centre of pressure sway characteristics during static one-legged stance of athletes from different sports. J Sports Sci. 2008;26(7):775-9.
23. Khuman PR, Kamlesh T, Surbala L. Comparison of static and dynamic balance among collegiate cricket, soccer and volleyball male players. Int J Health Allied Sci. 2014;3(1):9-13.
24. Mattacola CG, Lloyd JW. Effects of a 6-week strength and proprioception training program on measures of dynamic balance: a single-case design. J Athl Train. 1997;32(2):127-35.
25. Fatma A, Kaya M, Baltaci G, Taşkin H, Erkmen N. The effect of eıght-week proprıoceptıon traınıng program on dynamıc postural control ın taekwondo athletes. Ovidius University Annals, Series Physical Education & Sport/Science, Movement & Health. 2010;10(1):93-9.
Download attachments: 10.4328_ACAM.20327
Muharrem Gokhan Beydagı, Burcu Talu. The effect of proprioceptive exercises on static and dynamic balance in professional athletes. Ann Clin Anal Med 2021;12(Suppl 1): S49-53
Clinical, laboratory features and minimal residual disease levels in childhood acute lymphoblastic leukemia at Hue Central Hospital, Viet Nam
Nguyen Thi Kim Hoa 1, Phan Hung Viet 2, Tran Kiem Hao 1, Bui Binh Bao Son 1, 2
1 Pediatric Center, Hue Central Hospital, Viet Nam, 2 Department of Pediatrics, Hue University of Medicine and Pharmacy, Viet Nam
DOI: 10.4328/ACAM.20328 Received: 2020-08-31 Accepted: 2020-10-02 Published Online: 2020-10-17 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S54-57
Corresponding Author: Nguyen Thi Kim Hoa, Pediatric Oncology, Hematology and Transplant Department, Pediatric Center, Hue Central Hospital, 16 Le Loi street, Hue city, Viet Nam. E-mail: firstname.lastname@example.org p: +84935645836 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2525-4368
Aim: Acute lymphoblastic leukemia (ALL) is the most common malignant disease in children. Minimal residual disease (MRD) levels after induction phase predict outcome and may select patients for therapy intensification. In this study, we aimed to analyze the clinical presentations, laboratory features, especially the MRD levels in childhood acute lymphoblastic leukemia patients
Material and Methods: It was a prospective study on childhood acute lymphoblastic leukemia patients who admitted to the hospital between April-2018 and May-2020.
Results: There were 38 new patients, of whom, 68.4% were with standard risk, and 31.6% were with high risk; the ratio of male to female was 2.16:1. The median age was 4.0 years (range: 0.66 to 15). The percentages of B-ALL and T-ALL were 84.2% and 15.8%, respectively. The most common symptoms were anemia (86.8%), fever (76.3%), hepatomegaly (68.4%), splenomegaly (60.5%), enlarged lymph nodes (55.3%). Regarding laboratory features, 26.4% of the pa- tients had white blood cell (WBC) ≥ 50×109/l, 76.3% had platelet (PLT) < 100×109/l, 84.6% had blood hemoglobin level (Hb) < 10 g/dl. After induction, complete remission based on less than 5% blasts, achieved 97.4%. However, MRD after the induction phase with a threshold ≤ 0.01% accounted for 78.9%. Based on MRD, we adjusted intensive chemotherapy for 4 patients.
Discusssion: The most common clinical presentations were anemia, fever, hepatosplenomegaly, bone pain and bleeding. The MRD levels is more sensitive and precise to evaluate the response after the induction phase. Therefore, we could adjust intensive therapy for some patients with high MRD levels to improve the treatment outcome.
Keywords: Acute lymphoblastic leukemia; Minimal residual disease (MRD) levels; Children
Acute lymphoblastic leukemia (ALL) is the most common malignant disease in children. It accounts for one-fourth of all childhood cancers and 72% of all cases of childhood leukemia. Approximately 4,900 children are diagnosed with ALL each year in the United States, with an incidence of 2 to 5 cases per 100.000 U.S children. The peak incidence of ALL occurs between 2 to 5 years of age. The outcome in acute lymphoblastic leukemia in children has shown a steady improvement. Overall survival reached 95% in 2007, compared to 21% in 1960 in high-income countries.
Complete remission in children with ALL is traditionally defined as less than 5% blasts with light microscopic examination of the bone marrow (BM) aspirate. The definition by light microscopy examination is limited since it is unable to distinguish leukemic blasts from normal hematopoietic progenitor cells. Patients with ALL in remission may have varying levels of minimal residual disease (MRD) that is not detectable by light microscopy. MRD levels after induction phase predict outcome and could select patients for therapy intensification.
Hue Central Hospital plays an important role to treat childhood acute lymphoblastic leukemia in the central zone of Vietnam, which covers geographically wide areas. Since 2008, ALL patients have been treated by the modified CCG 1961 & 1991 protocol. In order to improve the treatment outcome, we carry out this research to analyze the clinical presentations, laboratory tests, especially the result of MRD levels after induction phase. Therefore, we could adjust intensive therapy for some patients to improve the treatment outcome.
Material and Methods
Thirty-eight patients were diagnosed with ALL at Hue Pediatric Center- Hue Central Hospital from April- 2018 to May- 2020. All ethical regulations were followed, and this study was approved by the Hue Central Hospital Ethical Committee (Institutional Review Board No. 18/NCKH-BVH). Consent was obtained from all participants in this study.
This is a prospective study. We described clinical presentations, laboratory tests and followed up the treatment.
Diagnosis of ALL on admission was made on the basis of bone marrow morphology, which showed more than 20% leukemic blasts. Children were treated according to the modified CCG 1991 & 1961 protocol. After the induction phase, all patients underwent bone marrow flow cytometry and MRD testing. Data were analyzed according to age, gender, clinical presentations, laboratory tests, MRD levels, and the events that happened during treatment. All statistical analysis was performed using SPSS v.18.0 (IBM Corp, Armonk, NY).
A total of 38 new patients with ALL were identified from April 2018 to May 2020 and met eligible criteria. Among these patients, 26 were males and 12 were females, the male to female ratio was 2.16:1. The median age was 4.0 years (range: 0.66 to 15). The peak incidence of ALL occurred in age group (1-< 10 years), accounted for 84.2%. The percentages of age group (< 1 year) and age group (≥ 10) were 2.6% and 13.2%, respectively (Table 3). Patient came from many different cities of the central zone: Hue (39.5%), Quang Tri (26.3%), Da Nang (10.5%), Quang Nam (10.5%), Quang Binh (5.3%), Quang Ngai, Kon Tum and Phu Yen had the same percentage (2.6%). Regarding clinical presentations, the median time from the onset of symptoms to the hospital admission was 10 days (1-90). The most common symptoms were anemia (86.8%), fever (76.3%), hepatomegaly (68.4%), splenomegaly (60.5%), enlarged lymph nodes (55.3%). The other signs were bone pain, hemorrhage, respiratory distress, and especially, there was one case with testicular involvement (2.65%). For laboratory features, 26.4% of the patients had white blood cell (WBC) ≥ 50×109/l, however, neutrophil was low, the median value was 0.41×109/l (0-68.95×109/l). 76.3% of the patients had platelet (PLT) < 100×109/l, 84.6% had blood hemoglobin level (Hb) < 10 g/dl. The median values of blast cells in the bone marrow and peripheral blood were 56.5% (20-90) and 14% (0-79), respectively. Lactate dehydrogenase (LDH) and C- reative protein (CRP) increased in most of patients, accounting for 89.5% and 73.7%, respectively. There was one case with renal failure which recovered (2.6%).
Among our patients, there were 68.4% of patients with standard risk, and 31.6% patients with high risk. The percentages of B-ALL and T-ALL were 84.2% and 15.8%, respectively. After induction, complete remission based on less than 5% blasts, achieved 97.4%. However, MRD after the induction phase with a threshold ≤ 0.01% accounted for 78.9%.
During the treatment, two patients refused treatment after achieving remission, one patient passed away due to severe sepsis, and three patients had relapse (one bone marrow relapse, one CNS relapse and one combined BM and CNS relapse). 84.2% patients are healthy and are receiving treatment.
Table 3 shows that the male to female ratio was 2.16:1 and the median age was 4.0 years old (0.66-15), which is similar to some other researches [3-9]. The higher proportion of age group (1- <10 years) (84.2%) has also been reported in Pakistan and Saudi-Arabia [3, 8].
Hue Central Hospital plays an important role to treat childhood acute lymphoblastic leukemia in the central zone of Vietnam, thus our patients came from different cities, not only from Hue (39.5%), but also from Quang Tri (26.3%), Da Nang, Quang Nam, Quang Binh, Quang Ngai, Kontum and Phu Yen.
The most common clinical presentation in our group was anemia (86.8%), followed by fever (76.33%), hepatomegaly (68.4%), splenomegaly (60.5%) and lymphadenopathy (55.4%). These clinical presentations were similar to those reported from Pakistan and they are common signs of acute lymphoblastic leukemia disease [3, 9]. In our research, while the proportion of B-ALL was the predominant subtype (84.2%), 15.8% had the same percentage of T-cell ALL as the report from developed countries [3, 8].
Regarding laboratory features, 26.4% of our patients had WBC counts ≥ 50×109/l, similar to what was reported in Pakistan , and was markedly higher than that reported in the Western literature (17%), thus contributing to a higher tumor burden with a poorer outcome . And it could be one of the reasons for the increase in LDH. Almost all our patients (89%) had elevated LDH. Moreover, 76.3% of our patients had PLT < 100×109/l, and Hb < 9g/dl. There was no patient with CNS involvement, which was significantly lower than that reported in Saudi Arabia (5% CNS3) . Similarly, the percentage of overt testicular involvement was lower (2.65% compared to 3.6%) .
After the induction phase, 97.4% of our patients achieved complete remission. However, 78.9% of patients had MRD ≤ 0.01% and 21.1% had MRD > 0.01%. It could be explained by the fact that patients with ALL in remission may have varying levels of minimal residual disease (MRD) that is not detectable by light microscopy. It is estimated that patients who are in complete remission can harbor up to 1010 leukemic cells . According to Vora, MRD ≥ 0.01% at the end of the induction phase could benefit from augmented post-remission therapy . Similar, Allen showed minimal residual- guided treatment deintensification for children with acute lymphoblastic leukemia . Therefore, among our patients, 4 had a standard risk of having MRD ≥ 0.01%, thus we transferred them to a high risk group.
The most common clinical presentations of acute lymphoblastic leukemia were anemia, fever, hepatosplenomegaly, bone pain, bleeding, which in turn reflected the failure of normal hematopoiesis.
The MRD levels is more sensitive and precise to evaluate the response after the induction phase. Therefore, we could adjust intensify therapy for some patients with high MRD levels to improve the treatment outcome.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Matloub Y, Bostrom BC, Hunger SP, Stork LC, Angiolillo A, Sather H, et al. Escalating intravenous methotrexate improves event-free survival in children with standard-risk acute lymphoblastic leukemia: a report from the Children’s Oncology Group. Blood. 2011; 118(2): 243-51. DOI: 10.1182/blood-2010-12-322909.
2. Seibel NL, Steinherz PG, Sather HN, Nachman JB, Delaat C, Ettinger LJ, et al. Early postinduction intensification therapy improves survival for children and adolescents with high-risk acute lymphoblastic leukemia: a report from the Children’s Oncology Group. Blood. 2008; 111(5): 2548-55. DOI: 10.1182/ blood-2007-02-070342.
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. DOI: 10.1002/pbc.25583.
4. Uckun FM, Gaynon PS, Sensel MG, Nachman J, Trigg ME, Steinherz PG, et al. Clinical features and treatment outcome of childhood T-lineage acute lymphoblastic leukemia according to the apparent maturational stage of T-lineage leukemic blasts: a Children’s Cancer Group study. J Clin Oncol. 1997; 15(6): 2214-21. DOI: 10.1200/JCO.19126.96.36.1994.
5. Gaynon PS, Desai AA, Bostrom BC, Hutchinson RJ, Lange BJ, Nachman JB, et al. Early response to therapy and outcome in childhood acute lymphoblastic leukemia: a review. Cancer. 1997; 80(9): 1717-26. DOI: 10.1002/(sici)1097- 0142(19971101)80:9<1717::aid-cncr4>3.0.co;2-b.
6. Ravindranath Y. Biology of childhood acute lymphoblastic leukemia (ALL) in low/middle-income countries–A case for using age at diagnosis for defining low- risk all. Pediatr Blood Cancer. 2015; 62(10): 1687-8. DOI: 10.1002/pbc.25639.
7. Howard SC, Pedrosa M, Lins M, Pedrosa A, Pui C-H, Ribeiro PC, et al. Establishment of a pediatric oncology program and outcomes of childhood acute lymphoblastic leukemia in a resource-poor area. JAMA. 2004; 291(20): 2471-5. DOI: 10.1001/jama.291.20.2471.
8. 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. DOI: 10.1002/pbc.24584.
9. Yasmeen N, Ashraf S. Childhood acute lymphoblastic leukaemia; epidemiology and clinicopathological features. J Pak Med Assoc. 2009; 59(3): 150-3.
10. Greaves MF, Colman SM, Beard ME, Bradstock K, Cabrera ME, Chen PM, et al. Geographical distribution of acute lymphoblastic leukaemia subtypes: second report of the collaborative group study. Leukemia. 1993; 7(1): 27-34.
11. Campana D, Pui CH. Detection of minimal residual disease in acute leukemia: methodologic advances and clinical significance. Blood. 1995; 85(6): 1416-34. 12. Vora A, Goulden N, Mitchell C, Hancock J, Hough R, Rowntree C, et al. Augmented post-remission therapy for a minimal residual disease-defined high-risk subgroup of children and young people with clinical standard-risk and intermediate-risk acute lymphoblastic leukaemia (UKALL 2003): a randomised controlled trial. Lancet Oncol. 2014; 15(8): 809-18. DOI: 10.1016/S1470-2045(14)70243-8.
13. Yeoh AE, Ariffin H, Chai EL, Sze Nga Kwok C, Chan YH, Ponnudurai K, et al. Minimal residual disease-guided treatment deintensification for children with acute lymphoblastic leukemia: results from the Malaysia-Singapore acute lymphoblastic leukemia 2003 study. J Clin Oncol. 2012; 30(19): 2384-92. DOI: 10.1200/JCO.2011.40.5936.
Download attachments: 10.4328_ACAM.20328
Nguyen Thi Kim Hoa, Phan Hung Viet, Tran Kiem Hao, Bui Binh Bao Son. Clinical, laboratory features and minimal residual disease levels in childhood acute lymphoblastic leukemia at Hue Central Hospital, Viet Nam. Ann Clin Anal Med 2021;12(Suppl 1): S54-57
Systemic and systemicplus regional antibiotic prophylaxis with cefazolin in total knee arthroplasty: A comparative study
Recep Öztürk 1, Aliekber Yapar 1, Emin Kürşat Bulut 1, Galip Beltir 1, Emre Özanlağan 2, Bedii Şafak Güngör 1
1 Department of Orthopedics and Traumatology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, 2 Department of Orthopaedics and Traumatology, Kahramanmaraş Necip Fazıl City Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20330 Received: 2020-09-01 Accepted: 2020-11-26 Published Online: 2020-12-09 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S58-62
Corresponding Author: Recep Öztürk, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Vatan Street, 06200 Yenimahalle, Ankara, Turkey. E-mail: email@example.com P: +90 5054634794 F: +903123360909 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6753-9321
Aim: Different studies show that prophylactic antibiotic concentration is higher with regional application compared to systemic application in total knee arthroplasty surgeries. The results of cefazolin, one of the most commonly used prophylactic agents, are not clear between systemic and local application after tourniquet.
Material and Methods: Forty-three patients with systemic intravenous (iv) 1000 mg cefazolin applied one hour before TKA surgery were compared with 29 patients who were treated with 1000 gr of cefazolin in the foot vein after tourniquet application in addition to the application of cefazolin 1000 g iv, all patients were evaluated in terms of infection findings on the 30th and 90th postoperative days . All patients were followed for at least 2 years.
Results: None of the patients had side effects after cefazolin application during or after surgery. There were no infections of the surgical site in the early postoperative period or during the follow-up period (mean duration, 41,5 months). In Group 1, only one patient had a superficial infection requiring drainage and antibiotherapy. Four patients in Group 1 and one patient in Group 2 had superficial infection treated with only antibiotherapy, respectively.
Discussion: Regional prophylaxis seems to be safe and valuable in TKA. Local plus systemic prophylactic antibiotics were more effective than in- travenous administration of the same dose in TKA.
Keywords: Local prophylaxis; Cefazolin; Knee arthroplasty; Infection; Prophylaxis
Infection rates after total knee arthroplasties (TKA) are higher than after total hip arthroplasty, and infection rates have been reported from 1% to5% . Although a small number of patients have deep infection, they may be destructive and result insignificant morbidity, which often requires additional surgery and long-term antibiotictherapy . Therefore, antimicrobial drugs are generally used for prophylaxis .
Gram positive cocci are the most common pathogens in infected orthopaedic prostheses, and staphylococci constitute75% of infections .
The most commonly used antibiotics are cephalosporins and semi-synthetic penicillins in the TKAs . By many authors, routine prophylaxis is applied as multiple cefazolin doses in clean surgical procedures, including elective orthopaedic surgeries [6,7]. Most of the early post-operative infections are the result of intraoperative contamination of the surgical site . In order for antibiotic prophylaxis to be effective, the concentration of antibiotics in the tissues must exceed the minimum inhibitory concentration (MIC) of the infectious organisms during the period between skin incision and wound closure. Coagulase negative staphylococci (CoNS) have relatively high MICs against cephalosporins. Therefore, the conventional systemic prophylactic dose of cephalosporin may lead to insufficient concentrations of these organisms in the tissues [9-11].
The application of a regional drug using a tourniquet allows the drug to achieve higher tissue concentrations than systemic application by providing the targeted limb distribution. Some authors have used a foot vein cannula to administer prophylactic antibiotics in TKA. With this approach, significantly higher concentrations of antibiotics in the tissues at the surgical site can be achieved without systemic side effects [1,12-14].
In the literature, there are studies of the regional antibiotic application with the aid of a foot vein or intraosseous application in TKA (Table1).These studies are mostly aimed at finding drug penetration into tissues. We have not find any study including comparative clinical results between systemic and systemic+regional cefazolin in the literature [1, 10-18].
In this retrospective study, we planned to define the efficacy and safety of systemic and regional prophylaxis with cefazolin in monolateral TKA. The aim of this study is to evaluate the comparative clinical outcomes after regional antibiotherapy.
Material and Methods
Seventy-two consecutive patients of both gender who admitted to our orthopaedics clinic between January 2014 and December 2016 and underwent elective monolateral total knee arthroplasty for chronic degenerative joint disease were included in this study. The mean age was 67,7±7 std (52-84 years) (9 males and 63 females) (Table2). Exclusion criteria were penicillin allergy, local or systemic active infection and previous operation history on the same knee. Data collection permissions were obtained from all patients to see the effects of local and systemic prophylactic application of cefazolin. The local medical expertise and education board approved the study protocol.
In the first group, 43 patients, 1000 mg of cefazolin was dissolved in 3ml of 0.9% sodium chloride solution and intravenously applied from the forearm veins one hour before the operation. In these patients, the tourniquet was inflated to 400 mm Hg (approximately 50 kPa) after 1 hour of cefazolin application. In the second group of 29 patients, in addition to intravenous cefazolin, after tourniquet 400 mm Hg (ca.50 kPa) inflation, 1000 mg of cefazolin, which is dissolved in 3ml of 0.9% sodium chloride solution was administered to the foot veins intravenously with bolus injection as a regional prophylaxis.
In both groups, the tourniquet was released after surgery and then hemostasis was performed. Jones bandage was applied to all patients. All patients in both groups received 1000 mg of cefazolin intravenously at the sixth hour after the operation. None of the patients used additional oral or parenteral antibiotics. All patients were evaluated for infection findings on the post-operative 30th and 90th days. All patients were followed for at least 2 years.
All operations were performed by the same three surgeons in the same operating room (with laminar flow). The skin on the surgical site was shaved with a disposable razor.
Briefly, a primary operative incision and/or implanted prosthesis infection or infections in the adjacent bone was considered a prophylactic failure. Also, any drainage procedure or debridement of surgical site and prosthesis was considered prophylaxis failure.
At least a two-year follow-up period was planned for all patients. The patients were clinically checked 15 days after discharge and at 1st, 3rd, 6th, and12th months postoperatively. Then they were called at intervals of 1 year and were clinically examined when necessary.
Statistical analysis was performed using the SPSS22.0 (ChicagoIL) computer program; in statistical analysis, categorical variables were given as numbers and percentages, and continuous variables were presented with mean±standard deviation (SD) and median (min-max value) for descriptive analyses. The sample calculation was performed with the Gpower 3.1 program. The effect size calculated in the light of the data of the reference study  was calculated as 0.4. The number of samples was calculated between 80% power and 95% confidence interval and found to be 69. The minimum number of patients required to participatein this study was 69 and 76 patients were enrolled in this study. Chi-Square tests were used for comparison of categorical variables between groups. The conformity of continuous variables to the normal distribution was evaluated using visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilktests). The Mann-Whitney U test was used for comparison of datasets which were not normally distributed for the variables. An Independent Sample test was used for comparison of datasets, which were normally distributed for the variables. P<0.05was considered statistically significant.
In the study period, monolateral TKR was applied to 72 patients. Systemic antibiotic prophylaxis was applied to 43 patients and systemic+local antibiotic prophylaxis was applied to 29 patients.
All 72 patients were evaluated for both efficacy and safety of cefazolin prophylaxis.
No statistically significant difference was found among age, sex distribution and follow-up period between the groups (Table3). None of the patients had any side effects during or after surgical cefazolin application.
In the follow-up period of two years or more, superficial infection was observed in8.3% of the patients in the postoperative period (Table2) (p>0,05). Both groups had no deep prosthesis infection requiring additional surgical intervention. Type 1  superficial infection, which can be completely treated with antibiotherapy, occured in 4 patients in the group without additional prophylaxis and in 1patient in the group with additiona lprophylaxis of this infection. Also, one patient in the patient group without additional prophylaxis, a 62-year-old female patient, developed type 2b 4 superficial infections requiring surgical drainage and antibiotherapy. There was no specific risk factor in this patient for infection (advancedage, obesity, diabetes mellitus, etc.). On the10thpost-operative day, she was admitted with the complaint of knee pain and purulent discharge in the surgical incision. On physical examination, the patient had a fever of 38.5°C. C-reactive protein level was high and leukocytosis was present in her laboratory tests results.
The rate of infection was 3.4% in the local+systemic prophylaxis group and 11.6% in the systemic prophylaxis group. There was no statistically significant difference between the two groups in the frequency of infection (p=0.391) (Table3).
Surgical drainage and systemic antibiotictherapy (given for 2 week) were successfully performed, and this resulted patient’s recovery without morbidity. No bone or implant infection occurred during the next 3.5 years of follow-up.
The mean follow-up period was 41,5months (between 24 and 59 months).When the groups were evaluated separately, the mean follow-up period in the first group was 39,7 month, and the mean follow-up time was 42,5 month in the second group. Any deep prosthesis infection requiring removal of the implant and replacement with another prosthesis was not observed in any patient in the long-term follow-up period ( 2 to 5 years).
Prosthetic joint infection (PJI) is one of the most serious complications affecting a patient’s quality of life after arthroplasty. The incidence of PJI for primary hip and knee arthroplasties in the literature is1 % and 2 %, respectively . The incidence of PJI after TKA surgery, according to Turkish National Surveillance Report in 2013, is 0,7-1,7 by (http:// www.saglik.gov.tr/DH/dosya/1-88693/h/uhesa-analiz-2013. pdf).
Therefore, prevention of post-operative infection is extremely important in this surgical discipline, and antibiotic prophylaxis is applied as routine in TKA. The benefits of prophylactic antibiotics were confirmed by a meta-analysis published in1997 comparing this anti-microbial administration with placebo or no prophylaxis .
PJIs can be classified as acute (first 3 months after surgery), delayed ( 3 to 24 months after surgery) or late (24 months or more after surgery) . Early and delayed infections are thought to be caused by organisms that occur during surgery, whereas late infections are more likely to be acquired as hematogenous. In addition, according to the classification system (proposed by Gorbach et al. in1992), infections can be grouped as superficial wound infection or suture abscess (class I), subcutaneous infection requiring antibiotics (class IIa), subcutaneous infection requiring antibiotics and surgical debridement or drainage (class IIb), and prosthesis and/or adjacent bone infection shown in surgery or autopsy (classIII) .
In recent years, studies have reported that resistance to cephalosporins is significantly increased in coagulase-negative streptococci. However, this increase in resistance is in consistent with clinical data on coagulase-negative streptococci. Regional administration of antibiotics can provide better protection against CoNS by achieving higher tissue concentrations [9, 10, 22]. Regional method of delivery would provide lower doses in a more rapid fashion to decrease the risk of toxicity while still seeking to maintain adequate tissue perfusion .
Although some antibiotics such as aminoglycosides and fluoroquinolones exhibit concentration-dependent killing, for b-lactamantibiotics such as cefazolin, time above MIC is the most important factor. However, higher b-lactam concentrations are known to lead to an earlier initiation of bacterial killing, which may be more important for prophylaxis against infection when the goal is to prevent initial bacterial adherence and colonization .
TKA surgery requires the use of a tourniquet completely obstructing systemic circulation to achievea bloodless surgical treatment. In most cases, this tourniquet is left in place during the surgery, thus preventing penetration of antibiotic penetration into the leg tissues through the arterial blood flow . As a result, the obtained antibiotic bone levels may be lower than those obtained from other localizations during TKA3. Researchers are trying different ways to eliminate this problem with prophylactic antibiotics.
Local prophylaxis practices include local irrigation with antibiotics, foot vein and intraosseous applications [1, 10, 13- 18]. Potential complications of intraosseous infusions include fluid extravasation with compartment syndrome due to improper needle placement in emergencies. Needle site infection has rarely been reported, and it is associated with the time needle is left in intraosseous way. Sub-clinical fat embolism has been observed histologically in animal studies .
Currently, the most common drugs used in prophylaxis of TKA are cephalosporins such as cephazoline, cefuroxime and cephalodol . We aimed to evaluate the clinical outcomes of regional prophylaxis with cefazolin by foot vein cannulation. In1990, Hoddinott et al. compareda regional cephalosporin(cefuroxim) given 1g into a foot vein with 1g of systemic cefamandole in five patients who underwent routine total knee arthroplasty, and they found that when applied regionally, the tissue concentration was 5-30 times higher. They found this method to be effective in maintaining high concentrations of cefuroxime in the surgical tissues . In 1993, Lalla et al. found that teicoplanin levels after local administration of 400 mg teicoplaninin to a foot vein were 2-10 times higher than levels obtained after 800 mg intravenous systemic prophylaxis in the tissues of the surgical site .
In 2000, Lalla et al. published the good clinical results of the application of teicoplanin into a foot vein in a patient who underwent 205 knee arthroplasty . Lazzarini et al., in their tissue penetration study in 2003, found that teicoplanin injected into a vein of the foot was about twice as high as systemic . Young et al. published the results of intraosseous application with cefamezin and vancomycinin 2013 and 2014. In both studies, tissue concentrations were higher than intravenous application [10,17].
In 2015, Chin et al. found the superiority of intraosseous application with vancomycin over intravenous application . In 2015, Young et al., who continued their studies on this subject, found that intraosseous application with cefamezin or vancomycin had better results in the mouse model study compared to the control group. Finally, in 2018, Young et al. found high tissue concentrations in intraosseous vancomycin application in patients undergoing revision knee arthroplasty [7,16].
Our study and this literature review show that regional prophylaxis application is the preferred way used for prophylaxis regardless of the drugin TKA. Each antibioticis potentially suitable for this route. However, the drug is rapidly released into the systemic circulation when the tourniquet is extinguished. Therefore, antibiotics suitable for regional prophylaxis are those that can only be applied as an intravenous bolus injection. Our study has some limitations. Our study is a retrospective analysis and the population is relatively small. The benefit of the new method in our study could not demonstrate statistical significance, but the rate of infection was lower in the new method. Further studies with a larger numbers of patients are needed in the future.
The regional route for prophylaxis in total knee prostheses is one of the best routes clinically and analytically regardless of which drug is used. A local antibiotic can be applied via a foot vein after the tourniquet is inflated. Local administration of cefazolin, in addition to intravenous prophylaxis, is a reliable and feasible prophylaxis technique in primary elective total knee prosthesis.
The authors would like to thank investigators, patients and their families.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. de Lalla F, Viola R, Pellizzer G, Lazzarini L, Tramarin A, Fabris P. Regional prophylaxis with teicoplanin in monolateral or bilateral total knee replacement: an open study. Antimicrob Agents Chemother. 2000;44(2):316– 19.
2. Gillespie WJ. Prevention and management of infection after total joint replacement. Clin Infect Dis. 1997;25(6):1310-7.
3. Paya CV, Wilson WR, Fitzgerald RH. Management ofinfection in total knee replacement. Curr Clin Top Infect Dis. 1988; 9:222–40.
4. Gorbach SL, Condon RE, Conte JE Jr, Kaiser AB, Ledger WJ, Nichols RL. Evaluation of new anti-infective drugs for surgical prophylaxis. Infectious Diseases Society of America and the Food and Drug Administration.Clin Infect Dis. 1992;15(Suppl 1.):S313-38.
5. Nichols RL, Condon RE, Barie PS. Antibiotic prophylaxis in surgery–2005 and beyond. Surg Infect (Larchmt). 2005;6(3):349-61.
6. Evrard J1, Doyon F, Acar JF, Salord JC, Mazas F, Flamant R. Two- day cefamandole versus five-day cephazolin prophylaxis in 965 total hip replacements. Report of a multicentre double blind randomised trial. Int Orthop. 1988;12:69-73.
7. Nelson JP, Fitzgerald RH Jr, Jaspers MT, Little JW. Prophylactic antimicrobial coverage in arthroplasty patients. J Bone Joint Surg Am. 1990;72(1):1.
8. Fletcher N, Sofianos D, Berkes MB, Obremskey WT. Prevention of perioperative infection. J Bone Joint Surg Am. 2007;89(7):1605–18.
9. Yamada K, Matsumoto K, Tokimura F, Okazaki H, Tanaka S. Are bone and serum cefazolin concentrations adequate for antimicrobial prophylaxis? Clin Orthop Relat Res. 2011;469(12):3486–94.
10. Young SW, Zhang M, Freeman JT, Vince KG, Coleman B. Higher cefazolin concentrations with intraosseous regional prophylaxis in TKA.Clin Orthop Relat Res. 2013;471(1):244-9.
11. Zalavras CG. Regional Intraosseous Administration of Prophylactic Antibiotics is More Effective Than Systemic Administration in a Mouse Model of TKA. Clin Orthop Relat Res. 2015; 473(11): 3585–7.
12. de Lalla F, Novelli A, Pellizzer G, Milocchi F, Viola R, Rigon A, et al. Regional and systemic prophylaxis with teicoplanin in monolateral and bilateral total knee replacement procedures: study of pharmacokinetics and tissue penetration. Antimicrob Agents Chemother. 1993;37:2693–8.
13. Hoddinott C, Lovering AM, Fernando HC, Dixon JH, Reeves DS. Determination of bone and fat concentrations following systemic cefamandole and regional cefuroxime administration in patients undergoing knee arthroplasty. J Antimicrob Chemother. 1990;26:823–9.
14. Lazzarini L, Novelli A, Marzano N, Timillero L, Fallani S, Viola R, et al. Regional and systemic prophylaxis with teicoplanin in total knee arthroplasty: a tissue penetration study. J Arthroplasty. 2003;18:342-6.
15. Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS Clinical Research Award: Intraosseous Regional Prophylaxis Provides Higher Tissue Concentrations in High BMI Patients in Total Knee Arthroplasty: A Randomized Trial.J Arthroplasty. 2018;33(Suppl. 7):S13-18.
16. Young SW, Roberts T, Johnson S, Dalton JP, Coleman B, Wiles S. Regional Intraosseous Administration of Prophylactic Antibiotics is More Effective Than Systemic Administration in a Mouse Model of TKA. Clin Orthop Relat Res. 2015;473:3573-84.
17. Young SW, Zhang M, Freeman JT, Mutu-Grigg J, Pavlou P, Moore GA. The Mark Coventry Award: Higher tissue concentrations of vancomycin with low-dose intraosseous regional versus systemic prophylaxis in TKA: a randomized trial. Clin Orthop Relat Res. 2014;472:57-65.
18. Young SW, Zhang M, Moore GA, Pitto RP, Clarke HD, Spangehl MJ. The John N. Insall Award: Higher Tissue Concentrations of Vancomycin Achieved With Intraosseous Regional Prophylaxis in Revision TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2018;476(1):66-74.
19. Alp E, Cevahir F, Ersoy S, Guney A. Incidence and economic burden of prosthetic joint infections in a university hospital: A report from a middle-income country. J Infect Public Health. 2016;9(4): 494-8.
20. Gallo J, Kolar M, Novotny R, Rihakova P, Ticha V. Patho-genesis of prosthesis-related infection. Biomed Papers. 2003;147:27-5.
21. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645-54.
22. Nickinson R, Board T, Gambhir A, Porter M, Kay P. The microbiology of the infected knee arthroplasty. Int Orthop. 2010; 34(4):505–10.
23. Dietz MJ. CORR Insights®: The John N. Insall Award: Higher Tissue Concentrations of Vancomycin Achieved With Intraosseous Regional Prophylaxis in Revision TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2018;476(1):75-6
24. Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial dosing of mice and men. Clin Infect Dis. 1998;26(1):1–10.
25. Hasan M, Kissoon N, Khan T, Saldajeno V, Goldstein J, Murphy S. Intraosseous infusion and pulmonary fat embolism. Pediatr Crit Care Med. 2001;2(2):133–8.
Download attachments: 10.4328_ACAM.20330
Recep Öztürk, Aliekber Yapar, Emin Kürşat Bulut, Galip Beltir, Emre Özanlağan, Bedii Şafak Güngör. Systemic and systemicplus regional antibiotic prophylaxis with cefazolin in total knee arthroplasty: A comparative study. Ann Clin Anal Med 2021;12(Suppl 1): S58-62
Isoniazid treatment in children and comparison of tuberculin skin test values before and after treatment
Özlem Özgür Gündeşlioğlu 1, Gönül Tanır 2
1 Department of Pediatric Infectious Diseases, Cukurova University, School of Medicine, Adana, 2 Department of Pediatric Infectious Disease, Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20334 Received: 2020-09-07 Accepted: 2020-12-14 Published Online: 2021-01-04 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S63-67
Corresponding Author: Özlem Özgür Gündeşlioğlu, Department of Pediatric Infectious Diseases, Balcalı Hospital, Cukurova University, School of Medicine, Sarıçam, Adana, Turkey. E-mail: firstname.lastname@example.org P: +90 5055677801 Corresponding Author ORCID ID: https://orcid.org/000-0003-2202-7645
Aim: In this study, it was aimed to evaluate the six-month isoniazid treatment and to compare Tuberculin Skin Test values before and after treatment in children with tuberculosis contact and latent tuberculosis infection.
Material and Method: The study included children older than 1 month and younger than 18 years of age who were started on isoniazid prophylaxis. In the treat- ment of latent TB infection, isoniazid was planned for six months. After the treatment, the tuberculin skin test was reapplied to all patients.
Results: A total of 106 pediatric patients (25.6%) with tuberculosis contact and 81 (76.4%) with latent tuberculosis infection were included in this study. The mean pre-treatment tuberculin skin test value of the patients was 16.57 ± 4.124 mm and 15.07 ± 4.017 mm after treatment. The average tuberculin skin test values before and after treatment were found to have a 1.5 mm difference and the tuberculin skin test values after treatment were found to be lower (t = 3.5, p <0.01). However, the number of patients who had increased, unchanged or decreased less than five millimeters tuberculin skin test values after treatment was 80 (75.5%), and the ratio of those with a reduction of five mm and more was only 24.5%.
Discussion: In previous studies, it has been concluded that isoniazid prophylaxis is effective in the prevention of tuberculosis and tuberculin skin test cannot be used to evaluate the efficacy of the treatment of latent tuberculosis infection. Recently, studies on the effectiveness of the treatment of latent tuberculosis infection and new diagnostic tests have become prominent, and we think that our study may draw attention to this issue in our country. It was concluded that tuberculin skin test is not adequate in evaluating the efficacy of treatment, the compliance with the six-month isoniazid treatment in children is good, and the treatment is well tolerated and effective.
Keywords: Children; Isoniazid; Tuberculosis infection; Tuberculin skin test
Despite the advances in the diagnosis and treatment of tuberculosis (TB), it is an important public health problem in the world and in our country. Although one-third of the world’s population is reported to be infected with TB, the incidence of latent tuberculosis infection (LTBI) is not fully known. Today, there is still no reliable biomarker showing the treatment efficacy of LTBI. Childhood TB usually develops after contact with adult or adolescent patients with pulmonary TB. Contact is usually within the home, but may also be in school, nursery, nursing home or other enclosed spaces [1,2]. Latent tuberculosis infection identifies the condition where after the inhalation of M. tuberculosis into the lungs, it is limited by the host immune response and there are no clinical and radiological findings of TB disease. The diagnosis of latent tuberculosis infection is established by detecting enhanced immunity against M.tuberculosis using TST or interferon-gamma release tests (IGRT) . The risk of disease progression is 10% in adults, and the risk of developing active disease is higher in pediatric patients. Due to the high risk of progression to active LTBI in infants and children under five years of age, the inverse proportion of the strength of infection with age, long-term risk developing clinical infection in children with latent infections later, and the increased infectiousness of children reaching adulthood, LTBI treatment is the most important step in TB prevention . INH has been the first choice in the treatment of latent tuberculosis infection for years. The success rate of the treatment with isoniazid for six to nine months is 60-90%. It has been shown that the effect of INH treatment lasts up to 19 years if there is no re-infection with tuberculosis . Due to low compliance with isoniazid treatment for six-nine months, short-term treatment regimens have emerged. It has been reported that compliance with treatment was higher in patients who received INH and rifampicin for three months compared to patients receiving isoniazid alone for six months .
The tuberculin skin test is associated with delayed-type hypersensitivity to tuberculin and is an indicator of cellular immunity in humans. Although new biomarkers are being researched, there is currently still no test revealing the success of treatment after the treatment of latent tuberculosis infection. In this study, we aimed to evaluate whether there is variability in TST values after latent tuberculosis infection in pediatric patients, especially whether there is a decrease or not, and the relationship between the variability and clinical and demographic data. Meanwhile, another aim of this study was to evaluate the compliance of children to 6-month INH treatment and the side effects, which may develop as a result of treatment.
Material and Methods
The study included children who had undergone INH treatment due to LTBE and TB contact who were older than one month and younger than 18 years of age. Ethics committee approval was obtained for this study. Written and oral consent were obtained from the parents of the patients. This study was conducted retrospectively. The causes of TST in patients included in the study were recorded. Latent tuberculosis infection was defined as the absence of clinical signs and symptoms consistent with TB, normal chest X-ray, and TST positivity. Tuberculin skin test positivity was considered for those without a Bacille Calmette Guérin (BCG) scar as 10 mm and above values, and as 15 mm and above for those with a BCG scar, regardless of the number of scars (T.C. Sağlık Bakanlığı Tanı ve Tedavi rehberi/ T.R. Ministry of Health Diagnosis and Treatment guide. 2019)
It was understood that for the Tuberculin Skin Test, 0.1 milliliter 5TU PPD solution was applied to the anterior surface of the left forearm using a 1 ml dizyem-adjustable injector with a 27-gauge needle. The measurement was done with a transparent flexible ruler by using the pen tip method. Tuberculosis contact was defined as contact with an adolescent or adult with pulmonary TB. People living in the same house were accepted as close contact. Close contacts of all the patients included in the study were examined for tuberculosis by using TST at VSD and lung x-ray with microfilm method. It was planned that the course of isoniazid treatment would last six months. The patients were reevaluated in the first week, and at one, two, three and six months. The patients were questioned about compliance with the treatment and drug side effects by interviewing the patient and their families when they came to the control. The patient’s body weight was measured and a dose adjustment was made if necessary. TST was reapplied to all patients after treatment. The tuberculin skin test was performed by trained health professionals and evaluated by the pencil tip method. Cases with increased TST values after treatment were evaluated in terms of the possibility of developing active disease. Statistical Analysis
Descriptive statistics of continuous data were given using mean ± standard deviation, median (minimum-maximum) values, and descriptive statistics for categorical data were given using percentages. Pre- and post-treatment TST values were compared using paired T-Test and universal mean significance test. SPSS for Windows (ver. 11.0) package program was used for statistical analysis. A p-value <0.05 was considered statistically significant.
A total of 106 patients, of which 25 (23.6%) had TB contact, were enrolled in the study. Among the patients included in the study, The TST value was positive in101 patients, and negative in 5 patients with TB contact history. Fifty-four (50.9%) patients were female and 52 (49.1%) were male. The ages of the patients were between 2 and 14 years, and the mean age was 8.18 ± 2.38 years. The reasons for performing TST for the patients included in the study are shown in Table 1.
INH treatment compliance and side effects
Ninety-eight (92.5%) patients completed the six-month INH treatment without interruption. It was learned that eight patients had disrupted treatment due to gastrointestinal symptoms such as abdominal pain, nausea and vomiting. Four of these patients (3.8%) were not treated for five days, one (0.9%) for seven days, two (1.9%) for 10 days and one (0.9%) for 15 days. None of these patients had increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, and these patients were advised to take their medication with meals. The patient’s complaints did not recur after this change. Thus, all patients completed six months of treatment.
Since there was no interruption of more than 15 days, the treatment was not prolonged for any patient. Eleven patients (10.3%) developed ALT elevation not exceeding the norm by 1.5 times. In these patients, it was observed that enzyme levels decreased to normal without the need to interrupt treatment. None of the patients had severe hepatic dysfunction. Tuberculin skin test values
Tuberculin skin test showed an increase of less than five mm in 22 (20.75%) cases, and five mm or more in 9 (8.4%) cases after treatment. In 49 (46.22%) cases, there was less than 5 mm, and in 26 (24.5%) cases there was a 5 mm or more decrease in TST values. The mean TST value in the patients before treatment was 16.57 ± 4.124 mm and 15.07 ± 4.017 mm after the treatment. The mean difference between the pre- and post- treatment TST values was 1.5 mm, and the post-treatment TST values were found to be lower (t=3.5 p<0.01). Table 2 shows the distribution of patients according to the change in TST before and after treatment. None of the patients with increased TST after treatment had any clinical and radiological findings of active disease.
There was no statistically significant difference in the mean age, gender, BCG scar count, contact presence, socioeconomic status in patients with a decrease of 5 mm in their TST values after treatment compared to the pre-treatment levels (p>0.05).
There are two tests in determining latent tuberculosis infection: TST and IGRTs. The tuberculin skin test is performed using the ’Mantoux, technique, which includes the intradermal injection of the five tuberculin units (TU) of the PPD-S purified protein derivative (PPD) or the two TUs of PPD RT23. In a person with cellular immunity to these tuberculin antigens, a delayed-type hypersensitivity reaction develops after 48-72 hours. This reaction causes an induration localized at the injection site [1,5]. It is well known that non-tuberculous mycobacteria can induce tuberculin sensitivity. Bacille Calmette-Guérin vaccine can also cause false- positive TST by cross-reaction with mycobacterial antigens. Interferon Gamma Release tests are the laboratory alternative to TST in the diagnosis of LTBI. Interferon Gamma Release assays are “ex vivo” tests that measure T cell response after stimulation with specific antigens relative to M. tuberculosis. These tests are a direct marker of M. tuberculosis exposure and show a cellular immune response to M. tuberculosis . In our study, LTBI was diagnosed with TCT. The change in TCT after INH prophylaxis in people with latent tuberculosis infection started to be studied after the 1950s, when this drug was put into use. In the early studies, it has been reported that a significant number of patients may become TCT negative after treatment [6-8]. However, in two studies conducted in the 1980s, these data could not be verified [8,9]. In a study that included 370 children with latent tuberculosis infection and followed up for three to nine years, the effect of INH treatment on the TST in the long term and whether the disease became active after INH prophylaxis was evaluated. In this study, 23.4% of patients had increased TST by 5 mm or more, 21.6% had a change of less than 5 mm, and 55% had a decrease of 5 mm or more. It was determined that TST was not negative in any of the patients. The researchers concluded that INH treatment prevents LTBI from progressing to active disease, but that TST positivity still persists, which is in fact beneficial for the patient, and that ongoing cellular mediated immunity may be protective against future exogenous re- infections . In another study, it was stated that in patients who received INH chemoprophylaxis, a single negative TST after treatment or negative results obtained several times after a short period of treatment should not be considered as a negative TST. The authors emphasized that the loss of tuberculin reactivity can only be confirmed by in vitro tests, by the evaluation of lymphocyte proliferation and lymphokine release in response to PPD . In our study, in children who had undergone six months of INH prophylaxis, repeated TST at the end of treatment showed an increase of less than five mm in 20.75% of patients after treatment and by 5 mm or more in 8.4% of patients after treatment. There was a 1.5 mm decrease in TST values before and after treatment, and this difference was found to be statistically significant. However, the number of patients who had increased, unchanged or decreased less than five millimeters tuberculin skin test values after treatment was 80 (75.5%), and the ratio of those with a reduction of five mm and more was only 24.5%. In our study, there were no patients who became TST negative after treatment. The signs and symptoms suggestive of active disease did not develop in patients with elevated TST after treatment. Among the patients with an increase compared to pre-treatment, 41.9% are TB contact patients, and it is known that the TST values in these patients may be increased after contact. One of the reasons for this increase in patients with increased TST after treatment may be the booster phenomenon. The Booster phenomenon is defined as a decrease in tuberculin reactivity over time due to a decrease in cellular immunity in patients sensitized with BCG vaccine or M. tuberculosis, and a significant increase in TST values if TST is repeated in a week to one year . According to our study, it was thought that evaluating the effectiveness of treatment according to the reapplication and negativity of TST after LTBI treatment was not appropriate. The hypothesis that T cell IFN-γ responses to Mycobacterium tuberculosis specific antigens will be reduced by the reduction of disease activity with TB treatment suggested that IGRTs can be used to monitor response to treatment. Although there were few studies supporting this view, in two large trials with 275 patients and 149 patients with active TB, serial IGRT measurements and sputum smear and culture results have been compared and no relationship has been found, most patients remained IGRT positive [12,13]. Both TST and IGRTs were not accepted as tests to verify M. tuberculosis was eradicated when LTBI treatment was completed. Very recently, in order to detect biomarkers that can potentially correlate with treatment success, changes in mycobacteria-specific antigens-induced cytokines in patients receiving latent or active TB treatment were investigated. Thirty- three adult patients with active TB and thirty-six with active TB were followed longitudinally throughout the treatment. Whole blood stimulation test was performed at zero, one, three, six and ninth months using mycobacteria-specific antigens (CFP- 10, ESAT-6, PPD), and cytokine responses in supernatants (IFN- 10, IL-1ra, IL-2, IL- 10, IL-13, IP-10, MIP-1β, and TNF-IP) were measured. In cases of active TB, the median IL-1ra, IP-10, and TNF-2 responses, as well as in cases of latent TB, the median IL- 1ra, IL-2 and IP-10 responses were significantly reduced during the course of the treatment. The researchers concluded that mycobacteria-specific cytokine responses changed significantly over the course of treatment and that their kinetics differed in active TB and latent TB, particularly mycobacterial-specific IL- 1ra responses were correlated with treatment success in both active and latent TB .
An important role of tuberculosis control programs is the identification of individuals with LTBI at risk of developing active TB. Treatment of patients with latent tuberculosis infection provides benefits for both one’s own health and public health. Immediately after the discovery of isoniazid in 1952, it has been used both as a component of active TB infection treatment and for the prevention of the development of active disease in patients who encounter the TB bacillus . If INH treatment is administered properly and without disruption, its efficacy is greater than 90%. However, 64-67% or less of the patients have been reported to have completed the treatment due to the length of treatment. People with latent tuberculosis infection may not be willing to continue treatment because they are not clinically ill . In a study of 105 children and adults diagnosed with latent tuberculosis infection, 28.5% of patients were found to interrupt treatment at least once . Nowadays, although the most commonly used LTBI treatment is six to nine months of INH treatment, rifampicin for four months, rifampicin together with INH for three to four months, and treatment regimens with rifapentine once a week for 3 months are also proposed to improve compliance [16-18]. In a study comparing treatment compliance between a 4-month rifampicin treatment and 9-month INH treatment for latent tuberculosis infection, the compliance with treatment was 91% in the rifampicin group and 76% in the INH group . In a retrospective large-scale study, 2149 patients were evaluated and similarly, treatment compliance to the rifampicin treatment was found to be 72%, while it was 53% in the INH group . In our study, patients with tuberculosis contact and LTBI diagnosis were given INH for six months. Full compliance with the treatment was determined in our patients. In our study, the reasons for the higher compliance with the treatment compared to the data in the literature were thought to be the inclusion of only pediatric patients in the study, sufficient information given about the importance of adherence to the treatment to the parents of the children in the study, and the patients being given the medication by their parents. The side effects of isoniazid, hepatotoxicity and peripheral neuritis can prevent the completion of treatment. The rate of transient liver enzymes level increase due to isoniazid use is 10-20%, but the rate of severe hepatotoxicity is reported as 2% [20-22]. In a large 7-year study including 11,141 patients, only 11 patients developed hepatotoxicity, and no fatalities were observed in any of these patients. The authors emphasized the importance of using current guidelines for patient selection for treatment, the importance of patient education and evaluation of patients monthly . In our study, 10.3% of patients had transient ALT elevation not exceeding 1.5 times normal levels. None of our patients had severe hepatotoxicity. In our study, because of the complaints of gastrointestinal intolerance in 7.5% of the patients, the treatment was temporarily stopped, and after which the treatment was completed. In the first weeks of isoniazid treatment, loss of appetite, nausea and vomiting may be seen. Although the intake of the drug with food delays or decreases its absorbance, this effect has little clinical importance. The guidelines for TB treatment published by the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC) and Infectious Diseases Society of America (IDSA) in 2016 recommends dividing the treatment dosage or taking the medication with meals, in cases where epigastric discomfort and nausea develop with first-line treatment . In our study, patients who developed gastrointestinal complaints were advised to take their medication with food. Complaints did not recur when this advice was followed.
As a result, in previous studies, it has been concluded that isoniazid prophylaxis is effective for the prevention of tuberculosis, and tuberculin skin test cannot be used to evaluate the efficacy of the treatment of latent tuberculosis infection. Nowadays, studies on the effectiveness of the treatment of latent tuberculosis infection and new diagnostic tests have become prominent, and we think that our study may draw attention to this issue in our country.
The co-evaluation of two separate groups of tuberculosis contact and latent tuberculosis infection, and the inability to perform the tuberculin skin test by the same person, were the limiting aspects of our study.
After six months of INH treatment/prophylaxis in children with latent tuberculosis infection or TB contact, there was a statistically significant decrease of 1.5 mm in TST. However, only one fourth had a decrease of 5 mm or more, and no patient had a negative TST, therefore, it was concluded that TST was not sufficient in the evaluation of treatment efficacy after treatment of LTBI with INH. None of the patients developed active TB disease, including those with increased TST after the treatment. It has been shown that good compliance to six months of INH treatment in children can be reached by sufficiently informing the parents about the importance of compliance with treatment and the parents administrating the medication themselves. Thus, when gastrointestinal intolerance complaints develop, treatment can be completed by taking the drug with food, while a mild increase in transaminase level during treatment does not require discontinuation of the treatment so that no serious hepatotoxicity developed and for the treatment to be effective. Large prospective studies are needed to evaluate biomarkers of treatment efficacy, using tests based on measuring changes in cytokines induced by mycobacteria-specific antigens, which have recently been reported as promising.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Lamb GS, Starke JR. Tuberculosis in Infants and Children. Microbiol Spectr. 2017;5(2). DOI: 10.1128/microbiolspec.
2. Clifford V, Tebruegge M, Zuffarey C, Germano S, Forbes B, Cosentino L, et al. Mycobacteria-specific cytokine responses as correlates of treatment response in active and latent tuberculosis. J Infect. 2017;75(2):132-45.
3. Getahun H, Matteelli A, Chaisson RE, Raviqlione M. Latent Mycobacterium tuberculosis infection. N Engl J Med. 2015; 372(22): 2127–35.
4. Comstock GW, Baum C, Snider DE. Isoniazid prophylaxis among Alaskan Eskimos: a final report of the Bethel Isoniazid studies. Am Rev Respir Dis. 1979;119(5):827-30.
5. Pai M, Denkinger CM, Ki SV, Rangaka MX, Zwerling A, Oxlade O, et al. Gamma interferon release assays for detection of Mycobacterium tuberculosis infection. Clin Microbiol Rev. 2014; 27(1): 3-20.
6. Adams JM, Kalajan VA, Mork BO, Rosenblatt M, Rothrock WJ, O’loughlin BJ. Reversal of tuberculin reaction in early tuberculosis. Dis Chest. 1959;35:348-56.
7. Houk VN, Kent DC, Sorensen K, Baker JH. The eradication of tuberculosis infection by isoniazid chemoprophylaxis. Arch Environ Health. 1968;16:46-50.
8. Atuk NO, Hunt EH. Serial tuberculin testing and isoniazid therapy in general hospital employees. JAMA. 1971;218:1795-8.
9. Hsu KH. Tuberculin reaction in children treated with isoniazid. Am J Dis Child. 1983;137:1090-2.
10. Tager IB, Kalaidjian R, Baldini L, Rocklin RE. Variability in the intradermal and in vitro lymphocyte responses to PPD in patients receiving isoniazid chemoprophylaxis. Am Rev Respir Dis. 1985;131:214-20.
11. Menzies D. Interpretation of Repeated Tuberculin Tests. Boosting, Conversion and Reversion. Am J Respir Crit Care Med. 1999; 159(1): 15-21.
12. Chee CB, Khinmar KW, Gan SH, Koh CK, Barkham TM, Shen L, et al. Tuberculosis treatment effect on T-cell interferon gamma responses to Mycobacterium tuberculosis specipic antigens. Eur Respir J. 2010;36(2):355-61.
13. Denkinger CM, Pai M, Patel M, Menzies D. Gamma interferon release assays for monitoring of treatmment response for active tuberculosis: an explosion in the spaghetti factory. J Clin Microbiol. 2013;51:607-10.
14. Menzies D, Dion MJ, Rabinovitch B, Mannix S, Brassard P, Schwartzman K. Treatment completion and costs of a randomized trial of rifampin for 4 months versus isoniazid for 9 months. Am J Respir Crit Care Med. 2004; 170(4): 445-9.
15. Eidlitz-Markus T, Zeharia A, Baum G, Mimouni M, Amir J. Use of the urine color test to monitor compliance with isoniazid treatment of latent tuberculosis infection. Chest. 2003; 123(3):736-9.
16. Cruz AT, Ahmed A, Mandalakas AM, Starke JR. Treatment of latent tuberculosis infection in children. J Pediatric Infect Dis Soc. 2013;2(3):248-58.
17. Sterling TR, Villarino ME, Borisov AS, Shang N, Gordin F, Biliven- Sizemore E, et al. Three months of rifapentine and isoniazid for latent tuberculous infection. N Engl J Med. 2011;365(23):2155-66.
18. Spyridis NP, Spyridis PG, Gelemse A, Sypsa V, Valianatou M, Metsou F, et al. The effectiveness of a 9-month regimen of Isoniazid alone versus 3- and 4-month regimens of Isoniazid plus Rifampin for treatment of latent tuberculosis infection in children: results of an 11-year randomized study. Clin Infect Dis. 2007;45(6):715-22.
19. Page KR, Sifakis F, Montes de Oca R, Cronin VA, Doherty MC, Federline L, et al. Improved adherence and less toxicity with rifampin vs isoniazid for treatment of latent tuberculosis: a retrospective study. Arch Intern Med. 2006; 166(1):1863-70.
20. Boelsterli UA, Lee KK. Mechanisms of isoniazid-induced idiosyncratic liver injury: emerging role of mitochondrial stress. J Gastroenterol Hepatol. 2014; 29:678-7.
21. Centers for Disease Controls and Prevention CDC 2010. Severe isoniazid associated liver injuries among persons being treated for latent tuberculosis infection-United states, 2004-2008. Morb Mortal Wkly Rep (MMWR). 2010; 59:224-9.
22. Metushi IG, Cai P, Zhu X, Nakagawa T, Uetrecht JP. A fresh look at the mechanism of isoniazid- induced hepatotoxicity. Clin Pharmacol Ther. 2011; 89(6): 911-4.
23. Nolan CM, Goldberg SV, Buskin SE. Hepatotoxicity associated with isoniazid preventive therapy: a 7- year survey from a public health tuberculosis clinic. JAMA. 1999;281(11):1014-18.
24. Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/ Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infec Dis. 2016;63(7):853–67.
Download attachments: 10.4328_ACAM.20334
Özlem Özgür Gündeşlioğlu, Gönül Tanır. Isoniazid treatment in children and comparison of tuberculin skin test values before and after treatment. Ann Clin Anal Med 2021;12(Suppl 1): S63-67
The comparison of radiofrequency and Cyanoacrylate embolization therapy in vena saphena magna ablation
Zafer Cengiz Er 1, Bugra Destan 2, Sedat Ozcan 3
1 Department of Cardiovascular Surgery, Bozok University Faculty of Medicine, Yozgat, 2 Department of Cardiovascular Surgery, Mehmet Akif Ersoy State Hospital, Çanakkale, 3 Department of Cardiovascular Surgery, Canakkale Onsekiz Mart University Faculty of Medicine, Çanakkale, Turkey
DOI: 10.4328/ACAM.20335 Received: 2020-09-08 Accepted: 2020-10-29 Published Online: 2020-11-03 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S68-71
Corresponding Author: Buğra Destan ,Mehmet akif Ersoy state hospital department of cardiovascular surgery, Çanakkale, Turkey. E-mail: email@example.com P: +90 5423221603 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0642-3429
Aim: Chronic venous insufficiency is a frequent and disabling illness causing loss of life quality and labor. In this study, we aimed to compare the cyanoacrylate embolization and radiofrequency methods in vena saphena magna ablation therapy.
Material and methods: Two hundred twenty patients with symptomatic venous insufficiency were involved in this study between November 2015 and January 2020 in Bozok University faculty of medicine cardiovascular surgery department. Patients were grouped into two groups. Group 1 included patients who were applied radiofrequency, and Group 2 included patients who underwent cyanoacrylate embolization. Preoperatively, Doppler ultrasound showed venous reflux and VSM diameter in all patients. Patient with non-tortuous veins and VSM diameter of more than 5.5 mm and a reflux duration of more than 0.5 seconds in the saphenofemoral junction were taken into consideration. This study included 110 cases in each group with similar demographic characteristics. After discharge, patients were called for control after one week, and in the first and sixth months they were evaluated with Doppler ultrasound.
Results: A month later, during the procedure in Doppler USG control, we found o that VSM in 108 out of 110 patients (%98.18) was obliterated in the RF group. In the cyanoacrylate embolization (CAE) group, VSM was totally obliterated in all patients. Six months later, obliteration was 107 (%97.27) in RF and 109 (%99.09) in the cyanoacrylate group. In a month, %8.18 ecchymosis, %0.9 cellulitis and %1.81 thrombophlebitis were seen in the RF group. Complications in the cyanoacrylate group were ecchymosis in %10.9, cellulitis in %2.72 and trombophlebitis in %0.9. The duration of the procedure was 32.14 minutes in the RF group and 15.32 minutes in the CAE group. Preoperatively, the patients were asked 8 questions about the symptoms. After six months, the same questions were asked and answers were compared with the previous ones. In both groups, the recovery was similar.
Discussion: Although the classical surgical procedure of venous insufficiency is a successful method, it has complications. When deciding the therapy method, cosmetic results should be kept in mind. Also, the short operation duration affects the choice. Frequently applied methods are EVLA, RFA, foam sclerotherapy, and CAE. RF and CAE technics were effective as classical surgery in chronic venous insufficiency. Effectiveness and complication rates were not different, but the shorter duration of procedure makes CAE more advantageous.
Keywords: Radiofrequency ablation; N-Butyl Cyanoacrylate; Embolization; Venous insufficiency
Chronic venous insufficiency and varicose veins are disabling illnesses causing loss of life-quality and labor. Its prevalence is %25-50 among the adult population . Pain, venous claudication, swelling, itching are the most encountered symptoms of venous insufficiency. As it may cause only cosmetic problems, ulceration can be a serious symptom of venous insufficiency . In parallel with medical and technical improvements, alternatives to the surgical treatment of chronic venous insufficiency have begun to be used. These methods can be classified as endovenous laser ablation (EVLA), radiofrequency ablation (RFA), foam sclerotherapy, and cyanoacrylate embolization (CEA). EVLA was first used in 1999. It prevents the reflux in the saphenofemoral junction by producing thermal injury that causes occlusion of saphenous vein endothelium . Side effects as postoperative ecchymosis, paresthesia, pain, thermal injury to skin, flebitis can be seen . Although foam sclerotherapy is a widely used, minimally invasive method, its disadvantages are higher recurrence rate, air embolism, pulmonary embolism, deep venous thrombosis, and headache . It is not recommended as a primary therapy in trunkal vein reflux in guidelines . RFA is a process of bipolar energy formed by sound waves. Endothelium contracts as a result of heat produced by the electrode upon contact with the endothelium.  CAE is an ablation technic that does not need tumescent anesthesia. IV application of N-butyl cyanoacrylate results in hardening by polymerization. After injection and application of pressure to the vein, the vessel closes.  In our clinic, we compared the results of examination of complications.
Material and Methods
Two hundred twenty patients with symptomatic venous insufficiency who applied to Bozok University Medical Faculty Cardiovascular Surgery Department between November 2015 and January 2020 were enrolled in the study. Demographic properties are classified in Table 1. Patients aged between 19 to 70 and those with Venasaphena magna diameter between 5.5 to 16 mm identified by Doppler examination, patients with a reflux period in saphenofemoral junction of morethan 0.5 seconds, C2-C5 in CEAP classification, and veins without tortuosity were included in the study. Exclusion criteria were symptomatic peripheric arterial disease, deep venous thrombosis, and pulmonary embolism history, pregnancy, and cyanoacrylate allergy. Patients were grouped into two groups. RFA was applied to the first group and CEA was applied to the second. Each group consisted of 110 patients with similar demographic characteristics. Preoperatively, each patient was examined with Doppler ultrasound in order to see reflux and veindiameter.Allofthemwereadmittedtothehospitalafter one week for examination and at the first and sixth months, they were examined with Doppler ultrasound. Questions were asked about eight symptoms, including pain, tiredness, swelling, itching, cramps, tingling, neuropathic symptoms, and a burning sensation, and six months later, at the control visit they were asked again about symptoms, and changes were noted. Surgical Procedures
N-butyl cyanoacrylate is a fast glue used in industry and medicine. After contact with moisture, blood and tissue, its monomer form rapidly polimerizes, and within 10 seconds tension force increases. It stabilizes in one to three minutes. In last stage, tension force increases logarithmically. With Dopler ultrasound guidance, saphenous vein catheterization was made and 5F introducer sheat was replaced. The J-Guide wire was inserted and after reaching to SFJ, a 4F catheter was placed 3 cm distal to the SFJ. The guide wire was pulled out and the syringe mechanism was attached. Compression was applied to the SFJ with an ultrasound probe. The catheter was pulled 2 cm per second and 0.3 ml of glue was inserted simultaneously with every shot. After 10 seconds of compression to SFJ, saphenous vein track obliteration was checked with Doppler ultrasound. Radiofrequency Ablation
In order to prepare a tumescent solution, we added 50 ml of lidocaine, 1 ml of adrenalin and 10 mEq NaHCO3 into 1000 ml NaCl. A 7 F vascular sheath was inserted in VSM, and an RFA fiber catheter was placed at least 2 cm away from SFJ under Doppler guidance. Later, the tumescent solution was injected throughout VSM. For every 7 cm of VSM, 10-40 watt and 120 0C ablation was applied twice every 20 seconds.
In the first month, during Doppler examination, in the RFA group, 108 out of 110 were found to be obliterated, while in CAE group, all were completely obliterated. At the sixth months, obliteration in the RFA group was 107 (%97.27) and in the
CAE group it was 109 (%99.09). Within the first month, %8.18 ecchymosis, %0.9 cellulitis, %1.81 thrombophlebitis was seen in the RFA group. In the CAE group, %10.9 ecchymosis, %2.72 cellulitis, %0.9 thrombophlebitis was seen as a postoperative complication. VSM diameter was 6.8±2.1 in the RFA group and 8.21±2.6 in the CAE group. The meanoperation duration was 32.14 in RFA and 15.32 in the CAE group. Preoperatively, 8 questions were asked again to see the differences. Six months later, the same questions were asked and noted. No significant difference was detected.
Although the classical surgical procedure of venous insufficiency is a successful method, it has complications such as infection on the incision side, lymphorea, hemorraghia, arterial
and venous injury, deep venous thrombosis, keloid scar.  When deciding the therapy method, cosmetic results should be kept in mind. Besides surgery, sclerotheraphy, RFA, EVLA (endovenous laser ablation) are the therapy methods. Endovenous ablation is easy, and better cosmetic results make it the first choice for surgery. [10,11] Also, the short operation duration affects the choice. Frequently applied methods are EVLA, RFA, foam sclerotherapy, and CAE. Foam sclerotherapy may cause amaurosis fugax, migraine, allergic reaction, confusion. Therefore, it is not recommended as the primary method for truncal reflux lesions. [12,6] Both EVLA and RFA obliterate the vein as a result of thermal injury. In CAE embolization, vascular obliteration is obtained by the chemical action of n-butyl cyanoacrylate. There are many studies comparing the treatment of chronic venous insufficiency with surgical and catheter-based technics. Van Den Bos conducted 119 research on 12320 patients. The success rate was %78 with classical surgery, %77 with foam sclerotherapy, %84 with RFA and %94 with EVLA.  In our country, Bozkurt and his team investigated 310 patients, comparing EVLA (156) and CAE (154), and a statistically short operation period, less pain, fewer ecchymosis in CAE were found significant. Permanent or temporary paresthesia was % 4 in EVLA, while it was not observed in CAE. 
In our study, we compared RFA and CAE technics. Demographically they were similar. The shorter operation period made CAE more preferable. The aforementioned operation duration differences, in our opinion, were caused by the application of tumescent anesthesia. In the literature, deep venous thrombosis (%1-3), thrombophlebitis (%1-2), sensorial damage (%1-3), hyperpigmentation (%1-2), skin burn (less than %1) are noted .
There was no deep venous thrombosis in our study. The most frequently seen complication was ecchymosis, which was cured medically. At the follow-up visit six months later, there was no significant difference between the groups.
RFA and CAE technics for minimally invasive therapy of venous insufficiency are as effective as surgery. No significant difference in effectiveness and complications were detected, but a shorter operation period makes CAE more preferable.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Jeanneret C, Karatolios K. Varicose veins: A critical review of the definition and the therapeutical options.Vasa. 2011; 40(5): 344-58.
2. Chiesa R, Marone EM, Limoni C, Volontè M, Petrini O. Chronic venous disorders: correlation between visible signs, symptoms and presence of functional disease. J Vasc Surg. 2007; 46(2):322-30.
3. Pannier F, Rabe E. Endovenous laser therapy and radiofrequency ablation of saphe nous varicose veins. J Cardiovasc Surg. 2006;47(1):3-8.
4. Morrison N. Laser treatment of the incom petent saphenous vein. In: Glovicz ki P, Dalsing MC, Eklöf B, Moneta GL, Wakefield TW, editors. Hand book of Venous Disorder,3rd ed. American Venous Forum. London: Edward Arnold; 2009. p.418- 28.
5. Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, Hoheim DF, et al. Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter,singleblinded, randomized study (RECOVERY study). J Vasc Interv Radiol. 2009;20(6):752-9.
6. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous disease: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011; 53(Suppl. 5): S2-48.
7. Nicolaides AN, Allegra C, Bergan J, Bradbury A, Cairols M, Carpantier P, et al. Management of chronic venous di sorders of the lower limbs: Guidlines according to scientific evidence. Int Angiol. 2008;27(1):1-59.
8. Almeida JI, Javier JJ, Mackay E, Bautista C, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord. 2013;1(2): 174-80.
9. Yang GK, Parapini M, Gagnon J, Chen JC. Comparison of cyanoacrylate embolization and radiofrequency ablation for the treatment of varicose veins. Phlebology. 2019;34(4):278-83.
10. Carroll C, Hummel S, Leaviss J, Ren S, Stevens JW, Cantrell A, et al. Systematic review, network meta-analysis andexploratory cost-effectiveness model of randomized trials of minimally invasive tech¬niques versus surgery for varicose veins. Br J Surg. 2014;101(9):1040-52.
11. Demirdaş E, Atılgan K, Çiçekçioğlu F, Erkoç MF. The Radiofrequency Ablation Therapy Results of our Newly-Established Bozok University Medicine Faculty Cardiovascular Surgery Centre Bozok Med J. 2017;7(3):67-72
12. Frullini A, Cavezzi A. Sclerosing foam in the treatment of varicose veins and telangiectases: history and analysis of safety and compli cations. Dermatol Surg. 2002;28(1):11-5.
13. Van den Bos R, Arends L, Kockaert M, Neumann M, Nijs ten T. Endovenous therapies of lower extremity varicosities: ameta-analysis. J Vasc Surg. 2009;49(1):230-9.
14. Bozkurt AK, Yılmaz MF. A prospective comparison of a new cyanoacrylate glue and laserablation for the treatment of venous insufficiency. Phlebology. 2016;31(Suppl. 1) 106-13.
15. Gale SS, Lee JN, Walsh ME, Wojnarowski DL, Comerota AJ. A randomized, controlled trial of endovenous thermal ablation using the 810-nm wavelength laser and the ClosurePLUS radiofrequency ablation methods for superficial venous insufficiency of the great saphenous vein. J Vasc Surg. 2010;52(3): 645-50.
Download attachments: 10.4328_ACAM.20335
Zafer Cengiz Er, Bugra Destan, Sedat Ozcan. The comparison of radiofrequency and Cyanoacrylate embolization therapy in vena saphena magna ablation. Ann Clin Anal Med 2021;12(Suppl 1): S68-71
Emotional dysregulation in mothers of children with attention deficit and hyperactivity disorder
Melek Gözde Luş 1, Meliha Zengin Eroğlu 2
1 Department of Child and Adolescent Psychiatry, University of Health Science, Haydarpaşa Numune Training and Research Hospital, 2 Department of Psychiatry, University of Health Science, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20336 Received: 2020-09-08 Accepted: 2020-11-07 Published Online: 2020-11-10 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S72-76
Corresponding Author: Melek Gözde Luş, University of Health Science, Haydarpaşa Numune Training and Research Hospital, Child and Adolescent Psychiatry Department, Tıbbiye Cad. No: 23, 34668, Üsküdar, Istanbul, Turkey E-mail: firstname.lastname@example.org P: +90 (216) 542 32 32 / 0 (216) 542 32 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0430-9289
Aim: Emotion dysregulation (ED) is frequently observed in attention deficit and hyperactivity disorder (ADHD). People suffering from ADHD have difficulty with ED, and the nature of the relationship between the two is an important area of research. In this study, we aimed to investigate ED in mothers of children with ADHD.
Material and Methods: Seventy-two children (n = 49 male, n = 23 female) with a diagnosis of ADHD and their mothers participated in the study Clinical In- terview was used for the the Diagnostic and Statistical Manual of Mental Disorders (fourth edition (DSM-IV) (SCID-II), Child Anxiety Sensitivity Index (CASI)). Mothers completed the McMaster Family Assessment Device (FAD) and Conners’ Parent Rating Scale (CPRS-48) as applied to individuals.
Results: The distribution of SCID-II diagnoses in mothers was as follows: without diagnosis 73.6 %, avoidant 8.3%, histrionic 5.6%, obsessive-compulsive 5.6%, passive-aggressive 2.8%, dependent 1.4%, self-defeating 2.8%. CASI scale points were higher in children with SCID II (±31.73, ±6.98 vs 27.84, ±7.19, p = .037). There was no difference in the subscales of Conners and McMaster scales according to the presence or absence of SCID-II diagnoses.
Discussion: The relationship of ED with ADHD and personality disorders has been frequently noted. However, a number of questions remain unaddressed about the association between ADHD and ED.
Keywords: Emotion dysregulation; Attention deficit; Parenting; Anxiety; Stress
Emotion regulation (ED) refers to the way emotions regulate other systems, such as thoughts, physiological responses, and behavior (regulated by emotions) as well as how emotions themselves are organized (regulation of emotions) . People suffering from attention deficit and hyperactivity disorder (ADHD) often have difficulty with ED, and the nature of the relationship between the two is an important area of research. The number of studies investigating ED and how the mothers of children with AHHD cope with this situation is limited. Information obtained from the studies showed that ED is frequently observed in ADHD, has an effect on functioning, and is important in the course of the disorder . ED difficulties in people with ADHD include difficulties in regulating stimulated emotions and difficulties in inducing positive and acceptable affective states . Genetic heritage plays an important role in the etiology of ADHD, but a multitude of contributing factors cause heterogeneity in the etiology of ADHD . The importance of parental attitudes and parental psychopathology is emphasized in studies on children with ADHD and their families . Studies on parents of children with ADHD have also shown higher rates of parental psychopathology, as well as conflicts in parent-child relationships . Since families also have poor problem-solving skills, some studies suggest that special interventions, starting as early as possible with parents, are needed to help children with ADHD develop adaptive skills. Padila R and Parsons MH (2019) ran a six-week, six-step parenting program (SsPP) for eight low-income, single-parent families at two community health centers. In their study, the researchers reported that six out of eight (75%) participating parents reported an improvement in their children’s symptoms. These studies emphasize the importance of understanding what ADHD is, demanding ADHD diagnostics for their children to improve their emotional life or social status, and special education to learn how to manage a child in enabling parents’ adaptation to an effective parenting role. Recently, ADHD has become an issue that concerns not only the child individually, but the entire family structure . In addition, parents with ADHD symptoms have been reported to have difficulty in responding to their child’s negative feelings . In particular, the presence of parent’s own emotional dysregulation makes life difficult for both parents and children . In light of these data, we aimed to investigate the presence of ED in mothers of children with ADHD and the correlation between ADHD in children and ED in their mothers. Emotion dysregulation is a dimensional entity, not a categorical diagnosis, and can also be seen in other psychopathologies such as bipolar disorder, borderline personality disorder, and substance use disorders. Therefore, The Structural Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) (SCID-II) was applied to all mothers of children diagnosed with ADHD in a manner covering psychiatric diagnosis. We hypothesized the existence of a link between ADHD and higher levels of maternal ED.
Material and Methods
The sample consisted of 72 children (n = 49 male, n = 23 female) with a diagnosis of ADHD aged 6-17 years old who had been referred to the University of Health Science, Haydarpaşa Numune Training and Research Hospital, Department of Child and Adolescent Psychiatry, Istanbul, Turkey. The study included all consecutive referrals that met the following criteria: a diagnosis of ADHD according to DSM-V, the mother’s informed consent, and the child’s consent for inclusion in the study. The study protocol was reviewed and approved by the Local Ethics Committee of Haydarpasa Numune Training and Research Hospital with protocol number 12.09.2018 version 1. The exclusion criteria for children were the presence of a chronic medical illness, any sensory-motor disability, or neurological disorder, and the diagnosis of autistic spectrum disorder or other developmental disorders. The exclusion criteria for mothers were the presence of a psychiatric disorder due to her general medical condition, significant cognitive deficiencies preventing understanding and participation in evaluations, age younger than 18 years, and inability to read and understand study procedures.
The study protocol was reviewed and approved by the institutional review board of the University of Health Science, Haydarpaşa Numune Training and Research Hospital. Mothers gave written consent for participation in the study. The diagnosis of children with ADHD was made according to a structured clinical interview based on DSM-V diagnostic criteria, which included questions about each symptom of ADHD, symptom onset and duration, and related impairment academic, family, social, and psychiatric history. All patients were drug-naive. Patients completed the Child Anxiety Sensitivity Index (CASI), while mothers completed the McMaster Family Assessment Device (FAD) and Conner’s Parent Rating Scale (CPRS-48) for all patients. Mothers were evaluated using a structured clinical interview for DSM-IV axis-II disorders according to the DSM-IV (SCID II) .
The CASI is a self-report scale developed to assess anxiety sensitivity in children . It consists of 18 items that measure the degree of anxiety caused by negative consequences in school-aged children (6-17 years of age). The index has a three- point rating for each item as none (1), some (2), or a lot (3), with the total score ranging from 18 to 54. A Turkish validity and reliability study was performed for the CASI .
The FAD was developed in 1983 to evaluate different functions and problem areas of the family  and has subsequently been adapted into Turkish . A general-functioning subscale score of two or above indicates non-healthy family functioning; a higher score indicates more problematic family functioning. The Conners’ Parent Rating Scale (CPRS-48) is one of the most commonly used behavioral scales for children with ADHD. The Turkish adaptation and validation of the CPRS-48 was performed by Dereboy, Şenol, Şener, and Dereboy . In this study, a 28-item short form was used from which three subscales (conduct problems, impulsive/hyperactive behavior, learning problems) and a total score were obtained. Higher scores indicate greater problems in the related subscale . The Conners’ Teacher Rating Scale (CTRS) exists in both long (38 items) and short (28 items) versions. In this study, the 28- item short form (CTRS-28) was used. A Turkish validity and reliability study of the CTRS was performed by Dereboy et al. .
The Difficulties in Emotion Regulation Scale (DERS) was used to evaluate maternal emotional dysregulation. This is a five-point Likert-type self-report scale, which contains 36 items along six dimensions : “Awareness” evaluates the state of being unaware of emotional responses. “Clarity” is related to the lack of emotional clarity. “Non-acceptance” evaluates acceptance of negative emotions. “Strategies” refers to the degree of access to effective emotion regulation strategies. “Impulse” evaluates the difficulty in controlling impulsive behaviors provoked by negative emotions. “Goals” refers to disengagement from goal- directed behavior while experiencing negative emotions. Higher scores indicate greater difficulties in emotion regulation. The scale was adapted to Turkish by Rugancı, and the Cronbach coefficient of the scale was 0.94 .
The IBM SPSS Statistics 22 for statistical analysis (SPSS IBM, Turkey) program was used when evaluating the findings obtained in this study. The suitability of the parameters to a normal distribution was evaluated using the Shapiro-Wilks test. Descriptive statistical measurements (mean, standard deviation, frequency) and quantitative data were compared using the Student’s t-test to compare normally distributed parameters. Pearson’s correlation analysis was used to investigate the relationships between the parameters of the normal distribution. The significance was evaluated at p < .05.
The study sample consisted of 72 (79.2% male, 20.8% female) children with ADHD and their mothers. The mean age of the children was 9.17 ±2.1 (range 6-14) years. The distribution of SCID-II diagnoses was as follows: without diagnosis 73.6%, avoidant 8.3%, histrionic 5.6%, obsessive-compulsive 5.6%, passive-aggressive 2.8%, dependent 1.4%, self-defeating 2.8%. CASI scale points were higher in children with an SCID-II diagnosis (31.73 ±6.98 vs. 27.84 ±7.19, p = .037). There was no difference in subscales of Conners’ and FAD scales in the presence or absence of SCID-II diagnoses.
A comparison of scales with and without SCID-II diagnoses is shown in Table 1. When we evaluated correlations between the mothers’ total emotion-dysregulation points and other scales, we found positive correlations in three subscales of the FAD: affective responsiveness, affective involvement, and behavioral control (Table 2). We evaluated correlations with mother’s subscales of the DERS and subscales of the FAD. Some correlations were statistically significant (Table 3).
The relationship between ED and ADHD and personality disorders has become the object of increased study. Although ED has been typically associated with borderline personality disorder, ED also has complicated connections with impulsivity. Not only does ED underlie impulsive behaviors, but impulsive behaviors themselves may also contribute to ED when engaging in impulsive behaviors is used as an emotion-regulation strategy . Since impulsivity has been established as a clinical part of ADHD, there may also be connections between impulsivity, ED, and ADHD . ADHD and ED are associated with risky behaviors such as substance abuse and risky sex . Therefore, they all cause high prevalence or degree of social impairment.
Our results showed that 26.4% of mothers have a personality disorder according to the SCID-II. Unexpectedly, there were no mothers with borderline personality disorder (BPD) in our clinical sample. The highest rates were avoidant (8.3%), histrionic (5.6%), and obsessive-compulsive (5.6%) personality disorders. Study results differ in the literature from Turkey. High rates of obsessive-compulsive personality disorder (23.7%) and histrionic personality disorder (11.9%) were found in a recent study . But some data show no difference in the prevalence of personality disorders in mothers of children with ADHD and those without. It is hypothesized that patients with borderline personality disorder are emotionally hyperresponsive. On the contrary, a study using the International Affective Picture System showed that patients with BPD showed lower scores on arousal than cluster-C personality disorder patients . Thus, ED may accompany many different personality disorders. Cluster-C personality disorders were frequent in our sample as well.
Mothers with personality disorders have more extreme emotion dysregulation problems. They scored higher in both the total and subscales of DERS. This was an expected result for us. Emotion regulation difficulties were found to be higher in mothers of children with ADHD compared to healthy children in the study. Mothers of children with ADHD had higher scores in goals, impulsivity, strategies and nonacceptance subscales of DERS compared to controls.
No difference was found in FAD scales between mothers with SCID-II diagnoses and those without. The structural and organizational characteristics of the families were similar. We anticipated more problematic family functioning in mothers with personality disorders. As a result, we explored the relationship between mothers’ ED and family functions and discovered a relationship between mothers’ ED and behavior control. High ED of mothers has a negative effect on standard-setting and discipline in behaviors of all family members. Mother’s emotion clarity and emotion nonacceptance contribute to effective behavior control. Difficulties related to a lack of clarity about what emotion is being experienced and a lack of acceptance of negative emotions have an unfavorable impact on mothers’ behavior control. Mother’s emotion nonacceptance is related to mothers’ affective responsiveness. Affective responsiveness is the ability of the family to respond to a stimulus with appropriate feelings because the mother is not open to her own negative emotions.
In addition, mother’s emotional awareness is related to communication and problem-solving. Active and successful problem-solving helps conserve family functioning and integrity. Problem-solving and communication are conceptually subdivided into instrumental and affective types. Thus, emotional awareness may have an effect on this affective division.
Unhealthy interactions between mothers and children with ADHD increase psychosocial troubles in these families. Mothers normally have an executive and coordinator role in the lives of children with ADHD. The use of maladaptive emotion regulation strategies by mothers of children with ADHD leads to inappropriate parenting manners. Cognitive strategies such as acceptance, distraction, problem-solving, and reappraisal are more effective than others in regulating emotions .
As mentioned above, most of the studies on ED and personality disorders were carried out with borderline individuals. Borderline-personality-disorder patients indeed engage in more maladaptive cognitive emotion-regulation strategies, such as thought suppression and rumination, and show fewer adaptive strategies, such as cognitive reappraisal or acceptance, compared to healthy individuals . In the next stages, authors evaluated ED in patients with ADHD and borderline personality disorders. Studies have shown that ED in ADHD is similar to the nature of ED found in borderline personality disorder, comprising increased instability and intensity of negative emotions and a slow return to emotional baseline when activated .
Some results suggest that there may be similarly inefficient cognitive emotional-regulation skills leading to ED in both ADHD and BPD. ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than borderline personality disorder patients.
Like personality disorders, ADHD is associated with higher rates of parental psychopathology . Although personality disorder is the basis for ED, psychosocial difficulties and stress associated with a child with ADHD accumulate as factors affecting the mother’s life. Conflicts between a mother and a child with ADHD increase the occurrence of psychopathologies in the mother. Feeling of guilt in mothers about a presumed genetic origin of ADHD is minimized . The relationship between a mother and a child with ADHD may influence the emotional regulation of children with ADHD.
Abuse, neglect, violence, and various forms of exposure to traumatic experiences have been recognized as potential socially related problems of ADHD. When we evaluated anxiety sensitivity in children with ADHD, we found higher CASI scales in ADHD children of mothers with personality disorders. However, a number of questions remain unaddressed about the link between ADHD and ED. Our study contributes to the understanding of the role of mother’s personality in relation to ED in a sample. The study was limited by small sample size, cross-sectional design, monocentric origin, not evaluating mothers with SCID-I, and not evaluating ED in children with ADHD. The results of this study, which examined ED in mothers of children with ADHD, may contribute to the creation of effective educational programs for families with neuropsychiatric diseases in order to maintain well-being and functionality.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Gross JJ. Emotion regulation: Past, present, future. Cognition and Emotion. 1999;13: 551-73. DOI:10.1080/026999399379186
2. Bunford N, Evans SW, Wymbs F. ADHD and emotion dysregulation among children and adolescents. Clin Child Fam Psychol Rev. 2015;18(3):185-217. DOI:10.1007/s10567-015-0187-5
3. Barkley RA, Fischer M. The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. J Am Acad Child Adolesc Psychiatry. 2010; 49(5):503-13. DOI: 10.1097/00004583- 201005000-00011
4. Faraone, SV, Mick E. Molecular genetics of attention deficit hyperactivity disorder. Psychiatr Clin North Am. 2010;33(1):159-80. DOI: 10.1016/j. psc.2009.12.004.
5. Deault LC. A systematic review of parenting in relation to the development of comorbidities and functional impairments in children with attention-deficit/ hyperactivity disorder (ADHD). Child Psychiatry Hum Dev. 2010;41(2):168-92. DOI: 10.1007/s10578-009-0159-4.
6. Dauman N, Haza M, Erlandsson S. Liberating parents from guilt:a grounded theory study of parent’sinternet communities for the recognition of ADHD Int J Qual Stud Health Well-being. 2019;14(1):1564520. DOI: 10.1080/17482631.2018.1564520.
7. Mazursky-Horowitz H, Felton JW, MacPherson L, Ehrlich KB, Cassidy J, Lejuez CW, Chronis-Tuscano A. Maternal emotion regulation mediates the association between adult attention deficit/ hyperactivity disorder symptoms and parenting. J Abnorm Child Psychol. 2015;43(1):121-31. DOI:10.1007/s10802-014-9894-5.
8. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. The Structured Clinical Interview for DSMIV Axis II Personality Disorders (SCID-II). Washington DC: American Psychiatric Press; 1997.
9. Silverman WK, Fleisig W, Rabian B, Peterson RA. Child Anxiety Sensitivity Index. Journal of Clinical Child Psychology. 1991;20(2):162-8. DOI: 10.1207/ s15374424jccp2002_7
10. Yılmaz S, Zinnur Kılıç E. Adaptation of the Childhood Anxiety Sensitivity Index for Use in Turkey. Turk Psikiyatri Derg. 2015;26(3):197-203.
11. Epstein NB, Baldwin LM, Bishop DS. The McMaster family assessment device. Journal of Marital and Family Therapy. 1983;9:171–80. DOI:10.1111/j.1752-0606.1983.tb01497.x
12. Bulut I. Aile degerlendirme ölçegi el kitabi [Manual of the McMaster family assessment device]. Ankara: Özgüzelis Matbaası; 1990.
13. Dereboy C, Şenol S, Şener S, Dereboy F. Validation of the Turkish versions of the short-form Conners’ teacher and parent rating scales. Turkish Journal of Psychiatry. 2007;18(1):48–8.
14. Goyette CH, Conners CK, Ulrich RF. Normative data on revised Conners Parent and Teacher Rating Scales. J Abnorm Child Psychol. 1978; 6(2):221-36. DOI: 10.1007/BF00919127
15. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess. 2004;26:41- 54. DOI:10.1007/s10862-008-9102-4.
16. Rugancı RN, Gençoz T. Psychometric properties of a Turkish version of the Difficulties in Emotion Regulation Scale. Journal of Clinical Psychology. 2010;66:442-55. DOI: 10.1002/jclp.20665.
17. Verdejo-Garcıá A, Bechara A, Recknor EC, Pérez-Garcıá M. Negative emotion- driven impulsivity predicts substance dependence problems. Drug Alcohol Depend. 2007;91(1-3): 213–19. DOI:10.1016/j.drugalcdep.2007.05.025
18. Winters KC, Botzet AM, Fahnhorst T, Baumel L, Lee S. Impulsivity and its relationship to risky sexual behaviors and drug use. J Child Adolesc Subst Abuse. 2009;18(1):43–56. DOI:10.1080%2F15470650802541095
19. Güçlü O, Erkıran M. Personality Disorders in Parents of Children with Attention Deficit Hyperactivity. Turkish Journal of Clinical Psychiatry. 2005;8:18-23.
20. Peter M, Arntz A, Klimstra TA, Faulborn M, Vingerhoets AJJM. Subjective emotional responses to IAPS pictures in patients with borderline personality disorder, cluster-C personality disorders, and non-patients. Psychiatry Res. 2019;273:712-18. DOI: 10.1016/j.psychres.2019.01.105
21. Aldao A, Nolen-Hoeksema S, Schweizer S Emotion regulation strategies across psychopathology: A meta-analytic review. Clin Psychol Rev. 2010;30(2): 217–37. DOI: 10.1016/j.cpr.2009.11.004.
22. Baer RA, Peters JR, Eisenlohr-Moul TA, Geiger PJ, Sauer SE Emotion-related cognitive processes in borderline personality disorder: a review of the empirical literature. Clin Psychol Rev. 2012;32:359–69. DOI:10.1016/j.cpr.2012.03.002
23. Faraone SV, Rostain AL, Blader J, Busch B, Childress AC, Connor DF, et al. Practitioner review: emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. J Child Psychol Psychiatry 2019;60(2):133–50. DOI:10.1111/jcpp.12899
24. Block RM, Macdonald NP, Piotrowski NP. Attention deficit hyperactivity disorder (ADHD). In: Magill’s medical guide (online edition). 2014;
Download attachments: 10.4328_ACAM.20336
Melek Gözde Luş, Meliha Zengin Eroğlu. Emotional dysregulation in mothers of children with attention deficit and hyperactivity disorder. Ann Clin Anal Med 2021;12(Suppl 1): S72-76
Waterpipe smoking among university students: Prevalence and association with mental health, risky health behaviors and psychosocial factors
Mehmet Göktuğ Kılınçarslan 1, Erkan Melih Şahin 1, Demet Güleç-Öyekçin 2
1 Department of Family Medicine, Canakkale Onsekiz Mart University, 2 Department of Psychiatry, Canakkale Onsekiz Mart University, Çanakkale, Turkey
DOI: 10.4328/ACAM.20338 Received: 2020-09-09 Accepted: 2020-10-15 Published Online: 2020-10-20 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S77-82
Corresponding Author: Erkan Melih Şahin, ÇOMÜ Sağlık Uygulama Araştırma Hastanesi Aile Hekimliği A blok kat:2 Terzioğlu Yerleşkesi, 17100, Çanakkale, Turkey. E-mail: email@example.com P: +90 505 302 55 71 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1520-8464
Aim: Waterpipe contributes significantly to the tobacco epidemic, especially among youth. The aim of this study is to investigate the prevalence of waterpipe smoking and its association with mental health, risky health behaviours and psychosocial factors in university students.
Materials and Methods: An online survey was applied to students of Çanakkale Onsekiz Mart University. In total, 4430 (15.49%) of 28582 students were reached. Waterpipe smoking was evaluated in categories of “ever” and “never”. After univariate analyzes, a “Hierarchical” Binary Logistic Regression model was performed.
Results: The mean age of the participants was 21.79±3.57 [17–63] years; 51.96% of the participants were ever waterpipe smokers. Male gender (OR=1.61), staying in students’ home in contrast to all other places (OR=1.43), low academic achievement (OR=1.24), ever smoking cigarettes (OR=4.83), ever drinking alcohol (OR=3.50), being sexually active after the age of 18 (OR=2.11), the inability to cope with anger (OR=1.26), higher level of sensation seeking (OR=1.14) and higher level of impulsivity (OR=1.13) were found to be significantly associated with being ever waterpipe smoker.
Discussion: Better understandings of the factors associated with waterpipe smoking may lead to more successful cessation and prevention strategies.
Keywords: Waterpipe smoking; Mental health; Risky health behavior; Psychosocial factors; Youth
Tobacco use is one of the main determinants of global health. Waterpipe smoking involves inhaling the smoke through water after the tobacco is heated with coal. This method of tobacco use contributed to the tobacco epidemic in some countries and specific age groups through exceeding cigarette smoking . Some studies have shown that ever waterpipe smoking ratios are between 3% – 65% . People perceive falsely that waterpipe is safer than cigarettes because the smoke is filtered by passing through water. However, smoking of waterpipe has been shown to cause diseases such as lung cancer, respiratory diseases, cardiovascular diseases and low birth weight . University years are an emotionally tempestuous transition period to adulthood, and mental disorders are quite common in this period. Understanding the causal links between tobacco use and mental disorders can help develop effective cessation interventions for young people of university age .The relationship between mental disorders and cigarette smoking has been clearly demonstrated, while for waterpipe smoking it is still unclear.
Risky health behaviors increase in youth and cause serious morbidity and mortality for both the present and future . Waterpipe smoking is also a kind of risky health behavior. It has been shown for a long time that risky health behaviors are related to each other and tend to cluster . Although many studies have shown that waterpipe smoking is associated with other forms of tobacco use, substance use, and alcohol drinking [7,8], more studies are needed to explain the relationship between waterpipe smoking and other risky health behavior. To develop successful prevention and treatment strategies for waterpipe smoking, psychosocial factors should be examined in a comprehensive manner . Impulsivity and sensation seeking factors are usually evaluated in tobacco and drug addiction studies, but there are few studies evaluating psychosocial factors in the context of waterpipe smoking.
There is an insufficient number of studies, which evaluate mental health, risky health behaviors and psychosocial factors in the context of waterpipe smoking. Also, the existing literature is still controversial. More studies are needed, especially in the young population, for a better understanding of waterpipe smoking and for developing more effective prevention and intervention strategies. The aim of this study is to investigate the prevalence of waterpipe smoking and its association with mental health, risky health behaviors and psychosocial factors in university students.
Material and Methods
Population and sample
This study was conducted as part of a multidimensional youth survey at Çanakkale Onsekiz Mart University, which hosted 28582 students in 9 faculties, 4 colleges and 11 vocational colleges during the 2011–12 educational year. Among the students, 15.49% (4430) participated in the research, and 3909 of 4430 (88.24%) replied to the waterpipe question. The study aimed to reach 10% of the student population of the university, as similar studies reached similar rates.
Measures and Variables
The original survey included 71 questions, but in this study, 54 of them were evaluated in accordance with our aim. The question regarding smoking waterpipe was asked “Do you smoke waterpipe? If you smoke waterpipe, how often do you use it?”; options such as “never”, “1-2 times in my life”, “1-2 times per month”, “1-2 times per week” and “every day” were proposed and recoded into a dummy variable with two categories as “ever waterpipe smoker” and “never waterpipe smoker”. Depressive symptoms, anxiety, hopelessness, anger management inability, lack of assertiveness, sensation seeking and impulsivity were measured by BAPI scales . All variables are given in Table1 with details.
An online survey was available for students to be completed between the September 2011 and May 2012 (one educational year). All students were informed of the survey through an automated system that students used for learning of class grades at various times during the year. The notification was repeated to boost the participation rates in the survey. Firstly, information about the study was given to the participants, and then consent was requested. Participants who gave consent were then requested to anonymously complete the survey questions. While completing the survey, participants could skip questions they did not want to answer.
Data were analyzed by using statistical software and univariate analyses were done using Chi-Square, Mann-Whitney U, and Kendall’s tau-b tests. A “Hierarchical” Binary Logistic Regression Analysis model was used to evaluate factors associated with ever waterpipe smoking. All independent variables were included in this model, except for subjective economic status, problem drinking, and lack of assertiveness, because they were not related to ever waterpipe smoking. Firstly, independent variables of general characteristics, then variables of risky health behavior, mental health and psychosocial factors were added to model respectively. All analyses were examined for two-way p-values, and a level of significance was accepted as p<0.05.
Permission and consent
Approval and permission for this study was obtained from the Clinical Research Ethics Committee and the Çanakkale Onsekiz Mart University rectorate.
Data from 3909 students who completed the waterpipe question are presented; 2104 (53.82%) of them were female and 1803 (46.18%) were male. The mean age of the participants was 21.79±3.57 [17–63] years. The mean age of females (21.70±3.77) was significantly lower than the mean age of males (21.89±3.30) (U=1776695, p=0.001), and1845 (47.20%) of the participants were ever cigarette smokers; 2031 (51.96%) were ever waterpipe smokers, and 599 (29.49%) of these people had never smoked cigarettes in their lifetime. Male gender, being older, being single in contrast to married, staying in students’ home in contrast to all other places, low academic achievement, lower self-rated health status, ever smoking cigarettes, ever drinking alcohol, ever drug and substance use, violent behaviors, exposed to intimate partner violence, more exercise, lower level of perceived mental health status, ever received psychiatrist and psychologist consultation, ever made a suicide attempt, being depressive, being anxietic, higher level of hopelessness, lower level of happiness, anger management inability, higher level of sensation seeking and higher level of impulsivity were associated with being ever waterpipe smoker in univariate analysis. Sexual risky behavior variable needs special attention because subcategories of safe sexual behavior groups show different pattern in the context of waterpipe smoking. People who are not sexually active has lower rates of ever waterpipe smoking, while people who became sexually active after the age of 18 have higher rates than people who became sexually active before the age of 18. Thus, in regression analysis, this variable was evaluated with all subcategories. All univariate analyses are given in the Table 2.
In the last model of regression, male gender (1.61), staying in students’ home in contrast to all other places (1.43), low academic achievement (1.24), ever smoking cigarette(4.83), ever drinking alcohol (3.50), being sexually active after the age of 18 (2.11), inability to manage anger (1.26), higher level of sensation seeking (1.14) and higher level of impulsivity (1.13) were found to be significantly associated with the fact of being ever waterpipe smoker. A summary of regression models is given in Table 3.
In our study, the rate of ever waterpipe smoking is 52.0%. It seems higher than ratios for US – up to 44.2% , and Europe -up to 11.6% , but lower than ratios for Eastern Mediterranean Region – up to 65.3% . Turkey shares some cultural properties with the Eastern Mediterranean Region, so ever waterpipe smoking ratio determined in our study seems to be coherent with the literature.
The first block of variables in our regression model included socio-demographic characteristics, academic achievement, and self-rated health status. These variables accounted for 11.8% of the variance in waterpipe smoking. Male gender is significantly associated with waterpipe smoking, as in most of the previous studies [4,7-9,13], on the other hand, few others state that there is no gender interaction . In Turkey, waterpipe smoking is more socially acceptable for females, and it should never be forgotten that the rate of waterpipe smoking among females (41.4%) is still high. We did not determine the significant relationship between age and waterpipe smoking in the same way as Jackson and Aveyard , but there are studies that suggest the opposite, as the waterpipe smoking rate decreases  or increases with age [7,14]. It seems confounding, but in our opinion, controversy over this is useless. Since the waterpipe smoking rate is highest between the ages of 18 – 24 , and we are already trying to evaluate people who are in this short age range. In our study, the rate of waterpipe smoking was higher among single people than married people.
Staying in students’ home (off-campus), in contrast to all other places, was also associated with higher waterpipe smoking, as in other studies . Family supervision  and dormitory codes led to lower rates of waterpipe smoking. Low academic achievement is also associated with higher waterpipe smoking rates.
Risky health behaviors, especially cigarette smoking[ 8,9,13] and alcohol drinking [9,14], were significantly associated with being ever waterpipe smoker, similar to previous studies. Only a study  conducted in Russia did not state a relationship between waterpipe and cigarette smoking. Some experts believe that waterpipe is a gateway for smoking cigarettes, but the direction of causality is not clear . Cigarette smoking is seen as one of the most powerful predictors of being ever waterpipe smoker, with an odds ratio of 4.8 in our last regression model, but one- third of waterpipe smokers still have not smoked cigarettes in their lifetime. It is already known that the cigarette smoking rate among young people has declined, probably due to effective cessation interventions, but the waterpipe smoking rate is increasing . To prevent this shift, waterpipe should be considered in tobacco cessation programs. We have not determined any relationship between waterpipe smoking and drug or substance use similar to Galimov et al. , in contrast to previous studies that stated a significant relationship [7,15]. Cultural and geographical features strongly affect drug and substance use . Drug and substance use rates in Turkey were far below than developed countries . Thus, differences in the cultural properties of the populations in which studies were conducted maybe the cause of irrelevance. Risky sexual behavior was not associated with being ever waterpipe smoker, similar to Berg at al. , who used the number of sex partners in the past year as an indicator of risky sexual behavior. According to Berg at al. , irrelevance was interesting and one question may not be enough to evaluate risky sexual behavior in the same way as our study in which we tried to measure risky sexual behavior with one question. Self-harm  and exercise  were not associated with being ever waterpipe smoker in the literature, similar to our data presented.
None of the mental health variables (perceived mental health status, ever psychiatrist and psychologist consultation, ever suicide attempt, depression, and anxiety) in this study were associated with being ever waterpipe smoker. In fact, the association between mental health and waterpipe smoking is highly controversial. King et al.  (weak association) and Primacket al.  demonstrated a moderate association between mental health and waterpipe smoking, while Goodwin et al.  and Bandiera et al.  reported no association. Differences in the methodology of studies (for example, scales used to measure mental health) or cultural properties of the populations in which studies were conducted, may be the cause of diversity in these results.
In our study, hopelessness was not associated with waterpipe smoking, but a previous study, which considered waterpipe as a drug or substance, demonstrated the association between hopelessness and drug and substance usage . Impulsivity was associated with being ever waterpipe smoker, according to our regression model. According to another study, conducted only with female university students, impulsivity was still not associated with being ever waterpipe smoker, while it was associated with the frequency of smoking waterpipe . Targeting impulsive adolescents may be effective in preventing waterpipe use as well as preventing cigarettes, alcohol or drugs. Sensation seeking was associated with being ever waterpipe smoker, as in one previous study . Sensation seekers are interested in rewarding actions and risky health behaviors such as waterpipe smoking . Suggesting healthy behaviors, such as exercise, may provide enough satisfaction for sensation seekers and may lead to a decrease in waterpipe smoking . Waterpipe smoking rates among young are increasing, while cigarette smoking rates are declining. In some regions, waterpipe smoking exceeds cigarette smoking and may be more harmful than cigarette smoking. Waterpipe should be included in tobacco cessation programs to prevent the transition between risky health behaviors. Also, it should be noted that nearly one-third of waterpipe smokers do not smoke cigarettes. A better understanding of the factors associated with waterpipe smoking may lead to more successful cessation and prevention strategies. Even for some of these factors determined in our study, the literature is still controversial. It may indicate that the nature of waterpipe smoking varies according to cultural or geographical features.
Firstly, this study was conducted only in one university, so the results should be generalized cautiously for the population. In this study, waterpipe smoking was evaluated only in two categories: “ever smoker” and “never smoker”, thus this may lead us to miss associations between the independent variables and other frequencies of waterpipe smoking. The mental health scales in this study were screening tools and their diagnostic capability may be restricted. Lastly, the real rejection rate of our questionnaire was not clear due to the technical limitations of the online survey methodology.
This study contributed to the deficient and controversial area of the relationship between waterpipe smoking and mental health, risky health behaviors and psychosocial factors, by using subjective measures and representing crowded university population.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R, et al. The global epidemiology of waterpipe smoking. Tob Control. 2015;24(Suppl. 1):S3–12.
2. Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA. The prevalence and trends of waterpipe tobacco smoking: a systematic review. PLoS One. 2018;13(2):e0192191. DOI: 10.1371/journal.pone.0192191.
3. Akl EA, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;39(3):834–57.
4. Primack BA, Land SR, Fan J, Kim KH, Rosen D. Associations of mental health problems with waterpipe tobacco and cigarette smoking among college students. Subst Use Misuse. 2013;48(3):211–9.
5. Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, et al. Youth risk behavior surveillance – United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114.
6. Hair EC, Park MJ, Ling TJ, Moore KA. Risky behaviors in late adolescence: co- occurrence, predictors, and consequences. J Adolesc Heal. 2009;45(3):253–61.
7. Goodwin RD, Grinberg A, Shapiro J, Keith D, McNeill MP, Taha F, et al. Hookah use among college students: Prevalence, drug use, and mental health. Drug Alcohol Depend. 2014;141:16–20.
8. Grekin ER, Ayna D. Waterpipe smoking among college students in the United States: A review of the literature. J Am Coll Heal. 2012;60(3):244–9.
9. Berg CJ, Schauer GL, Asfour OA, Thomas AN, Ahluwalia FS. Psychosocial factors and health-risk behaviors associated with hookah use among college students. J Addict Res Ther. 2011;Suppl 2:001.
10. Ögel K, Karadağ F, Evren C. Bağımlılık profil indeksi (BAPİ) uygulama rehberi (Addiction profile index (BAPI) application guide). Istanbul: Yeniden Yayınları; 2012. p.1-26.
11. Salloum RG, Thrasher JF, Getz KR, Barnett TE, Asfar T, Maziak W. Patterns of waterpipe tobacco smoking among U.S. young adults, 2013−2014. Am J Prev Med. 2017;52(4):507–12.
12. Grant A, Morrison R, Dockrell MJ. Prevalence of waterpipe (shisha, narghille, hookah) use among adults in Great Britain and factors associated with waterpipe use: data from cross-sectional online surveys in 2012 and 2013. Nicotine Tob Res. 2014;16(7):931–8.
13. Jackson D, Aveyard P. Waterpipe smoking in students: Prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health. 2008;8(1):174.
14. Galimov A, El Shahawy O, Unger JB, Masagutov R, Sussman S. Hookah use among Russian adolescents: prevalence and correlates. Addict Behav. 2019;90:258–64.
15. Fielder RL, Carey KB, Carey MP. Predictors of initiation of hookah tobacco smoking: a one-year prospective study of first-year college women. Psychol Addict Behav. 2012;26(4):963–8.
16. Hu SS, Neff L, Agaku IT, Cox S, Day HR, Holder-Hayes E, et al. Tobacco product use among adults — United States, 2013–2014. MMWR Morb Mortal Wkly Rep. 2016;65(27):685–91.
17. Malta DC, Hallal ALC, Machado ÍE, Prado RR, Oliveira PPV, Campos MO, et al. Factors associated with the use of waterpipe and other tobacco products among students, Brazil, 2015. Rev Bras Epidemiol. 2018;21(Suppl. 1):e180006.
18. Toprak S, Cetin I, Akgul E, Can G. Factors associated with illicit drug abuse among Turkish college students. J Addict Med. 2010;4(2):93–8.
19. Kotan Z, Ilhan SO, Ilhan MN, Arıkan Z. Fundamental characteristics, attitudes and behaviors regarding substance use focusing on cannabis: findings from the general population survey in Turkey, 2011. Community Ment Health J. 2018;1–5.
20. Fakhari A, Mohammadpoorasl A, Nedjat S, Hosseini MS, Fotouhi A. Hookah smoking in high school students and ıts determinants in Iran. Am J Mens Health. 2015;9(3):186–92.
21. King JL, Reboussin BA, Spangler J, Ross JC, Sutfin EL. Tobacco product use and mental health status among young adults. Addict Behav. 2018;77:67–72.
22. Bandiera FC, Loukas A, Wilkinson AV, Perry CL. Associations between tobacco and nicotine product use and depressive symptoms among college students in Texas. Addict Behav. 2016;63:19–22.
23. Zivari-Rahman M, Lesani M, Shokouhi-Moqaddam S. Comparison of mental health, aggression and hopefulness between student drug-users and healthy students (A study in Iran). Addict Heal. 2012;4(1–2):36–42.
24. Hampson SE, Tildesley E, Andrews JA, Barckley M, Peterson M. Smoking trajectories across high school: sensation seeking and hookah use. Nicotine Tob Res. 2013;15(8):1400–8.
Download attachments: 10.4328_ACAM.20338
Mehmet Göktuğ Kılınçarslan, Erkan Melih Şahin, Demet Güleç-Öyekçin. Waterpipe smoking among university students: Prevalence and association with mental health, risky health behaviors and psychosocial factors. Ann Clin Anal Med 2021;12(Suppl 1): S77-82
Effect of smoking on the hematopoietic stem cell count in cord blood
Akdeniz University Teknokent Babylife Cord Blood Bank and Human Cell-Tissue Production Center, Antalya, Turkey
DOI: 10.4328/ACAM.20339 Received: 2020-09-10 Accepted: 2020-10-09 Published Online: 2020-10-22 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S83-85
Corresponding Author: Durmuş Burgucu, Akdeniz University Teknokent Babylife Cord Blood Bank and Human Cell-Tissue Production Center, Akdeniz University, Campus, 07070, Antalya, Turkey. E-mail: firstname.lastname@example.org P: +90 242 226 16 80 F: +90 242 226 16 79 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3980-982X
Aim: The risk of undesirable and harmful effects of the negative environmental factors on fetal development during pregnancy has been extensively estab- lished. Smoking during pregnancy has been considered one of the important modifiable risk factors. Studies have shown that the hematopoietic stem cell content and the number of colony-forming units in cord blood obtained from pregnant women who smoke are low. The present study aimed to determine the rate of smoking among women who presented to our center to receive autologous cord blood banking services in Turkey. The study also aimed to compare the CD34+ hematopoietic stem cell counts in smoker and non-smoker cord blood donors.
Materials and Methods: This study is a cross-sectional and retrospective study. The product files of the first 1000 pregnant women who presented to our center for autologous cord blood donation and whose cord blood was procured for permanent storage were retrospectively analyzed. The SPSS 21.0 software package was used for statistical analysis. P < 0.05 was considered statistically significant. An independent two-sample test was used between the groups for comparing cord blood volumes, and the Mann–Whitney U test was used for comparing CD34 cell counts.
Results: The rate of smoking among pregnant women who presented to receive cord blood banking services was 0.22%, with the mean CD34+ cell counts being 2.0 × 106 and 2.6 × 106 in smokers and non-smokers, respectively. Moreover, the mean cord blood volumes were 81.3 and 85.1 mL in smokers and non-smokers, respectively.
Discussion: In Turkey, the rate of smoking behavior was low among those who applied to receive autologous cord blood banking services, and actual nationwide rates of smoking could be demonstrated using larger study groups if other centers also provide their results. The hematopoietic stem cell content of cord blood obtained from pregnant women who were smokers was lower than that obtained from non-smokers.
Keywords: Cord blood; Hematopoietic stem cell; Smoking
Smoking during pregnancy is considered one of the important modifiable risk factors associated with adverse pregnancy outcomes . Some epidemiological data have shown that 20%– 30% of women continued to smoke during their pregnancy . However, a decrease in the rates of smoking among pregnant women has recently been reported in several countries . In addition to the effects of smoking during pregnancy on fetal development, such as restricted growth and negative effects on the immune system , it has extensively been recognized that smoking causes an increased incidence of complications, such as substantial metabolic and biochemical changes, as well as adaptive responses in both the fetus and the mother, resulting in spontaneous abortion, placental abruption, preterm birth, intrauterine growth restriction, and stillbirth [5, 6].
Cord blood is an important resource owing to its hematopoietic stem cell content. In particular, in recent years, the use of hematopoietic stem cell transplantation therapy, also known as bone marrow transplantation, has become more common. Cord blood that contains a sufficient amount of stem cells is used in transplantations to siblings and unrelated patients because cord blood can be collected and processed during birth and cryopreserved for several years . The number of studies concerning cord blood obtained from mothers who smoke is limited in the literature. Reportedly, the hematopoietic stem cell content and colony-forming unit (CFU) counts were low in cord blood obtained from mothers who smoke .
The purpose of the present study was to determine the rate of smoking among women who presented to our center to receive autologous cord blood banking services in Turkey. Further, the study aimed to compare the CD34+ hematopoietic stem cell counts in smoker and non-smoker cord blood donors.
Material and Methods
In this cross-sectional retrospective study, the product files of the first 1000 pregnant women who presented to our center for autologous cord blood donation and whose cord blood was procured for permanent storage were retrospectively analyzed. First, the rate of smoking was determined in pregnant women who applied for cord blood donation. Thereafter, the CD34+ hematopoietic stem cell counts were compared between equal numbers of women who answered positively and negatively to the question “Do you smoke” on the completed form obtained before cord blood collection. Further, cord blood volume, which is an important parameter that determines cord blood quality, was compared between the two groups. Approval for the study was obtained from the Clinical Research Ethics Committee of Akdeniz University Medical Faculty with the decision number 147 (dated 02.21.2018). The SPSS 21.0 software was used for statistical analyses. P < 0.05 was considered to indicate statistical significance. An independent two-sample test was used for comparing cord blood volumes, and the Mann–Whitney U test was used for comparing CD34+ cell counts between both groups.
The study included data of the first 1000 donations from women who presented to our center to receive autologous cord blood
banking services and whose blood was placed into permanent (long-term) storage. The rate of smoking was 0.22%. The cord blood volumes obtained from equal numbers of smokers and non-smokers were evaluated. No significant difference was observed between the two groups (Figure 1).
Hematopoietic stem cell counts (CD34+ cells) were compared between the two groups. The CD34+ cell count of the smoker group was significantly lower than that of the non-smoker group (Figure 2).
The practice of cord blood banking has developed in the last 30 years . Although cord blood was used in bone marrow transplantation as a source of hematopoietic stem cells in the 1990s, it has recently been used in regenerative and reparative medicine. This preference for cord blood in such medical practices can be attributed to the mesenchymal stem cells contained in it . Other important reasons for preferring cord blood include its ability to be frozen and stored for long-term use and the ease of access to cord blood within a short period of time, if needed. Besides these, studies on the expansion of hematopoietic and mesenchymal stem cells contained in cord blood have successfully been ongoing in the laboratory environment [11, 12]. Cord blood, preferred in this respect, is accepted as an important source of stem cells.
In studies evaluating the quality and use of cord blood, the donor, newborn, cord blood content, collection, transfer and placenta were identified as the main factors . Studies evaluating the rate of smoking among cord blood donors and its effect on hematopoietic stem cell count are scarce. Although the number of samples differs in these studies, it was emphasized that smoking had a negative impact on the number of CD34+ hematopoietic stem cells [14-16]. In Turkey, cord blood banking has exhibited rapid growth in the last 10 years. Currently, one center is present per 10 million individuals. The main type of banking, termed the Turkish Model in the literature, can co- implement the autologous and allogeneic banking models.
All pregnant women included in this study presented to our center for autologous cord blood storage. The aim was to preserve cord blood for their children in case of any requirement in the future, wherein the costs of storing cord blood are covered by the families. In the present study evaluating the first 1000 donations, the rate of smoking among pregnant women who applied for cord blood storage was 0.22%, and this rate was considerably lower compared to the overall rate of smoking among pregnant women . No significant difference was observed between smoking and non-smoking pregnant women in terms of cord blood volumes. However, larger studies are needed to support this result, considering that various factors affect blood volume (factors related to the mother and child, the experience of the physician collecting cord blood, etc.). The number of CD34+ hematopoietic stem cells was significantly lower in the group of pregnant women who smoked than in non- smokers. In this regard, the study results are consistent with those of previous studies in the literature.
The hematopoietic stem cell content of cord blood obtained from pregnant women who were smokers was lower than that obtained from non-smokers. The rate of smoking was low among women applying for autologous cord blood banking services in Turkey, and the overall nationwide rate of smoking can be determined with large study groups that include findings from other centers.
I would like to thank statistician Ezgi Afşar Gür for her contributions to statistical analyses and Antalya Teknokent Babylife Özel Sağlık Yatırımları San. Tic. A.Ş. for providing the laboratory infrastructure.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Votavova H, Dostalova Merkerova M, Krejcik Z, Fejglova K, Vasikova A, Pastorkova A, et al. Deregulation of gene expression induced by environmental tobacco smoke exposure in pregnancy. Nicotine Tob Res. 2012; 14 (9): 1073- 1082.
2. Kareli DE, Pouliliou SE, Nikas IH, Psillaki AN, Galazios GC, Liberis VA, et al. Cytogenetic evaluation of pre-pregnancy smoking in maternal and newborn lymphocytes. Eur J Obstet Gynecol Reprod Biol. 2012; 165 (2): 205-9.
3. Mårild K, Tapia G, Midttun Ø, Ueland PM, Magnus MC, Rewers M, et al. Smoking in pregnancy, cord blood cotinine and risk of celiac disease diagnosis in offspring. Eur J Epidemiol. 2019; 34 (7): 637-49.
4. Butler NR, Goldstein H, Ross EM. Cigarette smoking in pregnancy: its influence on birth weight and perinatal mortality. Br Med J. 1972; 2 (5806): 127-30.
5. Andres RL, Day MC. Perinatal complications associated with maternal tobacco use. Semin Neonatol. 2000; 5 (3): 231-41.
6. Gallo C, Renzi P, Loizzo S, Loizzo A, Piacente S, Festa M, et al. Potential therapeutic effects of vitamin e and C on placental oxidative stress induced by nicotine: an in vitro evidence. Open Biochem J. 2010; 4: 77-82.
7. Mayani H, Wagner JE, Broxmeyer HE. Cord blood research, banking, and transplantation: achievements, challenges, and perspectives. Bone Marrow Transplant. 2020; 55 (1): 48-61.
8. Shlebak AA, Roberts IA, Stevens TA, Syzdlo RM, Goldman JM, Gordon MY. The impact of antenatal and perinatal variables on cord blood haemopoietic stem / progenitor cell yield available for transplantation. Br J Haematol. 1998; 103 (4): 1167-71.
9. Huang X, Guo B, Capitano M, Broxmeyer HE. Past, present, and future efforts to enhance the efficacy of cord blood hematopoietic cell transplantation. F1000Res. 2019; 8: F1000 Faculty Rev-1833. DOI: 10.12688/f1000research.20002.1
10. Brown C, McKee C, Bakshi S, Walker K, Hakman E, Halassy S, et al. Mesenchymal stem cells: Cell therapy and regeneration potential. J Tissue Eng Regen Med. 2019; 13 (9): 1738-55.
11. Islami M, Soleimanifar F. A review of evaluating hematopoietic stem cells derived from umbilical cord blood’s expansion and homing. Curr Stem Cell Res Ther. 2020; 15 (3): 250-62.
12. Song JS, Hong KT, Kim NM, Jung JY, Park HS, Kim YC, et al. Allogenic umbilical cord blood-derived mesenchymal stem cells implantation for the treatment of juvenile osteochondritis dissecans of the knee. J Clin Orthop Trauma. 2019; 10 (Suppl. 1): S20-5.
13. Faivre L, Couzin C, Boucher H, Domet T, Desproges A, Sibony O, et al. Associated factors of umbilical cord blood collection quality. Transfusion. 2018; 58 (2): 520-31.
14. Ballen K, Wilson M, Wuu J, Ceredona AM, Hsieh C, Stewart FM, et al. Bigger is better: maternal and neonatal predictors of hematopoietic potential of umbilical cord blood units. Bone Marrow Transplant. 2001; 27: 7 -14.
15. Hussein AA, Bawadi RM, Tahtamouni LH, Frangoul H, Elkarmi AZ. Feasibility of collecting umbilical cord blood in jordan and the effect of maternal and neonatal factors on hematopoietic stem cell content. Mediterr J Hematol Infect Dis. 2014; 6 (1): e2014019.
16. 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.
17. Brand JS, Hiyoshi A, Cao Y, Lawlor DA, Cnattingius S, Montgomery S. Maternal smoking during pregnancy and fractures in offspring: national register-based sibling comparison study. BMJ. 2020; 368: l7057.
Download attachments: 10.4328_ACAM.20339
Durmus Burgucu. Effect of smoking on the hematopoietic stem cell count in cord blood. Ann Clin Anal Med 2021;12(Suppl 1): S83-85
Evaluation of the relationship between D-dimer levels and endoscopic findings of patients with upper gastrointestinal hemorrhage
Ali Saglık 1, Dogac Niyazi Ozucelik 2, Utku Murat Kalafat 3, Serkan Dogan 3, Rabia Birsen Tapkan 3, Alp Yılmaz 4, Busra Bildik 3
1 Istinye University Liv Hospital, 2 Department of Social Work, Faculty of Health Science, Istanbul University Cerrahpasa, 3 Department of Emergency Medicine, Ministry of Health, University of Health Science Kanuni Sultan Süleyman Training and Research Hospital, 4 Istanbul Taksim Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20340 Received: 2020-09-10 Accepted: 2020-10-19 Published Online: 2020-10-26 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S86-90
Corresponding Author: Busra Bildik, The University of Health Science,Kanuni Sultan Suleyman Training and Research Hospital,Department of Emergency Medicine, 34303, Kucukcekmece, Istanbul, Turkey. E-mail: email@example.com P: +90 532 605 47 36 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1546-4612
Aim: Gastrointestinal (GI) bleeding is the most common reason for admission to the emergency department, and, despite technological advances, mortality is still high. The aim of our study was to evaluate the relationship between endoscopic findings and D-Dimer in patients presenting with suspected upper GI bleeding.
Materials and Methods: This retrospective, cross-sectional descriptive study included all patients who met the inclusion criteria for patients with GI bleeding who applied to the Department of Emergency Medicine between August 15, 2016 and February 15, 2017. Demographic characteristics, history, D-dimer and endoscopy were evaluated. Significance was evaluated at p<0.05.
Results: Among the 90 patients included in the study, 61.1% were male (n=55) and 38.9% were female (n=35). While there was a statistically significant differ- ence between the systolic blood pressure measurements and the stages according to the Forrest classification (p=0.020); no difference was found between the other vital findings and the stages. There was no statistically significant difference in mean D-Dimer levels or D-Dimer limit values between the patients with and without a history of GI hemorrhage or hospital admission (p> 0.05). No statistical difference was found between D-Dimer mean values and limit values and the stages according to Forrest classification (p>0.05).
Discussion: In the study, there was no relationship between the endoscopic findings (Forrest classification stage I, II, III) and the increased D-Dimer levels.
Keywords: D-dimer; Endoscopy; GI hemorrhage
Gastrointestinal system (GI) bleeding is one of the most common reasons for admission to the emergency department; it is a clinical picture that draws attention with its high mortality, diagnosis, and treatment costs, often requiring hospitalization and even intensive care, as well as the need for follow-up with a multidisciplinary study. GI bleeding is seen in 1-2 out of 1000 people in the community and its mortality varies between 6-10% . Through using flexible endoscopy in 1957, a radical change occurred in the diagnosis and treatment approaches of upper GI bleeding. Surgical procedures previously performed before the use of endoscopy in diagnosis and treatments have now been replaced by endoscopy . D-Dimer is a product of the enzymatic degradation of cross-linked fibrin by plasmin. Fibrin is the main component of the thrombus and is formed by the activation of the coagulation system. Fibrin formation and plasmin mediated destruction of fibrin are in equilibrium under normal physiological conditions and play a key role in hemostasis. In the study conducted by Akbaş et al., D-Dimer levels were found to be increased approximately 3-4 times the normal in patients with extravascular fibrin formation (traumatic hematoma, gastrointestinal bleeding) or liver failure . Our study aims to correlate endoscopy findings with laboratory values in patients with GIS bleeding and to retrospectively evaluate the guidance of these findings in terms of re-application.
Material and Methods
This retrospective, cross-sectional descriptive study was performed in the Emergency Medicine Department of Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital from 15 August 2016 to 15 February 2017. Ethic committee approval was obtained (Number 2017-09-12). The study included patients who presented with signs of upper GI bleeding such as melena, syncope, hematemesis or prediagnosed with upper GI bleeding and had undergone emergency endoscopy for upper GI bleeding. Patients with active bleeding other than the GI, a history of recent surgery and embolic diseases, and patients with GIS bleeding without endoscopy were excluded from the study.
In 2017, it was determined that the number of patients in ED was 694000 and 528 of these patients were diagnosed with GI bleeding. The number of patients diagnosed with upper GI bleeding between August 15, 2016, and February 15, 2017; was reported as 210. By analyzing the accessed files, patient gender, age, admission time, admission outpatient clinic number, systolic and diastolic blood pressure, pulse rate, fingertip saturation, respiratory rate, presence of re-admission in history, presence of syncope before admission, presence of liver disease and heart failure, the presence of melena at patient’s arrival, history of acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drug (NSAID) use, history of previous GI bleeding, hemoglobin, hematocrit, BUN, D-Dimer and INR results and endoscopy reports were obtained. The study was approved by the Local Ethics Committee. All included patients gave informed consent.
We used NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program for statistical analysis. While evaluating the study data, besides descriptive statistical
methods (Average, Standard Deviation, Median, Frequency, Ratio, Minimum, Maximum), the Kolmogorov-Smirnov test, and box plot graphs were used for the conformity of numerical data to a normal distribution. While the One-way Anova Test was used for comparing numerical data with normal distribution, the Kruskal Wallis test is used for comparisons of three or more groups that do not show a normal distribution; the Mann- Whitney U test was used in the evaluation of two groups. The Pearson Chi-Square test and the Fisher-Freeman-Halton test were used for comparison of non-numerical data. Significance was evaluated at the p <0.05 level.
The study was carried out with 90 cases; 61.1% (n=55) were males and 38.9% (n=35) were females. The ages of the cases ranged from 19 to 96, with a mean of 61±22 years. The vital signs and histories of the cases are summarized in Table 1. Re- application rate was 21.1% (n=19). Pre-admission syncope was observed in 11.1% (n=10) of the patients, liver disease in 8.9% (n=8), congestive heart disease in 17.8% (n=16) and melena on rectal examination in 68.9% (n = 62). The rate of using ASA was 27.8% (n=25), the rate of NSAID use was 34.4% (n=31), the rate of Coumadin use was 13.3% (n=12), and 21.1% (n=19) of the patients had a history of gastrointestinal bleeding.
The diagnostic examination findings, intervention, and examination values of the cases are also summarized in Table 1. Bleeding was detected in nasogastric lavage in 32.2% (n=29) of the cases. Hemoglobin measurements ranged from 3.3 to 18.5, with a mean of 9.03±3.26; Hematocrit measurements ranged from 4.6 to 53, with a mean of 27.49±9.66; BUN measurements ranged from 9.4 to 411.1, with a mean of 44.84±49.44 and INR measurements from 0.8 to 12, with a mean of 1.50±1.55. D-Dimer measurements ranged from 0 to 23.8, with a mean of 1.25±2.75; It is less than 0.50 in 44.4% of the cases (n=40), and greater than 0.50 in 55.6% (n=50).
The distribution of the patients based on the Forrest classification is shown in Table 2. Based on the Forrest classification, the differences between the groups in terms of age and gender are summarized in Table 3.
Based on the Forrest classification, the differences between the groups with previous GI bleeding or history of hospital admission, pre-admission syncope, liver disease, congestive heart disease, use of ASA, and NSAID, history of GI bleeding are summarized in Table 3. According to the Forrest classification, the rate of heart disease in grade I cases was significantly higher than in grade III cases (p=0.006). According to the Forrest classification, the rate of using NSAIDs in grade I (p=0.007) and grade II (p=0.012) cases was significantly higher than in grade III cases (p=0.01).
There was no statistically significant difference (p> 0.05) between the D-Dimer mean values, cut-off values (0.50), and the stages according to the Forrest classification (Stage I, II, III) (Table 3).
No statistically significant difference was found in terms of mean D-Dimer levels and D-Dimer cut-off values between the patients with previous GI bleeding or a history of hospital admission and the patients without these histories (p=0,774 and 0,453, respectively).
Our study was conducted on the patients with a diagnosis of GI bleeding undergoing endoscopy and included 90 cases; 61.1% (n=55) of cases were males and 38.9% (n=35) were females. Olt et al. also found a high rate of male patients (72%) . In our study, the ages of the patients ranged from 19 to 96, and the mean was found to be 61±22 years. In other studies, the mean age was found to be 57±21 and 57±17 years, respectively [5,6]. Our study is similar to previous studies in terms of both age and gender distribution.
When the vital signs of the cases were evaluated, the mean systolic blood pressure was 119.31±20.69; the mean diastolic blood pressure 70.48±12.80; the mean heart rate was measured as 87.31±16.91 and these findings were found to be close to the results of the study conducted by Çete et al, in Turkey. In the mentioned study, the mean systolic blood pressure was measured as 129.5; the mean diastolic blood pressure was measured as 70.71, and the mean pulse rate was measured as 100.7 . The rate of previous GI bleeding or hospital admission history was 21.1% (n=19). In the study conducted by Bayır et al. in 2003, it was found to be 59%, unlike this study . We think that the reason for this difference in two different studies conducted in our country may be the widespread use of endoscopic procedures in our country in the last 14 years and the development of early diagnosis and treatment methods. When the patients were evaluated in terms of other accompanying diseases, liver disease was detected in 8.9% (n=8) and congestive heart disease in 17.8% (n=16) of the patients.
In the study of Gürel et al., 58.4% of the patients had comorbid diseases and comorbidity was found as a risk factor for mortality in varicose veins and upper GI bleeding other than malignancy . We think that the reason for the lower rate of comorbid diseases in our study is that only patients who underwent endoscopy were included in the study.
In 68.9% of the study cases (n=62), melena was observed on rectal examination and it was observed that hemorrhagic fluid came from the nasogastric catheter in 32.2% (n=29) of the cases.
In the study by Lewis et al., melena was found in 48% of the patients . In the study by Adamopoulos et al., melena was found in 66.3% of the patients . In the study conducted by Chassaignon et al in France, hematemesis was found to be the most frequent complaint with 39%, and it was observed that the melena accounted for 28% . In our study, we found compatible results with other studies in the literature.
NSAIDs and acetylsalicylic acid, which are used frequently worldwide, have an important place in the etiology of upper gastrointestinal bleeding . In our study, we found that the rate of ASA use was 27.8% (n=25), while the rate of NSAID use was 34.4% (n=31). In a study conducted in our country by Coşar et al. , it was seen that the use of ASA was more frequent in cases with GI bleeding (NSAID, n=35 (40%); ASA, n=51 (60%)) . We think that the reason for the lower rate of ASA use in our study is due to the lower GI side effect profile of new antiplatelet drugs.
In our study, D-Dimer was less than 0.50 in 44.4% (n=40) of the cases, and greater than 0.50 in 55.6% (n=50). A study showed that patients with high plasma D-Dimer levels had a 7.5 times worse prognosis than the group without high D-Dimer levels and had a positive predictive value of 20.5% in terms of outcomes such as death or re-admission. In this study, the increase in D-dimer levels in patients with upper gastrointestinal bleeding is consistent with local fibrinolysis, suggesting that plasma fibrinolytic tests may be a suitable prognostic marker for upper GI bleeding . In another study, upper GI bleeding was observed in 30% (n=34) of patients with high D-Dimer levels, who were followed up for liver cirrhosis . In our study, we found no statistically significant difference between D-Dimer levels and previous GI bleeding or hospital admission history. As a reason for this; we think that the D-Dimer level may vary depending on the bleeding time, the interaction of other drugs used by the patients, and comorbid diseases.
In our study, based on the Forrest classification, the most seen stage was stage 3 (47.8%, n=43). In two separate studies conducted in our country where cases were classified according to the Forrest classification, class III cases were more common, as in our study [4,17].
Gastric ulcer develops in 10% of chronic NSAID users. The risk of developing peptic ulcer is 5-10 times higher in chronic NSAID users than in those who do not take NSAIDs . In studies conducted by Unsal, Çetinkaya, Kaplan, and Shafi et al., it was found that NSAID use was observed in patients with peptic ulcer (42%, 32.2%, 80%, and 38.4%, respectively) [19-22]. In our study, NSAID use was found in 35.3% of the patients with peptic ulcer which is consistent with the literature.
In our study, no statistically significant difference was found between the groups according to the presence of a history of melena on rectal examination and ASA use (p> 0.05). In the study conducted by Okutur et al., the number of patients who were admitted with only melena symptoms was significantly higher in the group without recurrent bleeding (p<0.01) . In another study in patients with upper GI bleeding, the most common etiology was peptic ulcer, 48% of the cases had comorbid diseases, the bleeding was found to be due to the use of ASA or NSAIDs in 19.1% . In our study, a statistically significant difference was found between the groups according to NSAID use (p=0.010). As a result of paired comparisons made to identify the group that creates difference, the rate of NSAID use in grade I (p=0.007) and grade II (p=0.012) cases was significantly higher than in grade III cases (p=0.01).
In this study, which investigated the relationship between D-Dimer and upper GI bleeding, no statistically significant difference was found between D-Dimer levels according to GI bleeding history (p>0.05). In the study by Primignani et al., the basic measurements of coagulation activation and fibrinolysis of cases were measured as more impaired in those with bleeding. High D-Dimer levels were found to be significant as a marker of poor prognosis in upper GI bleeding . In the study conducted by Junquera et al. in patients with upper GI bleeding due to angiodysplasia, D-Dimer levels were found to be higher in patients who had upper GI bleeding due to angiodysplasia than control groups, and it was concluded that high D-Dimer levels may be an indicator of bleeding from angiodysplasia . In the study by Gutiérrez et al. on 84 patients, in which the prognostic values of fibrinolytic tests in terms of discharge were investigated in patients with upper GI bleeding, surgical or D-Dimer plasma levels were found to be significantly higher than those who had positive results. (p=0.01) .
No relationship was found between endoscopic findings (Forrest classification) and D-Dimer elevation in patients who underwent emergency endoscopy for upper GI bleeding. Consistent with the literature, the most common causes of GI bleeding were peptic ulcer and NSAID use. We believe that rational drug use and preventive medicine should be developed to prevent GI bleeding, and further studies on this subject are needed. Limitations
As limitations of our study, we can mention the inclusion of only patients who can undergo endoscopy, not including all the patients with a diagnosis of GI bleeding, and a small number of patients who were admitted for 6 months
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Hernandez-Diaz S, Garcia-Rodriguez L.A. Incidence of serious upper gastrointestinal bleeding/perforation in the general population: Review of epidemiologic studies. J Clin Epidemiol. 2002; 55(2): 157-63.
2. Memişoğlu K. Acute upper gastrointestinal bleeding. Türkiye Klinikleri J Surg Med Sci. 2005; 1(4): 1-6.
3. Akbaş SH, Can M, Kılıçaslan, Özdem S, Çete Y, Gültekin M. The Distribution of Diagnosis and The Relation of D-dimer Levels with Hospitalization and Mortality Rates in Emergency Department Patients with High D-dimer Levels. Türkiye Acil Tıp Dergisi. 2004; 4: 149-54.
4. Olt S, Uslan İ, Eminler AT, Tamer A, Akçay EÜ, Baştemir A, et al. Retrospective Examination of Patients Followed for Upper Gastrointestinal Bleeding. Sakarya Med J. 2015; 5(3): 130-4.
5. Erkuş E, Helvacı A, Bodur Ö, Özsoy N. Examination of 99 Cases with Upper Gastrointestinal System Bleeding. Okmeydanı Tıp Dergisi. 2013; 29(2): 76-80.
6. Miño Fugarolas G, Jaramillo Esteban JL, Gálvez Calderón C, Carmona Ibáñez C, Reyes López A, De la Mata García M. An analysis of a general prospective series of 3270 upper digestive hemorrhages. Rev Esp Enferm Dig. 1992; 82(1): 7-15.
7. Çete Y,Göksu E, Erken Ö, Erçetin Y,Kılıçaslan İ, Çete Y. Factors Determining Mortality and Demographic Characteristics of Patients Admitted to Akdeniz University Hospital Emergency Department with Upper Gastrointestinal System Bleeding. Türkiye Acil Tıp Dergisi. 2004; 4-3: 121-6.
8. Bayır A, Okumuş M, Köstekçi ŞK, Şahin TK. Risk factors in upper GI bleeding. Genel Tıp Derg. 2003; 13(4): 157-61.
9. Güler K, Vatansever S, Halıcı E. Factors affecting the clinical course in upper gastrointestinal system bleeding. Turkish Journal of Trauma and Emergency Surgery. 1997; 3: 62-6.
10. Lewis JD, Shin EJ, Metz DC. Characterization of gastrointestinal bleeding in severely ill hospitalized patients. Crit Care Med. 2000; 28(1): 46-50.
11. Adamopoulos AB, Baibas NM, Efstathiou SP, Tsioulos DI, Mitromaras AG, Tsami AA. Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study. Eur J Gastroenterol Hepatol. 2003; 15(4): 381-7.
12. Chassaignon C, Letoumelin P, Pateron D; Group HD 2000. Upper gastrointestinal heamorrhage in Emergency Departments in France: Causes and management. Eur J Emerg Med. 2003; 10(4): 290-5.
13. Vargas E, Cabrera L, Morón A, García M, Soto J, Guadarrama I. Assessment of hospital costs related to the diagnosis and treatment of upper gastrointestinal haemorrhages in patients consuming non steroid anti-inflammatory drugs. Rev Esp Enferm Dig. 2001; 93(6): 390-7.
14. Özdil B, Cosar A, Akkiz H, Sandikçi M. Atherosclerosis and acetylsalicylic acid are independent risk factors for gastric and duodenal ulcer bleeding. The Anatolian Journal of Cardiology. 2011; 11(1): 53-6.
15. Gutiérrez A, Sánchez-Payá J, Marco P, Pérez-Mateo M. Prognostic value of fibrinolytic tests for hospital outcome in patients with acute upper gastrointestinal hemorrhage. J Clin Gastroenterol. 2001; 32(4): 315-8.
16. Violl F, Basili S, Ferro D, Quintarelli C, Alessandril C, Cordova C. Association between high values of D-dimer and tissue-plasminogen activator activity and first gastrointestinal bleeding in cirrhotic patients. Thromb Haemost 1996; 76(2): 177-83.
17. Paksoy F, Ulaş T, Çakır A, Baştürk T, Dal MS, Borlu F. GIS bleeding in patients with CRF. Journal of Clinical and Experimental Investigations. 2011; 2(2): 207- 13.
18. Kayaçetin E, Polat H. Examination of 52 cases with upper gastrointestinal system bleeding. General Medical Journal. 2003; 13(3): 119-22.
19. Kaplan RC, Hecbert SR, Psaty BM. Risk factors for hospitalized upper or lower gastrointestinal tract bleeding in treated hypertensives. Prev Med. 2002; 34(4): 455-62.
20. Çetinkaya H, Soykan İ, Beyler AR, Örmeci N, Görem A, Sipahi N, et al. Factors causing bleeding from the upper gastrointestinal tract. Türk J Gastroenterol. 1995; 6: 251-2.
21. Shafi MA, Fleischer DE. Risk factors of acute ulcer ble¬eding. Hepatogastroenterology Review. 1999; 46: 727-31.
22. Ünsal B, Altınay Z, Kara B. Upper gastrointestinal system hemorrhages hospitalized in our clinic between 1987-1991 and evaluation of drug related ones among these. Gastroenterology. 1993; 4: 460-2.
23. Primignani M, Dell’Era A, Bucciarelli P, Bottasso B, Bajetta MT, de Franchis R, et al. High-D-dimer plasma levels predict poor outcome in esophageal variceal bleeding. Dig Liver Dis. 2008; 40(11): 874-81.
24. Junquera F, Saperas E, Anglés A, Abadía C, Monasterio J, Malagelada JR. Increased plasma fibrinolytic activity in bleeding gastrointestinal angiodysplasia. Eur J Gastroenterol Hepatol. 2005; 17(2): 199-205.
25. Gutiérrez A, Sánchez-Payá J, Marco P, Pérez-Mateo M. Prognostic value of fibrinolytic tests for hospital outcome in patients with acute upper gastrointestinal hemorrhage. J Clin Gastroenterol. 2001; 32(4): 315-8.
Download attachments: 10.4328_ACAM.20340
Ali Saglık, Dogac Niyazi Ozucelik, Utku Murat Kalafat, Serkan Dogan, Rabia Birsen Tapkan, Alp Yılmaz, Busra Bildik. Evaluation of the relationship between D-dimer levels and endoscopic findings of patients with upper gastrointestinal hemorrhage. Ann Clin Anal Med 2021;12(Suppl 1): S86-90
Evaluation of knowledge, attitude and awareness of medical faculty students about human papilloma virus
Jule Eriç Horasanlı 1, Nur Demirbaş 2
1 Department of Gynecology and Obstetrics, Necmettin Erbakan University Meram Medical School, 2 Department of Family Medicine, Necmettin Erbakan University Meram Medical School, Konya, Turkey
DOI: 10.4328/ACAM.20341 Received: 2020-09-09 Accepted: 2020-10-09 Published Online: 2020-10-20 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S91-95
Corresponding Author: Jule Eriç Horasanlı, Department of Gynecology and Obstetrics Necmettin Erbakan University Meram Medical School, Konya, Turkey. E-mail: firstname.lastname@example.org P: +90 555 4793394 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8238-7126
Aim: In this study, we aimed to evaluate the knowledge levels and awareness of medical students about the diagnosis, transmission routes and prevention methods of Human Papilloma Virus (HPV), which is very common worldwide.
Materials and Methods: This cross-sectional study was carried out on 4th grade medical faculty students in the 2019-2020 academic year. A brief socio- demographic information form, an information form on general knowledge, diagnosis, contamination routes, and methods of HPV prevention, and a question- naire on HPV awareness levels were applied to the students.
Results: The average age of the students was 22.31 ± 1.3 (19-30) years; 44.5% (n = 89) of the students were female and 55.5% (n = 111) were male. Among the students, 84% had information about the diseases caused by the virus, transmission routes, prevention and diagnostic methods. The correct response rate of students to knowledge questions was 84.4% for women and 82.7% for men (p = 0.042). It was found that students’ levels of knowledge about HPV protection methods and especially vaccines were lower than their knowledge about diagnosis and transmission.
Discussion: In this study, it was found that the general knowledge level of medical school students about HPV was high, but their knowledge about prevention and vaccination was low. Medical school students should be encouraged to increase their knowledge and get vaccinated, and importance should be given to HPV vaccination training.
Keywords: HPV; Knowledge level; Awareness; Vaccine
Human Papilloma Virus (HPV) infection is the most common sexually transmitted disease that causes urogenital system diseases and cancers in both women and men . The risk of HPV transmission increases with early sexual intercourse. The lifetime risk of encountering HPV is at least 50% for both sexes . Cervical cancer causes death of a woman every two minutes in the world, and it is the second most common cancer in women after breast cancer . According to Cancer Statistics in Turkey, when the incidence of cancer in women according by age groups is considered, it ranks 4th among women aged 25-49 with the ratio of 3.6% and 8th among women aged 50-69 with the ratio of 2.7%. National screening programs positively affect the incidence of cancers and associated mortality rates. Good implementation of cancer screening and prevention programs, healthcare professionals having adequate knowledge are very important for the success of a screening program .
To prevent cervical cancer, first of all, HPV, which is one of the most important factors, should be well known by the society, timely screening should be done, protective measures should be taken and girls should be vaccinated early. Today, vaccines developed against HPV infections are available. In order to protect against cervical cancer, in 2006, the quadrivalent HPV vaccine which is effective against types 6, 11, 16, 18, and in 2009, the bivalent HPV vaccine which is effective against types 16, 18 were developed . Despite being widely used in many western countries, the HPV vaccine is not in the national immunization program and not covered by social security payments in Turkey.
While the level of awareness about HPV increases in the Western world, the level of awareness is lower in other regions where the disease is more common . Although the level of awareness is higher in groups with high levels of education and income, undoubtedly, every country, even different regions of the same country, has created its own awareness patterns depending on the characteristics of the region, such as conservatism and the age of onset of sexual intercourse [7,8]. Determining the level of regional key features and basic information related to HPV-related diseases will provide important data for future awareness-raising initiatives. Health professionals should have the highest levels of knowledge and awareness about HPV. In this regard, raising public awareness and reducing anxiety should be the primary duty of healthcare professionals. In order for healthcare professionals, nurses, physicians and medical school students who become physicians in the future to guide the society, they must first have information about HPV infection and vaccines themselves and then counsel individuals on this issue. In this context, the aim of our study is to measure the awareness and knowledge levels of medical students about HPV, HPV related diseases, cervical cancer and HPV vaccines, and to evaluate their attitudes towards people with HPV.
Material and Methods
The type, place, and universe of the research
This study, which is cross-sectional analytical research, was carried out with 4th grade students studying at Necmettin Erbakan University Meram Medical Faculty during the 2019- 2020 academic year.
Ethical Permit of the Study
Ethical approval was received from Necmettin Erbakan University, Meram Medical Faculty, Ethics Committee (Number: 2019/2171) before the study started. All participants provided electronic informed consent. All participants provided verbal informed consent.
The students participating in the study were administered a short sociodemographic information form and two different questionnaires measuring the level of knowledge and awareness about HPV. The information form prepared by the researchers based on the previous studies contains 25 questions about HPV, HPV-cancer connection, diagnosis, transmission and prevention ways. Again, a questionnaire with 15 questions was applied in order to learn the approach and personal awareness of patients with HPV.
In order to make a more accurate assessment, the questions were evaluated as closed-ended, and the answers were true/false and 3-point Likert (disagree-undecided-agree). Knowledge questions were divided into general knowledge (8 questions), diagnosis (4 questions), transmission (7 questions), and prevention (6 questions). If the rate of the correct answer to the questions was 80-100%, it was accepted as a good level of knowledge, 60-80% as a medium level of knowledge, and below 60% as a low level of knowledge.
A sample group was not selected for the study, and it was planned to reach all the 4th grade students of our faculty. Those who did not want to participate in the study, who did not complete the questionnaire completely, who did not have the mental capacity to answer the questions, or who could not communicate due to language differences were excluded from the study. The study involved 200 out of 235 students studying in the 4th -grade in the 2019-2020 academic year at our faculty (85.1%).
SPSS (Statistical Package for Social Sciences) for Windows 20.0 program was used to evaluate the study results. Frequencies, mean, standard deviation, median, minimum and maximum values were calculated. The Chi-square test was used to compare qualitative data. Compatibility with normal distribution was evaluated with the Kolmogorov-Smirnov test. Accordingly, the differences between the averages were determined by Student’s t-test or One-way ANOVA variance analysis. The significance level was accepted as p <0.05.
The mean age of the students in our study was 22.31±1.3 (19- 30) years; 44.5% (n=89) were female and 55.5% (n=111) were male. Among the students, 37.0% (n=74) were staying alone, 59.5% had income equal to their expenses, 66.5% lived in urban areas and 60.0% had a nuclear family structure. When students were asked about their school success, 54.5% stated that they were at a medium level. Participants’ level of knowledge about HPV was generally high; 84% of the students knew about the diseases caused by the virus, transmission routes, prevention, and diagnostic methods. The correct response rate given by students to knowledge questions was found to be 84.4% for women and 82.7% for men (p=0.042).
The correct response rate given to general knowledge questions about HPV was 94.5%, 95.2% for women, and 94.0% for men (Table 1). While male students (96.4%) knew better than female students (87.6%) that HPV causes diseases other than cervical CA (p=0.019), all female students knew that HPV Type 16 and Type 18 are the most common types of cervical cancer (p=0.006).
An average of 82.1% of all students (Female: 82.1% Male: 82.0%) answered correctly the questions about diagnosis, and an average of 83.0% of all students (Female: 84.9%, Male: 81.4%) answered the questions about transmission correctly. A statistically significant relationship was found between gender and HPV contamination knowledge level (p=0.038). However, it was found that students’ knowledge levels about HPV protection ways and especially vaccines were lower. The correct answer rate in this section was 75.7%, 77.5% for women, and 74.3% for men (Table 2). A statistically significant relationship was found between the knowledge levels of female students and male students (p = 0.029). While 88% of the participants correctly knew that vaccination should be done before the first sexual intercourse, 44.0% of them stated that it could be done at all ages and 62.5% of them stated that a single dose of vaccine is sufficient. The rate of men who answered correctly by saying “HPV vaccine can only be given to women” was 91.0%, the rate of women who answered correctly was 80.9%, and a statistically significant relationship was found between the genders (p=0.038).
A statistically significant correlation was found between the students’ general HPV knowledge levels and protection knowledge levels and school success. General knowledge levels and protection knowledge levels of students with good school success were higher than those with moderate and bad success (p=0.002, p<0.001). Participants’ attitudes and behaviors towards HPV are shown in Table 3.
Human Papilloma Virus (HPV) infection is the most common sexually transmitted disease and causes cancers (cervical cancer, anogenital cancers, penile cancers) in both men and women. According to CDC, the risk of both sexes encountering HPV is at least 50% throughout their lives. When we look at the literature, although there are many studies on HPV, related diseases and prevention ways, the results of our study are important since it is one of the few studies about the level of knowledge of medical students. In our study, we observed that medical students’ general level of knowledge about HPV, transmission and diagnostic methods were high, while both male and female students did not have sufficient knowledge about prevention and HPV vaccines.
According to CDC, approximately half of the diagnosed HPV infections occur in young people aged 15-24. According to a population-based study on women in the US, the general prevalence of HPV was 26.8%, while the highest prevalence was reported to be 44.8% observed in women aged 20-24 years . Approximately 70% of young women encounter HPV in the first 5 years after onset of sexual activity . University students are also in the age group at risk for HPV. For this reason, the level of knowledge of university students about HPV is very important. In the present study, participants’ level of knowledge about HPV was generally high. More than three-quarters of the students knew the virus-related diseases, transmission routes, prevention and diagnosis methods correctly. Knowledge levels of female students were higher than male students. In a study of university students, only 16.8% of students stated that they heard about HPV. In studies comparing gender and HPV knowledge level, the knowledge levels of women were found to be higher than men [10,11]. In our study, a significant relationship was found between HPV awareness and different variables such as age, gender, marital status, history of family cancer and talking about sexual issues . In studies conducted, HPV awareness varied between 16-57% in our society [7,13,14].
Cervical cancer is a type of cancer that causes frequent deaths in women in our country but can be treated if diagnosed early. Regarding its development, HPV is accused of being the biggest risk factor . In a study conducted on medical school students, 91% of students knew about HPV and 85.6 % knew about HPV vaccine . In the present study, more male students knew that HPV caused cervical CA, while more female students knew that cervical CA is caused by HPV types 16 and 18. In another study, 89.8 % of medical students knew that HPV caused cervical CA. Knowledge of female students was higher than male students . Güdücü et al. reported in their study that 64.2 % of the participants, who were healthcare professionals and medical students, knew that HPV caused cervical cancer . Although many HPV infections are temporary and asymptomatic, HPV types 6 and 11 cause about 90% of types genital warts. Types 16, 18, 31, 33, 45, 52 and 58 are considered as high-risk oncogenic types .
The level of knowledge about transmission ways of HPV was higher among female students than male students. In a different study, 80% of the participants knew that HPV was sexually transmitted, but there was no statistically significant difference between the genders . In a study carried out in men and women aged 18-25 attending vocational schools in Germany, 50% of women and 42% of men thought that only women could be infected with HPV, and the majority did not know that HPV was sexually transmitted .
In the present study, the level of knowledge of students about the ways of protection from HPV was found to be 75.7%. Although 84.5% of the students have heard of HPV vaccine, especially the knowledge level of male students about the dose of the vaccine was found to be quite low. When we look at the studies in the literature, HPV vaccine knowledge level is low in the society [18,19]; moreover,, it is not at the expected level in studies conducted on health workers [20, 21]. In a study conducted among medical students, the HPV vaccine awareness rate was 75.7% . In the studies conducted, female students knew about HPV vaccine more than male students [15,22]. This difference between genders may be related to the thought that HPV causes only cervical CA and that the vaccine is given to women. In a study about HPV conducted in various faculties of a university, it was found that only 62.5% of the medical students heard about HPV vaccination and that this rate was lower in other faculty students. Interestingly, however, the knowledge of vaccination among male students was higher than among female students . HPV awareness and knowledge level increase as the level of education increases . Studies have found an independent relationship between employees and non- workers, those with higher education levels, and those living in the city and those living in rural areas .
Prophylactic HPV vaccine is the most effective primary prevention method against cervical cancer. Therefore, the HPV vaccine should be given before the first sexual contact and before exposure to HPV. There are three vaccines used in primary prevention from HPV. Gardasil 4 was approved by the FDA in 2006 as a quadrivalent vaccine that prevents HPV 6, 11, 16 and 18 types. Cervarix was produced in 2009 as a bivalent vaccine that prevents HPV types 16 and 18, which can cause cervical cancer and precancerous lesions. Gardasil 9 is a vaccine, which provides additional protection in the prevention of diseases caused by 9 types of HPV, such as HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58, and was approved by the FDA in December 2014. Cervarix, Gardasil 4 and 9 are recommended for women. Gardasil 4 and 9 are recommended for men 29. The World Health Organization (WHO) recommended a vaccination program for girls aged 9-13 in 2014, where two doses of HPV vaccine were administered before exposure to sexual contact and HPV. The HPV vaccine is not part of the national immunization program, and implementation is entirely at the request of individuals/families and is paid. But in Germany, 67% of women were vaccinated because the vaccine was reimbursed among women aged 18-20 .
University-age men and women who have not previously vaccinated or completed the vaccine are still within the appropriate age range for the recommended vaccination. For these students, university period represents the opportunity to acquire or complete the HPV vaccine series, and university health centers are an excellent resource for HPV vaccination efforts. It is important for medical students to have a sufficient level of knowledge about HPV transmission and prevention ways, which will have an important place in the future.
In a previous study, only 8.2% of the participants stated that they received information about HPV and HPV vaccination from family physicians, 64.6% received information through TV and the internet. In a study conducted with physicians currently on duty, 85% of obstetricians and 78% of pediatric-family physicians stated that they recommended the vaccine when they were asked whether they recommend HPV vaccine to their relatives / patients .
Consequently, the level of knowledge of medical students about the diagnosis and transmission of HPV is high, but their knowledge about prevention routes and vaccination is low. Methods for early diagnosis of cervical cancer, screening for HPV, and HPV vaccine trainings in the medical school curriculum should be reviewed to improve students’ level of knowledge and awareness. Doctors and medical school students are required to receive training to overcome barriers to vaccination and anti-screening behaviors in women and men. At the same time, the level of evidence-based knowledge about HPV and the HPV vaccine is important for providing counseling and training to the community it will serve.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Castellsagué X, Díaz M, de Sanjosé S, Muñoz N, Herrero R, Franceschi S, et al. Worldwide human papillomavirus etiology of cervical adenocarcinoma and its cofactors: implications for screening and prevention. J Natl Cancer Inst. 2006;98(5):303-15.
2. Brianti P, De Flammineis E, Mercuri SR. Review of HPV-related diseases and cancers. New Microbiol. 2017;40(2):80-5.
3. Aydogdu M, Ozsoy U. Cervical cancer and HPV. Androl Bul. 2018;20:25−9.
4. Kaya C, Ustu Y, Ozyoruk E, Aydemir O, Simsek C, Demirci Sahin A. Knowledge, Attitudes and Behaviors of Health Workers About Cancer Screenings. Ank Med J. 2017;17(1):73-83.
5. Oshman LD, Davis AM. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP). JAMA. 2020;323(5):468.
6. Vaccarella S, Bruni L, Seoud M. Burden of human papillomavirus infections and related diseases in the extended Middle East and North Africa region. Vaccine. 2013;31(6):G32-44.
7. Kurtuncu M, Arslan N, Alkan I, Bahadır O. Knowledge, attitude and behaviors of the mothers of 10-15 year old daughters regarding cervical cancer and HPV vaccine. J Hum Sci. 2018;15(2):1072-85.
8. Gorkem U, Arslan E, Togrul C, Efeturk T, Gungor T. Which people should be targeted in terms of awareness about the human Papilloma virus infection? A survey. Turkish Bulletin of Hygiene and Experimental Biology. 2015;72(4): 303-10.
9. Stratton K, Ford A, Rusch E, Clayton EW, editors. Adverse Effects of Vaccines: Evidence and Causality. Washington (DC): National Academies Press (US); 2011.
10. McCusker SM, Macqueen I, Lough G, Macdonald AI, Campbell C, Graham SV. Gaps in detailed knowledge of human papillomavirus (HPV) and the HPV vaccine among medical students in Scotland. BMC Public Health. 2013;13:264.
11. Blodt S, Holmberg C, Muller-Nordhorn J, Rieckmann N. Human Papillomavirus awareness, knowledge and vaccine acceptance: A survey among 18-25 year old male and female vocational school students in Berlin, Germany. Eur J Public Health. 2012;22(6):808-13.
12. Cinar İO, Ozkan S, Aslan GK, Alatas E. Knowledge and Behavior of University Students toward Human Papillomavirus and Vaccination. Asia-Pac J Oncol Nurs. 2019;6(3):300-7.
13. Kaya Şenol D. How Much I Am Aware of Human Papilloma Virus (HPV)? Turk J Fam Med Prim Care. 2019;462-71.
14. Saylam Kurtipek G, Cihan FG, Ataseven A, Ozer I, Can Turhan Z. The Knowledge, Attitude and Behaviours of Women above 18 Years Old about Genital Warts, Cervical Cancer and Human Papilloma Virus Vaccination. Turk J Dermatol. 2016;10(3):105-9.
15. Emre N, Ozsahin A, Edirne T. Pamukkale University Medical Faculty Students’ Knowledge Level of Human Papilloma Virus Infection and Vaccine. Eurasian J Fam Med. 2020;9(1):42-50.
16. Borlu A, Gunay O, Balci E, Sagiroglu M. Knowledge and Attitudes of Medical and Non-Medical Turkish University Students about Cervical Cancer and HPV Vaccination. Asian Pac J Cancer Prev. 2016;17(1):299-303.
17. Guducu N, Gonenc G, Isci H, Yigiter AB, Dunder I. Awareness of human papilloma virus, cervical cancer and HPV vaccine in healthcare workers and students of medical and nursing schools. J Clin Exp Investig. 2012;3(3):318-25.
18. Costa A de S, Gomes JM, Germani ACCG, da Silva MR, Santos EF de S, Soares Júnior JM, et al. Knowledge gaps and acquisition about HPV and its vaccine among Brazilian medical students. PloS One. 2020;15(3):e0230058.
19. Rashid S, Labani S, Das BC. Knowledge, Awareness and Attitude on HPV, HPV Vaccine and Cervical Cancer among the College Students in India. PLoS One. 2016;11(11):e0166713.
20. Pereira JEG, Gomes JM, Costa A de S, Figueiredo FWDS, Adami F, Santos EF de S, et al. Knowledge and acceptability of the human papillomavirus vaccine among health professionals in Acre state, western Amazon. Clin Sao Paulo Braz. 2019;74:e1166.
21. Swarnapriya K, Kavitha D, Reddy GMM. Knowledge, Attitude and Practices Regarding HPV Vaccination Among Medical and Para Medical in Students, India a Cross Sectional Study. Asian Pac J Cancer Prev. 2015;16(18):8473-7.
22. Ozsaran Z, Demirci S. Questionnaire study evaluating HPV vaccine knowledge level among medical faculty students. Turkish Gynecological Onkol Journal. 2011;14(2):40-4.
23. Ismail H, Rafiq S, Shakoor S, Karim MT, Raheel R. Assessing The Role Of Education In Adult Women’s Knowledge And Awareness Of Human Papillomavirus And Human Papillomavirus Vaccine. J Ayub Med Coll Abbottabad. 2017;29(1):128- 31.
24. Topçu S, Ulukol B, Emüler DS, Topcu HO, Peker GC, Dökmeci F. Physicians’ awareness and approaches to human papillomavirus infection and vaccination. Cukurova Med J. 2018;43(2):326-31.
Download attachments: 10.4328_ACAM.20341
Jule Eriç Horasanlı, Nur Demirbaş. Evaluation of knowledge, attitude and awareness of medical faculty students about human papilloma virus. Ann Clin Anal Med 2021;12(Suppl 1): S91-95
Cytogenotoxic and forced degradation studies of pendimethalin using root growth, comet assay and LC-MS/MS
Büşra Taşdemir 1, Recep Liman 1, Süleyman Gökçe 2, Eslem Amaç 1, İbrahim Hakkı Ciğerci 3, Safiye Elif Korcan 4
1 Department of Molecular Biology and Genetics, Uşak University, Faculty of Arts and Sciences, Uşak, 2 Central Research Laboratory, Uşak University, Uşak, 3 Department of Molecular Biology and Genetics, Afyon Kocatepe University, Faculty of Arts and Sciences, Afyonkarahisar, 4 Health Services Vocational School Medical Laboratory Program, Uşak University 1 Eylül Campus, Uşak, Turkey
DOI: 10.4328/ACAM.20343 Received: 2020-09-11 Accepted: 2020-10-12 Published Online: 2020-11-02 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S96-100
Corresponding Author: Recep Liman, Uşak University, Faculty of Arts and Sciences, Molecular Biology and Genetics Department, 1 Eylül Campus, 64300, Uşak, Turkey. E-mail: email@example.com; firstname.lastname@example.org P: +90 5556214251 F: +90 276 221 21 35 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7944-4952
Aim: This study aimed to assess the effects of pendimethalin herbicide, which has been used for controlling broadleaf weeds and annual grasses for approxi- mately 30 years, on growth and DNA damage in Allium cepa root tips using root growth and the comet assays. Total pendimethalin in A. cepa root tips and the stability of pendimethalin under stress conditions were also determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS).
Materials and Methods: The effective concentration (EC50) value of pendimethalin (50% reduction in root length compared to the negative control group) was found to be approximately 10 mg/L by the Allium root growth inhibition test. The roots were exposed to three different concentrations of pendimethalin (5, 10 and 20 mg/L), distilled water, and 10 mg/L methyl methanesulfonate (MMS) to determine DNA damage by the comet assay and the amount of pendimethalin by LC-MS/MS for different treatment periods (24, 48, 72 and 96 h). The stability profile of pendimethalin under various stress conditions of UV light, acid and base hydrolysis, oxidation, and thermal conditions was also assessed via LC-MS/MS.
Results: All tested concentrations of pendimethalin statistically increased DNA damage and the amount of pendimethalin in A. cepa roots compared to the control group, not only dose-dependently but also time-dependently. Pendimethalin was extremely degraded under thermal, oxidative and basic conditions, and relatively degraded under acidic and UV light conditions.
Discussion: Pendimethalin should be stored and used carefully. Further studies are needed to identify the cytogenotoxic mechanism of pendimethalin at mo- lecular levels and under different forced conditions.
Keywords: Pendimethalin; DNA damage; LC-MS/MS; Forced conditions; Allium cepa
Amid® 330 EC is a liquid emulsified dinitroaniline-type herbicide, whose active ingredient is pendimethalin (330 g/L). Pendimethalin [N-(1-ethylpropyl)-2,6-dinitro-3,4-xylidine] is a pre-emergence herbicide of dinitroaniline used in large field crops including cotton, rice, onion, garlic, soybean, cabbage, peanut and tobacco etc. to control broadleaf weeds and annual grasses . Pendimethalin has been available on the market for about 30 years and ranked third in all of the herbicides behind glyphosate and parquet. Pendimethalin halts cell division and cell elongation in plant cells by inhibiting the microtubule assembly, like other dinitroaniline herbicides, hence preventing the growth of roots and shoots of weeds . It was classified as a persistent bioaccumulative toxic herbicide and a Group C carcinogen (possible human carcinogen) that contaminates the soil and aquatic environments as a consequence of drainage and leaching [3,4]. Herbicides provide effective weed control in agriculture, yet their continuous and excessive use may cause toxicological problems in non-target organisms. Some of the properties of pendimethalin are given in Table 1.
A. cepa root tips have been used for determining the DNA damage of herbicides by the comet assay (single-cell gel electrophoresis) because onions are easy to obtain and store. Root tips can be used independently of mitosis, and few cells are needed for the examination. In addition to these, the comet assay is a relatively inexpensive, fast, reliable, and highly reproducible method [5-7].
LC-MS/MS is extensively used for the qualitative and quantitative analysis of herbicides in environmental samples because it is a fast, simple, effective, and safe method . Stress testing offers detailed information on the pathways for degradation and potential degradation products. The findings of stress tests can then be used to improve production strategies or to choose suitable packaging. Tests carried out under forced conditions show under which conditions a pesticide remains stable and under which conditions it degrades . No previous method was reported regarding the degradation behavior of pendimethalin.
This research aimed to assess the effects of pendimethalin on growth and DNA damage of A. cepa root tips using root growth and the comet assays. LC–MS/MS analysis was also performed for the estimation of total pendimethalin in A. cepa root tips and the stability of pendimethalin under stress conditions.
Material and Methods
Equal-sized (25–30 mm diameter) and healthy A. cepa bulbs and Amid® 330 EC (330 g/L pendimethalin) were obtained from the local market in Uşak and Astranova (Turkey), respectively. MMS,
sodium chloride, ethidium bromide (EtBr), potassium phosphate monobasic, glacial acetic acid, low melting point agarose (LMPA), sodium hydroxide, hydrochloric acid, disodium hydrogen phosphate, Triton X-100, potassium chloride, methanol, formic acid, magnesium chloride hexahydrate, normal melting point agarose (NMPA), trizma hydrochloride, trizma base and EDTA were bought from Sigma Aldrich (Munich, Germany).
Allium root growth inhibition test
The Allium root growth inhibition test was carried out as described by Küçük and Liman  with minor modifications. The outer dry brown layers and roots of the onions were eliminated without destroying the root primordia. Onions bulbs were treated with pendimethalin at increasing concentrations (0.5, 1, 2.5, 5, 10, 25, 50 and 100 mg/L) and distilled water (negative control) in dark at room temperature for 96 hours. Solutions were renewed every 24 hours. The average length of 50 roots from 5 onions per each application was calculated after 96 hours to determine EC50.
Onions were germinated in distilled water for 48 hours until their root lengths reached 2-3 cm. Distilled water (negative control), 5 (1⁄2xEC50), 10 (EC50) and 20 (2xEC50) mg/L of pendimethalin, and 10 mg/L of MMS (positive control) were exposed to Allium roots for 24-96 hours in dark at room temperature. The effect of pendimethalin on DNA damage was studied with minor modifications, as defined by Küçük and Liman . Nuclei were isolated by gently slicing 7 root tips (~1 cm) with a new razor blade in pre-cooled Tris-MgCl2 buffer (0.5% w/v Triton X-100, 0.2 M Tris, 4 mM MgCl2-6H2O, pH 7.5) into a Petri dish kept over an ice base. After filtration, the samples were centrifuged for 7 min at 1200 rpm. Pelleted cells were resuspended for comet analysis, while the supernatant was used with LC-MS / MS for quantitative experiments. Then a (50:50 μL) mixture of 1.5 % LMPA and nuclear suspension was smeared on the pre- coated slides with 1% NMPA at 40 °C with a cover slip. After the samples were left in the ice cassette for 5 min, the coverslips were carefully removed. The slides were incubated at 4 °C for 20 min in a cold electrophoresis buffer (1 mM EDTA and 300 mM NaOH, pH>13), and then electrophoresed under the same conditions at 25 V (0.8 V/cm). The slides were neutralized three times with 0.4 M Tris (pH 7.5) and stained with 70 μL EtBr (20 μg/mL) for 5 min. Randomly 50 comets per each slide were analyzed for determining DNA damage expressed as arbitrary unit (AU) into five categories (0-4) using a TAM-F fluorescence microscope (BAB, Ankara, Turkey) according to Özkan and Liman . Three slides were evaluated for each application. Determination of pendimethalin in A. cepa root meristem cells The supernatants (described above) were used for quantitative analysis of pendimethalin in A. cepa root meristem cells by LC-MS/MS. Agilent 6460 triple quad mass spectrometer was used for the LC-MS/MS analysis. This instrument was equipped with electrospray ionization, operating in positive mode and configuration scan mode monitoring, and multi reaction mode. First, optimized chromatographic conditions (flow rate, column temperature, and mobile phase composition) were found using Zorbax Eclipse Plus C18 (2.1×5 mm, 1.8 μ) column 1 mL/ min, 40 °C and methanol-H2O with 0.1% formic acid (75-25, V/V), respectively. Then mass spectrometric detections were optimized (Table 2). Pendimethalin molecular weight was 282 g/mol. Each application was repeated three times. The constructed calibration curve was found to be linear over the concentration range of pendimethalin (0.00125-0.1 mg/L). The linearity of the calibration curve was confirmed by the high value of the correlation coefficient for pendimethalin (r2=0,9998). The limit of detection, the limit of quantitation, and relative standard deviation % values were calculated as 0.05595, 0.0965, and 1.6375 μg/L, respectively.
Forced Degradation Studies
The experimental conditions were analyzed according to the guidelines for stability testing of new drug substances and products of the International Council for Harmonization of Technical Criteria for Pharmaceuticals for Human Use with minor modifications. Forced degradation studies were performed under stress conditions of UV light, thermal, oxidation, acid and base hydrolysis to evaluate the stability of pendimethalin using the optimized method as described above for LC-MS/MS. The pendimethalin stock solution (100 mg/L, 1 mL) was transferred to a 10 mL flask and 9 mL of 0.1 and 1MHClor0.1and1MNaOHor3%and30%ofH2O2 (V/V) was added for 30 min at 80 °C. Pendimethalin stock solution was diluted to 10 mg/L with distilled water for the thermal and UV studies. The diluted solution was exposed to UV light (254 nm) in a UV cabinet at room temperature for 6 and 24 hours and heat for 6 and 24 hours in an incubator (100 °C) for UV and thermal degradations, respectively. Each application was repeated three times.
The results (mean ± standard deviation) were analyzed with One-Way Analysis of Variance (ANOVA) and Duncan multiple range tests at p≤0.05 using IBM SPSS Statistics for Windows (version 23). Dose-response and dose-time relationships of pendimethalin were also determined with Pearson correlation analysis at p=0.01 significance level.
Pendimethalin decreased root growth within the range from 22.1% (0.5 mg/L) to 91.2% (100 mg/L) dose-dependently (r=- 0.965) compared to the control group. The EC50 of pendimethalin was found to be approximately 10 mg/L (49.57 %) by Allium root growth inhibition test (Figure 1).
The effect of pendimethalin on DNA damage using the comet assay on A. cepa roots is shown in Figure 2. All concentrations of pendimethalin statistically increased DNA damage between 68.67±5.03 and 136.33±2.52 Arbitrary Unit compared to the control group, not only dose-dependent (for 24 hours r=0.984, for 48 hours r=0.979, for 72 hours r=0.969, and for 96 hours r=0.924) but also time-dependent (for 5 mg/L r=0.986, for 10 mg/L r=0.964, and for 20 mg/L r=0.937). LC-MS/MS, which enables analysis in μg/L degree is samples, is suitable for both trace residue analysis in the samples and the analysis of the products obtained as a result of the degradation study. Figure 3a shows quantitative analysis of pendimethalin in A. cepa roots by LC-MS/MS. The amount of pendimethalin increased from 0.13±0.04 to 4.9±0.42 μg/L dose (for 24 hours, r=0.926, for 48 hours, r=0.916, for 72 hours, r=0.804, and for 96 hours, r=0.949) and time (for 5 mg/L r=0.895, for 10 mg/L r=0.884, and for 20 mg/L r=0.838) dependently.
The stability of pendimethalin under stress conditions (UV light, acidic and base hydrolysis, oxidation and thermal) was investigated by LC-MS/MS. Pendimethalin was chemically unstable under all stress conditions tested (Figure 3b). The extent of degradation strictly depended on the different experimental conditions. The percentage of pendimethalin degradation for UV light reached 35.98% and 17.37% for 24 and 6 hours, respectively. When treated thermally at 100 °C in an incubator, pendimethalin was most unstable during 6 and 24 hours, recording 67.31% and 70.3% degradation percentages, respectively. After 30 min exposure to H2O2, pendimethalin showed 43.61 and 46.33% degradation for 3% and 30% H2O2. Under basic stress conditions, degradation occurs more rapidly than under acidic stress conditions.
The percentage of the recommended dose (7.5 mL/L) of pendimethalin at EC50 was found 0.16% for A. cepa after 96 hours . Inhibition of root length was also observed on A. cepa treated with pendimethalin at 0.033, 0.044, 0.055 and 0.066 g/kg soil for 7 to 45 days  and at 0.033, 0.066, 0.099, 0.132 and 0.264 g/L for 48 hours  compared to control group. Reduction of root growth was also observed in Tradition azalea exposed to pendimethalin for 4 and 8 weeks . Yield in Oryza sativa seedlings was decreased with pendimethalin rate increased from 800 to 1600 g ai ha−1 .
Similar to our results, pendimethalin induced DNA damage observed by the comet assay on Chinese hamster ovary cells , on Channa punctatus blood, liver, and gill cells , on Chinese hamster lung fibroblast cells and on human peripheral lymphocytes , on Oreochromis niloticus liver and gills tissues , on human lymphocytes, rat bone-marrow and rat peripheral blood mononuclear cells  and on Biomphalaria alexandrina snails for 48 hours at a concentration of 1.299 mg/L . The DNA damage could be attributed to oxidative stress generated by pendimethalin exposure via the generation of reactive oxygen species leading to inhibition of antioxidant enzymes, as well as causing lipid peroxidation and carbonylation of proteins, etc. [21,22]. Pendimethalin was also observed in honeybees at 75 μg/L  and in eggs at 88.1 μg/L with LC-MS/MS . The results of the present study confirmed cytogenotoxic effects of pendimethalin by reducing root growth and DNA damage in A. cepa roots. The amount of pendimethalin in A. cepa increased dose and time dependently. Forced degradation studies of pendimethalin have not previously been described. Pendimethalin was extremely degraded under thermal, oxidative and basic conditions, and relatively degraded under acidic and UV light conditions. Therefore, forced conditions should be taken into consideration during the use and storage of pendimethalin. In addition, more research should be performed to establish pendimethalin’s cytogenotoxic function at molecular levels and different forced conditions.
The authors thank Usak University, Scientific Analysis Technological Application and Research Center (UBATAM) for LC-MS/MS analysis.
Scientific Responsibility Statement
Animal and human rights statement
Funding: This work was partially funded by the Scientific and Technological Research Council of Turkey (TUBITAK) 2209-A-Research Project Support Programme for Undergraduate Students (1919B01100255).
Conflict of interest
1. Hamed HS, El-Sayed YS. Antioxidant activities of Moringa oleifera leaf extract against pendimethalin-induced oxidative stress and genotoxicity in Nile tilapia, Oreochromis niloticus (L.). Fish Physiol Biochem. 2019;45(1):71-82.
2. Vighi M, Matthies M, Solomon KR. Critical assessment of pendimethalin in terms of persistence, bioaccumulation, toxicity, and potential for long-range transport. J Toxicol Environ Health B Crit Rev. 2017;20(1):1–21.
3. U.S. Environmental Protection Agency (US-EPA) Reregistration Eligibility Decision (RED)- Pendimethalin List A Case 0187. Washington D.C: US EPA- National Service Center for Environmental Publications (NSCEP); 1997.p.1-227.
4. Tabassum H, Afjal MA, Khan J, Raisuddin S, Parvez S. Neurotoxicological assessment of pendimethalin in freshwater fish Channa punctate. Bloch Ecol Indic. 2015;58:411–17.
5. Liman R, Acikbas Y, Ciğerci İH. Cytotoxicity and genotoxicity of cerium oxide micro and nanoparticles by allium and comet tests. Ecotoxicol Environ Saf. 2019;168:408-14.
6. Küçük D, Liman R, Cytogenetic and genotoxic effects of 2-chlorophenol on Allium cepa L. root meristem cells. Environ Sci Pollut. 2018;25(36):36117-23.
7. Özkan S, Liman R. Cytotoxicity and genotoxicity in Allium cepa L. root meristem cells exposed to the herbicide penoxsulam. Celal Bayar Üniv Fen Bilim Derg. 2019;15(2):221-6.
8. Petrie B, Muñoz MDC, Martín J. Stereoselective LC–MS/MS methodologies for environmental analysis of chiral pesticides. Trac-Trend Anal Chem. 2019;110;249- 58.
9. Patel DK, Swami B, Rajawat TL. Development and validation of stability indicating UPLC method for simultaneous quantification of imidacloprid, carboxin and captan in pesticide formulation. IJRAR. 2018;5(2):1278-85.
10. Promkaew N, Soontornchainaksaeng P, Jampatong S, Rojanavipart P. Toxicity and genotoxicity of pendimethalin in maize and onion. Kasetsart J (Nat Sci). 2010;44:1010-15.
11. Verma S, Srivastava A. Morphotoxicity and cytogenotoxicity of pendimethalin in the test plant Allium cepa L. A biomarker based study. Chemosphere. 2018;206:248-54.
12. Tylicki A, Kowalska-Wochna E, Ościłowicz A, Ilasz R. Mitodepressive and cytotoxic effects of short-term exposure to relatively small doses of pendimethalin evaluated by allium test. Pol J Environ Stud. 2010;19(1):193–9.
13. Derr JF, Simmons LD, Pendimethalin influence on azalea shoot and root growth. J Environ Hortic. 2006;24(4):221-5.
14. Ahmed S, Chauhan BS. Efficacy and phytotoxicity of different rates of oxadiargyl and pendimethalin in dry-seeded rice (Oryza sativa L.) in Bangladesh. Crop Prot. 2015;72:169-74.
15. Patel S, Bajpayee M, Pandey AK, Parmar D, Dhawan A. In vitro induction of cytotoxicity and DNA strand breaks in CHO cells exposed to cypermethrin, pendimethalin and dichlorvos. Toxicol In Vitro. 2007;21(8):1409-18.
16. Ahmad I, Ahmad M, Fresh water fish, Channa punctatus, as a model for pendimethalin genotoxicity testing: A new approach toward aquatic environmental contaminants. Environ Toxicol. 2016;31(11):1520-9.
17. Kılıç ZS, Aydın S, Bucurgat ÜÜ, Başaran N. In vitro genotoxicity assessment of dinitroaniline herbicides pendimethalin and trifluralin. Food Chem Toxicol. 2018;113:90-8.
18. El-Sharkawy NI, Reda RM, El-Araby IE. Assessment of Stomp® (Pendimethalin) toxicity on Oreochromis niloticus. J Am Sci. 2011;7(10):568-76.
19. Ansari SM, Saquib Q, Attia SM, Abdel-Salam EM, Alwathnani HA, Faisal M, et al. Pendimethalin induces oxidative stress, DNA damage, and mitochondrial dysfunction to trigger apoptosis in human lymphocytes and rat bone-marrow cells. Histochem Cell Biol. 2018;149(2):127-41.
20. Ibrahim AM, Ahmed AK, Bakry FA, Rabei I, Abdel-Ghaffar F. Toxicological impact of butralin, glyphosate-isopropylammonium and pendimethalin herbicides on physiological parameters of Biomphalaria alexandrina snails. Molluscan Res. 2019 ;39(3): 224-33.
21. Tabassum H, Ashafaq M, Khan J, Shah MZ, Raisuddin S, Parvez S. Short term exposure of pendimethalin induces biochemical and histological perturbations in liver, kidney and gill of freshwater fish. Ecol Indic. 2016;63:29-36.
22. Ahmad MI, Zafer MF, Javed M, Ahmad M. Pendimethalin-induced oxidative stress, DNA damage and activation of anti-inflammatory and apoptotic markers in male rats. Sci Rep. 2018;8(1):1-9.
23. Kiljanek T, Niewiadowska A, Semeniuk S, Gaweł M, Borzęcka M, Posyniak A. Multi-residue method for the determination of pesticides and pesticide metabolites in honeybees by liquid and gas chromatographycoupled with tandem mass spectrometry—Honeybee poisoning incidents. J Chromatogr A. 2016;1435:100-14.
24. Zhang X, Song Y, Jia Q, Zhang L, Zhang W, Mu P, Qiu J. Simultaneous determination of 58 pesticides and relevantmetabolites in eggs with a multi- functional filter by ultra-highperformance liquid chromatography-tandem mass spectrometry. J Chromatogr A. 2019;1593:81-90.
Download attachments: 10.4328_ACAM.20343
Büşra Taşdemir, Recep Liman, Süleyman Gökçe, Eslem Amaç, İbrahim Hakkı Ciğerci, Safiye Elif Korcan. Cytogenotoxic and forced degradation studies of pendimethalin using root growth, comet assay and LC-MS/MS. Ann Clin Anal Med 2021;12(Suppl 1): S96-100
Factors affecting the length of hospitalization after elective spinal surgery
Sezgin Bahadır Tekin 1, H. Bahadır Gökçen 2, Bahattin Kemah 3, Çağatay Öztürk 4
1 Department of Orthopedics, 25 Aralık State Hospital, Gaziantep, 2 Department of Orthopedic Surgery, Medicalpark Bahçelievler Hospital, Istanbul, 3 Department of Orthopedic Surgery, Umraniye Education and Research Hospital, Istanbul, 4 Department of Orthopedic Surgery, Istinye University Liv Hospital Ulus Istanbul, Turkey
DOI: 10.4328/ACAM.20344 Received: 2020-09-12 Accepted: 2020-10-26 Published Online: 2020-10-30 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S101-104
Corresponding Author: Sezgin Bahadır Tekin,Department of Orthopedics, 25 Aralık State Hospital, Gaziantep, Turkey. E-mail: email@example.com P: +90 5317916686 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4740-9949
Aim: In this study, it was aimed to investigate the factors affecting the length of hospital stay of patients who underwent elective spinal surgery.
Material and Methods: A total of 120 patients who underwent elective spinal surgery between 2015 and 2018 were included in the study (29 men and 91 women). The mean age of the patients was 62.2 (Mean+/-13.9 SD) years. For each patient, data such as preoperative hemoglobin and albumin levels, age, gender, instrumentation level, revision surgery, preoperative anticoagulant use, duration of surgery, and bleeding volume were recorded.
Results: Among the 120 patients participating in the study, 31 underwent revision surgery and 89, primary surgery. Statistically significant correlation was found between age and length of hospital stay (p=0.001), between instrumentation level and length of stay (p<0.001), between preoperative albumin level, blood loss and length of stay (p<0.001). There was a moderate and statistically significant correlation between the duration of the operation and the length of hospitalization (p<0.001). There was no statistically significant correlation between preoperative hemoglobin levels and length of hospitalization (p=0.247).
Discussion: There are many modifiable and unchangeable factors that affect the length of hospital stay after elective spinal surgery. By evaluating these fac- tors preoperatively, the length of hospitalization can be estimated.
Keywords: Elective spinal; Spine; Length of stay; Blood; Spine surgery
Postoperative morbidity rates are high for patients undergoing spinal surgery, and for those who undergo thoracolumbar surgery, the morbidity ranges from 17.8% to 20.4% . Traditionally, the risk of developing postoperative complications has been highly dependent on the patient’s additional comorbidities . The development of postoperative complications has many consequences, one of which is a prolonged hospital stay. Increased duration of hospitalization leads to an increase in costs . Due to prolonged hospital stays, rehabilitation programs are required after elective spinal surgeries, and some additional problems may be encountered, resulting in additional burdens to the healthcare system . Many medical factors influence the length of hospital stay after spinal surgery, and extended hospital stays are known to have socioeconomic consequences .
With the advances in spinal procedures, the number of cases overall as well as complicated cases undergoing spinal surgery has increased (complication rates rose from 1.3 to 19.9 per 100,000 population receiving Medicare in the United States) . Higher complication rates than in other types of surgeries, relatively advanced age of the patients having a degenerative diseases, and a higher risk of complications such as bleeding during the procedure are some of the problems associated with spinal surgery, which increase the duration of hospitalization . There are many factors that affect hospitalization time, such as age, gender, ASA score, Oswestry Disability index, fusion level, increased operation time, and medical comorbidities [8, 9]. Therefore, the length of hospital stay after elective spine surgery can be affected by many factors.
In this study, we hypothesize that the length of hospitalization is affected by many factors that could be changed or not. In our study, we aimed to evaluate some of the parameters that could be easily obtained preoperatively and may affect the length of hospital stay after spinal surgery. For this purpose, parameters such as preoperative hemoglobin and albumin levels, level of instrumentation, duration of surgery, the volume of blood loss, gender, and preoperative anticoagulant use were evaluated. The extent to which each parameter affects the length of hospital stay was investigated.
Material and Methods
A total of 120 patients who underwent elective spinal surgery were included in the study (29 men and 91 women) between the years 2015-2018. This is a single-center study and all patient data were taken from our hospital achieves and analyzed retrospectively. The patients who were operated on urgently, who had additional injuries or additional surgical procedures and those whose data about the hospitalization process were not found were excluded from the study. All surgery procedures were open procedures, closed procedures were excluded from the study. All the patients were categorized according to the surgery type into revision and primary spinal surgery procedures. Preoperative hemoglobin and albumin levels, age, gender, instrumentation level, revision surgery, preoperative anticoagulant use, operation duration, the volume of blood loss during the operation, and comorbid diseases were recorded for each patient. The statistical correlation between these parameters and the length of hospital stay was calculated. All surgical procedures were performed by a single surgeon. The distribution of the levels of posterior instrumentation applied to the patients is shown in Table 1. The design and protocol of this retrospective study were approved by the Institutional Review Board of the local ethics committee.
The normality of the distribution of continuous variables was analyzed by the Shapiro-Wilks test. Binary comparison of the independent and non-normally distributed variables was carried out by the Mann-Whitney U test. The SPSS 22.0 Windows software was used for all statistical analyses. A p-value of less than 0.05 was considered statistically significant.
Among the 120 patients participating in the study, 31 underwent revision surgery and 89, primary surgery. The average levels of preoperative hemoglobin and albumin were 12.5 g/dL and 4.1 g/dL respectively. The average age of the participants was 62.2 (+/-13.9) years.
The volume of blood loss was calculated during each procedure and the mean volume was 540.6 mL (range: 100–1100 mL). Preoperative anticoagulant usage was reported for only 14 patients (11.7%). Associated comorbid diseases were found in 62 of the 120 patients. The comorbid diseases were hypertension, cardiovascular disease, diabetes mellitus. The median duration of postoperative hospital stay was 8.1 days (range: 2–30 days).
According to the results of statistical interpretation of our data, length of hospital stay was found to be significantly correlated with the following parameters: age (weak correlation; p = 0.001), level of instrumentation (strong correlation; p < 0.001), preoperative albumin level (weak, negative correlation; p < 0.001), duration of surgical procedure (moderate correlation; p < 0.001), and amount of blood loss during surgery (moderate correlation; p < 0.001). Preoperative hemoglobin level was not found to be correlated with hospitalization duration (p = 0.247) (Table 2).
The average hospitalization duration was statistically analyzed with regard to gender, whether the procedure was a revision surgery or not, whether the patient had other comorbidities, and the presence of anticoagulant medication; male patients undergoing revision surgery, patients with accompanying comorbidities, and patients on anticoagulant medication had significantly longer hospital stays than females patients, patients without any comorbid conditions, and patients who did not use any anticoagulant, respectively (Tables 3).
In this study we found that length of hospitalization is correlated with age, level of instrumentation, preoperative albumin level, duration of surgical procedure and amount of blood loss during surgery. In previous studies, many preoperative factors have been found to result in prolonged hospital stay, such as age, ASA scores, high BMI, gender, opioid use, inoperative complications, and postoperative complications . In addition, cardiac, pulmonary, and urinary complications can also lead to a prolonged hospital stay. On the other hand, intraoperative factors such as prolonged operation time , blood transfusion , emerging adverse complications, and drain use [13,14] may result in long hospitalization duration. In another study with 5803 patients, aged over 60 years, an ASA score higher than two and operation time longer than four hours were found to be associated with increased risk of complications .
The other study in the literature has examined how pre- and perioperative values affect the length of hospital stay. Zheng et al. retrospectively analyzed 112 patients who had undergone revision lumbar decompression surgery and found that only patient age was a significant risk factor . In a study by Leu S., preoperative laboratory values were found to be directly related to postoperative complication rates and prolonged hospital stay . Spinal surgery procedures are complex procedures associated with high rates of perioperative complications. Approximately 2.3% of these complications occur after spinal decompressions and 5.6%, after other complex surgeries. In our study, as the number of instrument levels increased, the length of hospital stay increased, which is suggestive of the fact that as the complexity of the surgical procedure increases, the duration of hospitalization also increases.
In our study, intraoperative variables such as bleeding amount and duration of surgery were found to affect patients’ postoperative hospital stay. However, it has been found that hemoglobin and albumin levels, which can be modified in the preoperative period, do not affect the duration of hospitalization significantly.
Postoperative hospitalization is costly and longer stays result in an economic burden both on the insurance system and social healthcare system . The average surgical cost for multilevel fusions can exceed $100,000, and lower complication rates and shorter hospital stay may provide a means for reducing this high cost . In our study, although we did not address the costs, we believe that the financial burden of long hospital admission is a very important issue.
In our study, factors affecting postoperative hospitalization duration such as age, comorbidities, preoperative hemoglobin and albumin levels, type of procedure (i.e. revision or primary surgery), number of instrument levels, operation duration, gender, and volume of blood loss were investigated individually. When the relationship between preoperative hemoglobin and albumin levels and hospitalization duration was evaluated, the albumin level showed a low level of correlation, and hemoglobin value showed no correlation with the length of hospital stay. On the other hand, in a study involving 1187 patients conducted by Khanna et al., preoperative anemia was found to increase hospitalization duration .
Regarding non-modifiable factors such as age and gender, it was found that age had a weak correlation with the duration of hospitalization, but male patients had a longer hospital stay than female patients. In a study conducted by De la Garza- Ramos et al., it was found that patients aged over 65 years had a longer hospital stay after posterior cervical surgery than those aged below 65 years .
Information regarding the use of preoperative anticoagulants is available in the literature  Subcutaneous heparin (i.e. BID or TID) and low-molecular-weight heparin preparations should be stopped 8–10 hours and 24 hours before the operation, respectively. Other fibrinolytic medications should be discontinued at least 48 hours preoperatively . Concurrent diseases can be problematic, and patients should be informed about the risks related to their accompanying conditions. Park JH. et al. showed that the amount of bleeding significantly differed between the patients in whom aspirin was stopped 3–7 days and 7–10 days before the operation .
Revision surgeries are more complicated than primary spinal surgery operations. After revision spinal surgeries, high complication rates and prolonged operation times may be indicative of the length of hospital stay. In our study, the duration of hospital stay of the patients who underwent revision surgery was found to be longer than that of patients who underwent primary surgery.
There are a number of limitations in our study. Our study sample had a wide clinical diversity, including patients undergoing deformity surgery, degenerative surgery, and revision surgery, indicating a level of heterogeneity. Another limitation was that the infection parameters were not evaluated. Postoperative infections are serious complications that cause high morbidity in spinal surgery cases; we think that infection parameters should be considered in future studies. Another limitation was that the BMI, tobacco usage, ASA scores of the patients and their effect on hospitalization duration was not assessed in our study. In addition, opioid is reported to affect the length of hospital stay, but opioid use was not considered in our study. Finally, although accompanying comorbidities are known to prolong hospital stay, we did not include these diseases in our study.
There are many factors that affect hospitalization after elective spinal surgery. Length of hospital stay was found to be significantly correlated with the following parameters: age, level of instrumentation, preoperative albumin level, duration of surgical procedure and amount of blood loss during surgery
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Nasser R, Yadla S, Maltenfort MG, Harrop JS, Anderson DG, Vaccaro AR, et al. Complications in spine surgery. J Neurosurg Spine. 2010; 13(2):144–57.
2. Schoenfeld AJ, Carey PA, Cleveland III AW, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013; 13(10):1171–9.
3. Missios S, Bekelis K. Hospitalization cost after spine surgery in the United States of America. J Clin Neurosci. 2015; 22(10):1632–7.
4. McGirt MJ, Parker SL, Chotai S, Pfortmiller D, Sorenson JM, Foley K, et al. Predictors of extended length of stay, discharge to inpatient rehab, and hospital readmission following elective lumbar spine surgery: introduction of the Carolina- Semmes Grading Scale. J Neurosurg Spine. 2017; 27(4):382–90.
5. Mai, D, Brand C, Haschtmann D, Pirvu T, Fekete TF, Mannion AF. Non-medical factors significantly influence the length of hospital stay after surgery for degenerative spine disorders. Eur Spine J. 2019; 16:3–5.
6. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spine stenosis in older adults. JAMA 2010; 303(13):1259–65.
7. Zhan H, Guo R, Xu H, Liu X, Yu X, Xu Q, et al. Hospital length of stay following first-time elective open posterior lumbar fusion in elderly patients: a retrospective analysis of the associated clinical factors. Medicine. 2019; 98(44):17740.
8. Gruskay JA, Fu M, Bohl DD, Webb ML, Grauer JN. Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis. Spine J. 2015; 15(16):1188–95.
9. Wadhwa RK, Ohya J, Vogel TD, Carreon LY, Asher AL, Knightly JJ. Risk factors for 30-day reoperation and 3- month readmission: analysis from the Quality and Outcomes Database lumbar spine registry. J Neurosurg Spine. 2017; 27:131–6.
10. Pakzad H, Thevendran G, Penner MJ, Qian H, Younger A. Factors associated with longer length of hospital stay after primary elective ankle surgery for end- stage ankle arthritis. J Bone Joint Surg Am. 96(1):32–9.
11. Gruskay, JA, Fu M, Bohl DD, Webb ML, Grauer JN. Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis. Spine J. 2015; 15(6):1188–95.
12. Basques BA, Varthi AG, Golinvaux NS, Bohl DD, Grauer JN. Patient characteristics associated with increased postoperative length of stay and readmission after elective laminectomy for lumbar spinal stenosis. Spine. 2014; 39(10):833–40.
13. Street JT, Lenehan BJ, DiPaola CP, Boyd MD, Kwon BK, Paquette SJ, et al. Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients. Spine J. 2012; 27:818–24.
14. Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine. 2008; 33:E543–7.
15. Leu S, Kamenova M, Mehrkens A, Mariani L, Schären S, Soleman J. Preoperative and Postoperative Factors and Laboratory Values Predicting Outcome in Patients Undergoing Lumbar Fusion Surgery. World Neurosurg. 2016; 92:323–38.
16. Medlineplus Medical Encyclopedia. Health care financing trends. Health Care Financ Rev. 2013; 9:127–32.
17. Khanna R, Harris D, McDevitt J, Fessler R, Carabini L, Lam S, et al. Impact of Anemia and Transfusion on Readmission and Length of Stay After Spinal Surgery: A Single-center Study of 1187 Operations. Clinical Spine Surgery. 2017; 30(10):E1338–42.
18. De la Garza-Ramos R, Goodwin CR, Abu-Bonsrah N, Jain A, Miller EK, Neuman BJ, et al. Prolonged length of stay after posterior surgery for cervical spondylotic myelopathy in patients over 65 years of age. J Clin Neurosci. 2016; 31:137–41.
19. Park J, Ahn Y, Choi B, Choi KT, Lee K, Kim S, et al. Antithrombotic Effects of Aspirin on 1- or 2-Level Lumbar Spinal Fusion Surgery: A Comparison Between 2 Groups Discontinuing Aspirin Use Before and After 7 Days Prior to Surgery. Spine. 2013; 38(18):1561–5.
20. Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 43(3):225–62.
21. Lee NJ, Kothari P, Kim JS, Shin JI, Phan K, Di Capua J, et al. Early complications and outcomes in adult spinal deformity surgery: an NSQIP study based on 5803 patients. Global Spine J. 2017; 7(5):432–40.
22. Raman T, Nayar SK, Liu S, Skolasky RL, Kebaish KM. Cost-effectiveness of primary and revision surgery for adult spinal deformity. Spine. 2018; 43(11):791– 7.
23. Zheng F, Cammisa FP Jr, Sandhu HS, Girardi FP, Khan SN. Factors predicting hospital stay, operative time, blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation. Spine. 2002; 27(8):818–24.
Download attachments: 10.4328_ACAM.20344
Sezgin Bahadır Tekin, H. Bahadır Gökçen, Bahattin Kemah, Çağatay Öztürk. Factors affecting the length of hospitalization after elective spinal surgery. Ann Clin Anal Med 2021;12(Suppl 1): S101-104
Endoscopic thoracic sympathectomy: Early, mid-term and late outcomes and patient satisfaction
Murat Kuru, Tamer Altinok
Department of Thoracic Surgery, Necmettin Erbakan University, Medical Faculty of Meram, Konya, Turkey
DOI: 10.4328/ACAM.20346 Received: 2020-09-17 Accepted: 2020-10-20 Published Online: 2020-11-05 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S105-109
Corresponding Author: Murat Kuru, Department of Thoracic Surgery, Necmettin Erbakan University, Medical Faculty of Meram, Hocacihan Mah. Abdulhamid Han Cad. No:3 42080, Konya, Turkey. E-mail: firstname.lastname@example.org GSM: +90 5053214799 P: +90 3322234070 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8680-547X
Aim: This study presents the outcomes and patient satisfaction after endoscopic thoracic sympathectomy (ETS) applied to patients unresponsive to medical treatment.
Material and Methods: Sixty-one patients who underwent ETS for axillary/palmar hyperhidrosis from June 2010 to June 2019 were retrospectively evaluated. Data were collected from patient charts and files. Patient satisfaction and preoperative and postoperative changes in patient’s social lives were assessed over the phone.
Results: The mean age of the included 61 patients was 23.2±5.63 years, the mean length of the postoperative follow-up period was 27.3 months. Moderate- severe compensatory hyperhidrosis was observed in 2 patients. A significant majority of patients were satisfied with the surgery and they stated that would recommend it to others. The loss of self-confidence in the preoperative period was significantly restored in the postoperative period.
Discussion: ETS with the incision of the sympathetic chain at the T3-T4 level is associated with significant reductions in pain severity and compensatory hyper- hidrosis and with significant patient satisfaction in the postoperative period. It should always be remembered that the likelihood of developing compensatory hyperhidrosis is high in patients over 30 years of age and that it occurs after the first postoperative month.
Keywords: Hyperhidrosis; Sympathectomy; ETS; Compensatory hyperhidrosis
Focal hyperhidrosis is a condition most commonly seen on the palm, armpits, face, and feet. The etiology of this condition has not been fully understood yet. Focal hyperhidrosis is aggravated by stress besides other physiological factors. The incidence of focal hyperhidrosis is around 1% and it is more common in young people in the population. This condition adversely affects the work and daily lives of patients . Topical treatments, botulinum toxin injections, and the excision of the sweat glands are primarily attempted in focal hyperhidrosis but successful outcomes cannot often be achieved. While surgical treatment for these diseases was performed with thoracotomy previously, advances in technology and endoscopic techniques have allowed performing thoracic sympathectomy with videothoracoscopy. Thoracoscopic sympathectomy is most commonly used for focal hyperhidrosis followed by facial blushing and Buerger’s and Raynaud’s diseases. This technique is less painful and allows for returning to work early. Endoscopic Thoracic Sympathectomy (ETS) performed by cauterization or clipping is the most effective surgical intervention in the treatment of focal hyperhidrosis . Also, this thoracoscopy-assisted surgery is associated with significantly less postoperative pain, short hospital stay, early return to work, and favourable aesthetic results. Although the outcomes of ETS are very good, the leading factors associated with poor patient satisfaction are compensatory hyperhidrosis (CH) and recurrences developing in some patients. Moreover, Horner Syndrome, prolonged air leak, and other general complications of surgery reduce patient satisfaction after the intervention.
In this study, we evaluated 61 patients who underwent ETS in the period from June 2010 to June 2019 using retrospective patient chart and file reviews and assessments over the phone.
Material and Methods
This study included 61 patients comprising 30 females and 31 males in the age range of 16-41 years, who did not respond to medical therapy, and who underwent ETS for the treatment of axillary/palmar hyperhidrosis at Necmettin Erbakan University, Medical Faculty of Meram and Omer Halisdemir University, Training and Research Hospital in the period from June 2010 to June 2019. Ethical approval was received from Omer Halisdemir University, Training and Research Hospital, Ethics Committee(Number: 2019/36) before the study started. A written informed consent was obtained from each participant. Chest X-rays were performed in all patients to exclude secondary causes. Blood samples of the patients were tested for hemogram, biochemical parameters, and thyroid functions. Patient consent was obtained provided that verbal and written information was provided to the patients about the possible outcomes and potential untoward effects of the operation before the surgery. Patient data and detailed information about the surgery that these patients underwent were collected by reviewing the patient files and charts. The outcomes of the surgery were assessed at outpatient clinic follow-up visits and by calling the patients over the phone (Table 1). The patients were evaluated by demographic data, the length of hospital stay, anaesthesia and surgery techniques, the length of the follow- up period, recurrences, complications, and patient satisfaction.
CH was graded as mild, moderate, or severe. Mild CH was defined as sweating that the formed sweat did not flow and no needs occurred to change clothes. Moderate CH was defined as sweating that did not require changing clothes, but the formed sweat coalesced into droplets that flowed. Nevertheless, it did not embarrass the patient despite being uncomfortable. Intense CH was defined as sweating with sweat droplets flowing profusely, necessitating a change of clothes one or more times a day. Hand dryness in the postoperative period was scored relative to a point of 10, which was arbitrarily attributed as the score of preoperative sweating. The first 30 days after the surgery was defined as the early term, the period between the first month of surgery to the 12th month was defined as the mid-term, and the period after the 12th month of surgery was defined as the long-term. Statistical analysis was performed using SPSS version 15.0 software. The study was conducted in compliance with the principles of the Declaration of Helsinki. Surgical Technique
After the single- or double-lumen intubation with the administration of general anaesthesia, patients were brought to the Semi-Fowler’s position. Then, the video-thoracoscopic surgery started. Thoracic sympathectomy was performed on the patients in the same or different sessions by thoracic surgeons. Access to the thorax was established by placing two or three 5 mm ports in the axillary region. Thoracic sympathectomy was carried out by cauterizing or clipping the sympathetic chain at different levels. Peripheral body temperature was measured in the preoperative and postoperative period in a group of patients. After the operation, the free air in the thorax was aspirated using an aspirator catheter, an underwater sealed drainage system was established, and the tubes were withdrawn at the end of the operation. After the extubation, the patients were transferred to the intensive care unit or to the inpatient ward. Appropriate analgesic, bronchodilator, and oxygen therapy were started. Chest x-rays and routine blood tests were performed in the first postoperative hour and before the hospital discharge. After the hospital discharge, the patients were evaluated via physical examination and chest X-rays at follow-up visits scheduled at regular intervals.
ETS was performed on 61 patients (30 females, 31 males). The mean age of the patients was 23.2±5.63 (16-41) years, the average height was 169.2±7.9 cm, and the mean body weight was 64.9±8.9 kg. Fifty-six patients were single and 5 were married. Twenty-eight patients were students and 36 patients were university graduates. Hyperhidrosis in first-degree relatives and second-degree relatives was found in 4 and 10 patients, respectively (Table 2). Two patients had psychiatric disorders, two had a goitre, one had polycystic kidney failure, and one had a substance use disorder. The mean length of postoperative hospital stay was 1.59±2.1 days (1-16 days). The mean length of the postoperative follow-up period was 27.3±24.8 (7-113) months. Fifty-seven patients had no history of previous thoracic surgery. Following the administration of general anaesthesia, single- and double-lumen intubation was performed in 31 and 30 patients, respectively. Videothoracoscopic surgery was performed in the axillary region via two 5 mm ports (3 ports in a total of 7 interventions). A sympathetic blockade was performed by clipping in only one patient. The remaining 60 patients underwent sympathetic nerve cauterization. ETS was performed bilaterally in the same session on 57 patients for focal hyperhidrosis. The procedure was performed in two different sessions due to preoperative and intraoperative bradycardia each occurring in 2 patients. Forty- eight patients had palmar/axillary hyperhidrosis (Figure 1). One patient underwent emergency thoracotomy due to bleeding during left sympathectomy and 1 patient underwent axillary thoracotomy due to pleural adhesion. Pleural adhesion was observed intraoperatively in 10 patients. Partial pneumothorax was observed on the left in three patients and on the right in two patients on chest X-rays. Three of these patients were treated by tube thoracostomy. Persistent air leak due to right pleural adhesion occurred in a patient with severe substance use disorder. This patient was treated with tube thoracostomy and no further need emerged for major surgery. Intense CH developed in one patient and moderate CH developed in another patient. Eleven patients developed mild CH. It was observed that CH developed most commonly in the trunk and in the period between the 1st and 60th month after surgery. CH developed only in one (6%) out of 15 patients aged 10-19 years, in 8 (21%) out of 37 patients aged 20-29 years, and in 4 out of 8 patients aged 30-39 years. It was observed that the patient who developed severe CH, underwent sympathectomy at the level of T2-3-4. Recurrences were mild in 3 patients and intense in one patient. They occurred in the first 12th months after the surgery. Sympathectomy was at the T3-4 level in 50 patients, at the level of T2-3-4 in 10 patients. Another patient underwent partial T4 sympathectomy on the left side because of vascular adhesion. Kuntz nerve cauterization was performed in all patients. The patients had presented most commonly to the outpatient clinic of the department of thoracic surgery (N: 47). It was observed that the patients became aware of the operation via social media (N: 35). Forty-two o patients who underwent surgery were highly satisfied, 16 were satisfied, and 2 were moderately satisfied. Only one patient reported dissatisfaction with the outcomes of the surgery (Table 3). A significant majority of patients were satisfied with the surgery and they stated that would recommend it to others. Spicy hot food did not aggravate sweating in 50 patients. The loss of self-confidence in the preoperative period was significantly restored in the postoperative period. The 10/10 severity of preoperative hyperhidrosis was found to be 0.9/10 in the postoperative period.
Hyperhidrosis is a condition that was recognized in the past; however, the advances, especially in the fields of medicine such as anatomy and physiology, continue to lead to many hypotheses to identify the factors causing this disorder. Hyperhidrosis was present in the family members of every fifth patients in our study. The cause of hyperhidrosis has not been explained completely yet but it is a disorder characterized by the hyperactivity of the sympathetic nervous system, affecting human life and impairing the quality of life. This has led the researchers to look for different treatment options. Previous studies have reported that thoracic sympathectomy was performed by severing the sympathetic chain at more than one level. Owing to the rapid advances in technology and medicine, high success and satisfaction rates have been observed with videothoracoscopy. Despite the advances in surgical techniques, CH remains to be the most untoward condition faced by the patient and physician in the postoperative period. Moreover, the aetiology of CH has not been clarified yet. A study comparing the outcomes of unilateral/bilateral sympathectomy reported that, compared to bilateral ETS performed in a single session, the likelihood of developing CH was lower in unilateral ETS surgery performed at one side in a session (19% vs 4%) . Another study compared the risk of developing CH by the level of sympathectomy and reported that T4 sympathectomy was associated with a lower risk of developing CH compared to T2 or T3 sympathectomy . Another study suggests that T3 or T4 sympathectomy should be preferred for symptomatic treatment instead of T2 sympathectomy . In our study, the rate of CH was 21.3% and only 3% of patients developed moderate and severe CH. We think that the low rates of CH in our study might have resulted from the fact that the majority of our patients were under the age of 30 and that T3-4 sympathectomy was performed. CH was significantly observed in the trunk of the patients (77%). We think that further studies are needed to investigate the reason for the occurrence of CH in the trunk area. Moreover, this untoward effect was observed from the 30th day to the 60th month after the surgery. In an effort to explain this finding, we can comment that a period is needed for the metabolism to recognize the failure to tolerate the unmet physiological need for sweating. We observed that the likelihood of developing CH increased with increasing age. Although the physiopathology of this increase is not fully understood, we think that physiological sweating is shifted to the palms or to the axilla with the advancing age. We recommend surgery for the patients because the potentially developing CH occurs at lower rates, at tolerable levels, and at levels not unfavourably affecting the daily lives of individuals.
Studies in the literature have shown that changes in cardiac parameters may occur after sympathectomy . We decided to perform the operation in different sessions in 4 of our patients because of bradycardia that emerged either in the preoperative or intraoperative period. However, the absence of abnormal cardiac findings in these patients after the surgery may indicate that T3-4 sympathectomy does not significantly affect cardiac parameters.
Both the physical and psychosocial aspects of quality of life were affected in hyperhidrosis patients. This situation can often cause functional disabilities that affect work, daily activities, social status, personal relationships, and sexual activities of these individuals . Compared to the normal population, these patients have high levels of anxiety, social phobia, and depression . A study by Vasquez et al. reported the therapeutic potential of ETS in addressing the difficulties associated with primary focal hyperhidrosis, improving the quality of life and alleviating anxiety and social phobia . Forty-two patients who underwent surgery were highly satisfied, 16 were satisfied, and 2 were moderately satisfied. Only one patient who underwent left thoracotomy, reported dissatisfaction with the outcomes of the surgery. Consistent with the literature, the loss of self- confidence and social phobia in the preoperative period was restored in 90% of our patients in the postoperative period. Because ETS is a cosmetic surgical intervention, potential complications of ETS may be less tolerated compared to those developing after other major thoracic surgery. Several factors may cause the development of complications. One of the major reasons causing difficulties during surgery is the presence of pleural adhesion. The incidence of pleural adhesion varies from 1.3 to 6.4% in the literature . In our study, this rate was found to be significantly high (16%). We think that the socioeconomic level in our country and the associated high likelihood of acquiring pneumonia and tuberculosis in childhood may be associated with this difference in the observed rates. Pneumothorax, which is one of the minor complications, is more commonly observed compared to major complications but it can usually be absorbed spontaneously with oxygen therapy. Rarely, tube thoracostomy and/or major surgery may be necessary. In a study conducted in Taiwan, pneumothorax was observed at a rate of 14.1% on the chest x-rays taken after ETS. Among those patients, only 2.6% required tube thoracostomy . In our study, the rate of postoperative pneumothorax was found to be 8% in agreement with the literature. Major complications after ETS are rare but they can be lethal. In a series of 940 procedures published by Gossot, it was reported that 25 cases required axillary thoracotomy due to a right subclavian artery injury and significant venous bleeding . Again, Kwon et al. reported that a patient who developed chylothorax required a second surgery . In our study, aortic injury developed during the left sympathectomy in one patient for whom a bilateral ETS was planned. This patient was treated with left thoracotomy. In another patient, the operation was completed with axillary thoracotomy because significant pleural adhesion was observed during the left sympathectomy. Although the postoperative measurements of the peripheral temperature showed a tendency to increase in the study patients, it was not possible to obtain adequate data to confirm this finding. Postoperative recurrences occurred, but mildly in 3 patients. In the patient with pleural adhesion, hyperhidrosis recurred significantly on the right. We think that the development of recurrence after the 30th day of surgery may be related to the postoperative activation of the thin nerve fibres around the sympathetic chain. This was found to be a major factor affecting patient satisfaction with surgery. In the literature, Drott and Claespersitan report that persistent sweating, and delayed sweating occurred at rates of 1.5% and 2%, respectively . We think that another reason for the lower recurrence rate in our patients may be the complete severance of the sympathetic chain by cauterization in 98% of the operations.
A study by Peter et al. reported that hyperhidrosis due to the consumption of spicy and acid-rich food could develop at a rate of 32% after sympathectomy. Furthermore, the investigators reported that the rate of 32% was associated with the width of the sympathectomy level . We found this rate as 2% in our study; however, further studies are needed to explain the factors resulting in this effect.
ETS with the incision of the sympathetic chain at the T3-T4 level is associated with significant reductions in pain severity and compensatory hyperhidrosis and with significant patient satisfaction in the postoperative period. It should always be remembered that the likelihood of developing compensatory hyperhidrosis is high in patients over 30 years of age and that it occurs after the first postoperative month.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Raposio E, Caruana G. Video-assisted Thoracic Sympathicotomy for the Treatment of Palmar and Axillary Hyperhidrosis: A 17-Year Experience. Surg Laparosc Endosc Percutan Tech. 2015;25(5):417-9.
2. Prasad A, Ali M, Kaul S. Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis. Surg Endosc. 2010;24(8):1952-7.
3. Ibrahim M, Menna C, Andreetti C, Ciccone AM, D’Andrilli A, Maurizi G, et al. Two- stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis. Interact Cardiovasc Thorac Surg. 2013;16(6):834-8.
4. Montessi J, Almeida EP, Vieira JP, Abreu MM, Souza RLP, Montessi OVD. Video- assisted thoracic sympathectomy in the treatment of primary hyperhidrosis: a retrospective study of 521 cases comparing different levels of ablation. J Bras Pneumol. 2007;33(3):248-54.
5. Ambrogi V, Campione E, Mineo D, Paterno EJ, Pompeo E, Mineo TC. Bilateral thoracoscopic T2 to T3 sympathectomy versus botilinum injection in palmar hyperhidrosis. Ann Thorac Surg 2009;88(1):238-45.
6. Tedoriya T, Sakagami S, Ueyama T, Thompson L, Hetzer R. Influences of bilateral endoscopic transthoracic sympathicotomy on cardiac autonomic nervous activity. Eur J Cardiothorac Surg. 1999;15(2):194-8.
7. Lessa LDR, Luz FB, De Rezende RM, Duraes SM, Harrison BJ, De Menezes GB, et al. The psychiatric facet of hyperhidrosis: demographics, disability, quality of life, and associated psychopathology. J Psychiatr Pract. 2014;20(4):316-23.
8. Bahar R, Zhou P, Liu Y, Huang Y, Philips A, Lee TK, et al. The prevalance of anxiety and depression in patients with or without hyperhidrosis. J Am Acad Dermatol. 2016;75(6):1126-33.
9. Vasquez LD, Staples NL, Sears SF, Klodell CT. Psychosocial functioning of patients after endoscopic thoracic sympathectomy. Eur J Cardiothorac Surg. 2011;39(6):1018-21.
10. Dumont P. Side effects and complications of surgery for hyperhidrosis. Thorac Surg Clin. 2008;18(2):193-207.
11. Chang YT, Li HP, Lee JY, Lin PJ, Lin CC, Kao EL, et al. Treatment of palmar hyperhidrosis:T4 level compared with T3 and T2. Ann Surg. 2007;246(2):330-6.
12. Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. Ann Thorac Surg. 2001;71(4):1116-9.
13. Kwong KF, Cooper LB, Benett LA, Burrows W, Gamliel Z, Krasna MJ. Clinical experience in 397 consecutive thoracoscopic sympathectomies. Ann Thorac Surg. 2005;80(3):1063-6.
14. Drott C, Claes G. Hyperhidrosis treated by thoracoscopic sympathicotomy. Cardiovasc Surg. 1996;4(6):788-91.
15. Licht PB, Pilegaard HK. Gustatory side effects after thoracoscopic sympathectomy. Ann Thorac Surg. 2006;81:1043-7.
Download attachments: 10.4328_ACAM.20346
Murat Kuru, Tamer Altinok. Endoscopic thoracic sympathectomy: Early, mid-term and late outcomes and patient satisfaction. Ann Clin Anal Med 2021;12(Suppl 1): S105-109
The impact of prophylactic percutaneous endoscopic gastrostomy (PEG) in head and neck cancer patients treated with radiotherapy
Gulhan Guler Avcı
Department of Radiation Oncology, Gaziosmanpaşa University Faculty of Medicine, Tokat, Turkey
DOI: 10.4328/ACAM.20348 Received: 2020-09-17 Accepted: 2020-11-03 Published Online: 2020-11-06 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S110-114
Corresponding Author: Gulhan Guler Avci, Gaziosmanpaşa University Faculty Of Medicine, Department of Radiation Oncology, Muhittin Fisunoglu street, 60100, Tokat, Turkey. E-mail: drgulhanguler @hotmail.com P: +90 356 212 00 46 F: +90 356 212 00 46 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6802-2984
Aim: The purpose of this study is to compare the patients with head and neck cancer (HNC) who underwent radiotherapy (RT) with or without prophylactic percutaneous endoscopic gastrostomy (PEG) in terms of weight loss, interruption of treatment, and survival.
Material and Methods: The data of 64 patients who were diagnosed with HNC and received RT in our clinic between November 2013 and July 2019 were evaluated retrospectively. Only cases with prophylactic PEG were included. Patients in the negative PEG (nPEG) (n:43) and positive PEG (pPEG) (n:21) arms are similar apart from the primary subsite.
Results: The median follow-up time was 20 months (range 2- 62 months). The 20-month OS was 76.3% and 58.8% for nPEG and pPEG patients, respectively (p=0.05). Weight loss after RT was higher in the nPEG arm compared to the pPEG arm, but not statistically significant (p=0.18). No significant differences were observed in terms of acute and late adverse effects. There was no significant difference between the duration of RT interruption in patients and the PEG status (p=0.53).
Discussion: No significant effect of the nutritional status by prophylactic PEG on weight loss, treatment interruption and oncological outcomes in patients with HNC who underwent RT has been demonstrated. However, well designed, larger studies are needed comparing patients with and without prophylactic enteral tube placement.
Keywords: Prophylactic PEG; Nutrition; Head and neck cancer; Chemoradiotherapy; Survival
Chemoradiotherapy (CRT) is an effective treatment option in the definitive treatment for locally advanced head and neck cancer (HNC). It is pleasing that CRT not only allows organ protection but also improves the disease and provides a complete cure. However, serious acute and late toxicity remains an important problem despite developing technology and advanced radiotherapy techniques [1, 2]. In most patients with HNC, there is a deterioration in nutrition and quality of life due to acute adverse effects such as mucositis, dysphagia, and odynophagia. In the oropharynx and oral cavity tumors, due to tumor-related swallowing difficulties, nutritional disorders and malnutrition are observed [3-6]. As a result, all this can lead to discontinuation of the treatment, which adversely affects disease control. It is undesirable because radiobiologically, interruption of radiotherapy (RT) in patients with HNC will cause the re-population of tumoral cells. It is predicted that the tumor control rate of HNC decreases by at least 1% by taking a break to RT for each day [7-10]. In the literature, it has been reported that pre-treatment nutritional status predicts response to therapy and even survival .
Enteral tube placement is used to support nutrition in patients with HNC who received CRT, which is most preferred the ease of use of percutaneous endoscopic gastrostomy (PEG) . In which part of the treatment PEG should be placed in patients with HNC, this issue is not clear in the literature. Unfortunately, there is no consensus as to whether PEG should be placed before treatment (prophylactic PEG) or in case of clinical necessity after treatment has started [13-16]. There are undesirable conditions caused by the utilize of PEG, such as PEG-associated dysphagia and long-term PEG dependence .
We also placed prophylactic PEG before RT in order to avoid interrupting treatment for some of the patients with HNC, selected according to clinician experience. The purpose of this study is to compare the patients of HNC who underwent RT with or without PEG in terms of weight loss, interruption of treatment, and survival. There is an opinion in the literature that reactive PEG (i.e. in case of nutritional support necessity) should be preferred instead of prophylactic PEG [12-16]. In this study, the results of our patients with HNC who had prophylactic PEG werecomparedwiththesestudiesintheliterature.Furthermore comparing patients with and without PEG in terms of survival makes our study important.
Material and Methods
The data of 64 HNC patients who received RT in Tokat Gaziosmanpaşa University Radiation Oncology Clinic between November 2013 and July 2019 were evaluated retrospectively. The Departmental Ethics Committee of Tokat Gaziosmanpaşa University’s Faculty of Medicine on non-invasive clinical research approved this trial in accordance with the Declaration of Helsinki with the decision no 2020/04, on 5 March 2020. Patient interview information, patient files, and electronic system data were used for the study. The patients’ demographic status, diagnosis dates, hematological results, PEG status, treatment details, weight follow-up during RT, adverse effect status, responses to treatment, and their last status were noted. There is no reactive PEG in our study. It was decided
to insert prophylactic PEG especially for patients who had swallowing problems due tumor localization. Weekly weight measurements were recorded just before the start of RT and during RT. The follow-up, training for using PEG and calorie calculation of patients with prophylactic PEG was performed by the same nurse.
The primary endpoint is the relationship between treatment- related weight loss, treatment interruption, and PEG status. The secondary endpoints of the study are overall survival (OS), progression- free survival (PFS). The date of diagnosis is considered as the onset date for OS and PFS. The endpoint for the OS is the last control date for the patients living and the exitus date for exitus ones. The endpoint for PFS is the first event date for patients with recurrence and distant metastasis, and the last control date for patients without relapse and metastasis. Adult patients with pathological evidence of HNC with full access to knowledge were included in the study. Patients with missing files and follow-up information were excluded.
The data were calculated using SPSS version 24. Descriptive statistics for continuous (quantitative) variables were expressed as mean, standard deviation, minimum and maximum values and for categorical variables, as number (n) and ratio (%). Nonparametric tests were used as the variables are not suitable for normal distribution. The categorical demographic characteristics of the patients were calculated with the Chi- square and Fisher’s exact test. Spearman’s rank correlation test was utilized for univariate correlation analysis. The Mann- Whitney U test was performed for two groups of independent statistical analysis, and the Kruskall-Wallis test for 3 or more independent group analyzes. After Bonferroni correction, significance was assessed by post-hoc analysis. Kaplan-Meier test was employed for survival analysis and the log-rank test for comparison. In multivariate analysis, the Cox regression test was applied. Statistical significance was admitted as less than 0.05.
Demographic data, treatment details of patients are summarized in Table 1. Twenty-one patients in the positive PEG arm and 43 patients in the negative PEG arm were studied. Patients in the negative PEG (nPEG) and positive PEG (pPEG) arms were similar in terms of median age, gender, operational status, comorbid disease, stage, RT details and chemotherapy (CT), and there was no significant difference between the two groups (Table 1). Apart from the primary subsite, nPEG and pPEG groups were similar. In the nPEG arm, the diagnosis of nasopharyngeal carcinoma was significantly higher, in the pPEG arm, oral cavity and oropharyngeal cancer were higher. The relationship between survival and PEG status
The median follow-up time was 20 months (range 2- 62 months). The 20-month OS was 76.3% and 58.8% for nPEG and pPEG patients, respectively (p=0.05). The 20-month PFS was 67.8% and 50.8% for nPEG and pPEG patients, respectively (p=0.02) (Figure 1). In the 20-month follow-up period, the use of PEG significantly negatively affected the oncological results of the patients.
Higher local recurrence was shown in patients with PEG, but not statistically significant (p0.073) (Table 2).
The relationship between weight loss-treatment interruption and PEG status
The main goal of prophylactic PEG implantation is the patients’ concern for weight loss / malnutrition . For this purpose, the weekly weight values of our patients were recorded before and during the treatment. The percentage value of weight loss in body weight was calculated. The duration of treatment interruptions was examined.
The median weight values of our patients before RT were similar in the nPEG and pPEG arms. Weight loss after treatment was higher in the nPEG arm compared to the pPEG arm (6.9% (0- 23.5) vs 4.3% (1.3-11.5)), but the difference was not statistically significant (p=0.18) (Table 3).
When the relationship between the duration of RT interruption in patients and PEG status was analyzed, no statistically significant difference was observed between the two groups (p=0.53) (Table 3) (Figure 2).
The relationship between acute and late adverse effects and PEG status
Acute adverse effects were observed in 12 (27.9%) patients in the nPEG arm and in 11 (52.4%) patients in the pPEG arm (0.052). The difference was close to the limit of significance. No significant differences were observed in terms of the details of acute adverse effects (grade, radiodermatitis or mucositis) (p=0.34) (Table 2). Grade 3 dysphagia was higher in the nPEG arm (2 (16.7%) vs 1 (9.1%) patient) (p=0.53).
There was no significant difference with respect to late adverse effects between the two groups (p=0.55).
In the present study, the effect of utilization of prophylactic PEG between two homogeneous groups in respect of adverse effects and long-term oncological results was evaluated. The most striking result of our study is that OS and PFS were adversely affected in patients with PEG. The 20-month OS was 76.3% and 58.8% for nPEG and pPEG patients, respectively (p=0.05). The 20-month PFS was 67.8% and 50.8% for nPEG and pPEG patients, respectively (p=0.02). In the 20-month follow-up period, the use of PEG significantly negatively affected the oncological outcomes of the patients. The median weight values of our patients before RT were similar between the two groups. Weight loss after RT was higher in the nPEG arm compared to the pPEG arm, but not statistically significant (p=0.18). No significant differences were observed in terms of acute and late adverse effects. When the relationship between patients’ duration of RT interruption and PEG status was analyzed, no statistically significant difference was observed between the two groups (p=0.53). In summary, less weight loss was observed in patients using PEG, but the difference was not significant. However, this did not change the oncological results and did not improve survival and local recurrences.
In a review, researchers investigated the results of prophylactic PEG (pPEG) and reactive PEG (rPEG) use in HNC patients undergoing CRT using 22 studies . They reported that pPEG reduced the number of malnourished patients, but the mean weight loss measured at different time points was similar for pPEG and rPEG. Prophylactic PEG improved the quality of life of patients in the first 6 months but increased long-term PEG dependence. According to this review, pPEG should be placed in patients who appear to have a high risk of developing malnutrition during treatment . Similarly, in our study, prophylactic PEG placement could not be illustrated as an advantage with respect to interrupting treatment, adverse effects, or oncological outcomes.
Yang et al.  retrospectively assessed 192 HNC patients with regard to PEG usage. Although 63% (121) of patients had prophylactic PEG, 80% of them provided actual use. Pretreatment KPS > 80, no pretreatment dysphagia, no concomitant chemotherapy and gabapentin use were associated with reduced PEG usage. Patients who will be placed prophylactic PEG should be chosen well . In another similar study, it was reported that prophylactic PEG may be indicated in the presence of nodal disease and if bilateral neck irradiation will be performed .
Nutritional support has been shown to reduce weight loss, hospitalization and RT interruption [6, 21]. Although this group of patients was thought to have received effective treatment and therefore had better oncological results, survival was significantly lower in the prophylactic PEG group in our study. The reason for this situation may be that the time from diagnosis to the start of treatment (minimum value) is 55 days in the negative PEG arm and 66 days in the prophylactic PEG arm. In other words, patients with prophylactic PEG could not start treatment earlier than 2 month. We believe that a significantly lower survival in the pPEG arm may be associated with prolonged time to onset of treatment. Another remarkable situation was that there was no difference between the two arms in all other aspects, whereas primary subsite nasopharynx tumor was more in the nPEG arm, and hypopharynx-oral cavity tumors, which have a poor prognosis, were more in the pPEG arm. Similarly, higher recurrence in the pPEG arm had a negative effect on survival. Based on all this, we thought that survival was reduced in the pPEG arm.
In one of the centers in Germany, 53 patients with hypopharynx Ca who underwent induction CT and CRT were investigated in respect of nutritional status and its effect on clinical outcomes . Prophylactic PEG was not placed at the start of treatment. Seventeen of the 53 patients required enteral feeding during therapy. Similar to our study, nutritional status had no effect on overall survival, recurrence-free survival and treatment-related toxicity . In another study , the authors compared prophylactic and reactive PEG in 74 patients with HNC who underwent CRT. The patients were exactly matched in terms of age, gender, TNM stage, tumor subsite, HPV status, and RT dose. There was no difference between the two groups with respect to weight loss, survival and disease control . Prophylactic PEG has been shown to be associated with worse quality of life after RT, more PEG dependence and complications [13-17]. In accordance with the literature, we could not demonstrate a positive effect of prophylactic PEG on weight loss, treatment- related toxicity, and oncological results in our study.
In their study, Silender et al.  randomized 134 HNC patients to either prophylactic PEG or nutritional care arms, for comparing weight loss, quality of life and dysphagia. There was no significant difference in weight loss in the first six months. The reason why weight loss is similar in both arms was that treatment-related dysphagia was further in the first six months . We found more acute adverse effects in the pPEG arm, but grade 3 dysphagia was higher in the nPEG arm (2 (16.7%) vs 1 (9.1%) patients) (p=0.53).
The weak point of the study was that the patients did not fill any quality of life form (EORTC QLQ-H & N35 Swallowing Scale, etc.), and the analyzes were made according to the clinician observation notes. Also, side effects, especially PEG- related dysphagia, could not be evaluated due to missing notes in the file. The strengths of our study are the assessment of PEG between two homogeneous groups, and despite the lack of OS and PFS evaluation in many studies, our study also provides data on this issue.
Consequently, no significant effect of the nutritional status by prophylactic PEG on weight loss, treatment interruption and oncological outcomes in patients with HNC who underwent chemoradiotherapy has been demonstrated. However, well designed, larger studies are needed comparing patients with and without prophylactic enteral tube placement.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, et al. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol. 2008;26(21):3582–9.
2. Russo G, Haddad R, Posner M, Machtay M. Radiation treatment breaks and ulcerative mucositis in head and neck cancer. Oncologist. 2008;13(8):886–98.
3. Langius JAE, van Dijk AM, Doornaert P, Kruizenga HM, Langendijk JA, Leemans CR, et al. More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life. Nutr Cancer. 2013;65:76-83.
4. van Bokhorst-de van der Schuer, van Leeuwen PA, Kuik DJ, Klop WM, Sauerwein HP, Snow GB, et al. The impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer. 1999;86(3):519–27.
5. Paccagnella A, Morello M, Da Mosto MC, Baruffi C, Marcon ML, Gava A, et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer. 2010;18(7):837–45.
6. Lopez MJ, Robinson P, Madden T, Highbarger T. Nutritional support and prognosis in patients with head and neck cancer. J Surg Oncol. 1994;55(1):33–6.
7. Robertson C, Robertson AG, Hendry JH, Roberts SA, Slevin NJ, Duncan WB, et al. Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers. Int J Radiat Oncol Biol Phys. 1998;40(2):319–29.
8. Herrmann T, Jakubek A, Trott KR. The importance of the timing of a gap in radiotherapy of squamous cell carcinomas of the head and neck. Strahlenther Onkol. 1994;170:545–9.
9. Bese NS, Hendry J, Jeremic B. Effects of prolongation of overall treatment time due to unplanned interruptions during radiotherapy of different tumor sites and practical methods for compensation. Int J Radiat Oncol Biol Phys. 2007;68(3):654–61.
10. Withers HR, Taylor JM, Maciejewski B. The hazard of accelerated tumor clonogen repopulation during radiotherapy. Acta Oncol. 1988;27(2):131–46.
11. Salas S, Deville JL, Giorgi R, Pignon T, Bagarry D, Barrau K, et al. Nutritional factors as predictors of response to radio-chemotherapy and survival in unresectable squamous head and neck carcinoma. Radiother Oncol. 2008;87(2):195–200.
12. Cady J. Nutritional support during radiotherapy for head and neck cancer: the role of prophylactic feeding tube placement. Clin J Oncol Nurs. 2007;11(6):875- 80.
13. Kramer S, Newcomb M, Hessler J, Siddiqui F. Prophylactic versus reactive PEG tube placement in head and neck cancer. Otolaryngol Head Neck Surg. 2014;150(3):407-12.
14. Hutcheson KA, Barringer DA, Rosenthal DI, May AH, Roberts DB, Lewin JS. Swallowing outcomes after radiotherapy for laryngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2008;134(2):178-83.
15. Raynor EM, Williams MF, Martindale RG, Porubsky ES. Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients. Otolaryngol Head Neck Surg. 1999;120(4):479-82.
16. Ringash J, Lockwood G, O’Sullivan B, Warde P, Bayley A, Cummings B, et al. Hyperfractionated, accelerated radiotherapy for locally advanced head and neck cancer: quality of life in a prospective phase I/II trial. Radiother Oncol. 2008;87:181-7.
17. McClelland S, Andrews JZ, Chaudhry H, Teckie S, Goenka A. Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review. Oral Oncol. 2018;87:77-81.
18. Shaw SM, Flowers H, O’Sullivan B, Hope A, Liu LW, Martino R, et al. The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review. Dysphagia. 2015;30(2):152-75.
19. Yang W, McNutt TR, Dudley SA, Kumar R, Starmer HM, Gourin CG, et al. Predictive Factors for Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement and Use in Head and Neck Patients Following Intensity- Modulated Radiation Therapy (IMRT) Treatment: Concordance, Discrepancies, and the Role of Gabapentin. Dysphagia. 2016;31:206-13.
20. van der Linden NC, Kok A, Leermakers-Vermeer MJ, de Roos NM, de Bree R, van Cruijsen H, et al. Indicators for Enteral Nutrition Use and Prophylactic Percutaneous Endoscopic Gastrostomy Placement in Patients With Head and Neck Cancer Undergoing Chemoradiotherapy. Nutr Clin Pract. 2017;32(2):225-32.
21. Rutter CE, Yovino S, Taylor R, Wolf J, Cullen KJ, Ord R, et al. Impact of early percutaneous endoscopic gastrostomy tube placement on nutritional status and hospitalization in patients with head and neck cancer receiving definitive chemoradiation therapy. Head Neck. 2011;33(10):1441–7.
22. Bozec A, Benezery K, Chamorey E, Ettaiche M, Vandersteen C, Dassonville O, et al. Nutritional status and feeding-tube placement in patients with locally advanced hypopharyngeal cancer included in an induction chemotherapy-based larynx preservation program. Eur Arch Otorhinolaryngol. 2016;273:2681-7.
23. Silander E, Jacobsson I, Berteus-Forslund H, Hammerlid E. Energy intake and sources of nutritional support in patients with head and neck cancer-a randomised longitudinal study. Eur J Clin Nutr. 2013;67(1):47–52.
Download attachments: 10.4328_ACAM.20348
Gulhan Guler Avcı. The impact of prophylactic percutaneous endoscopic gastrostomy (PEG) in head and neck cancer patients treated with radiotherapy. Ann Clin Anal Med 2021;12(Suppl 1): S110-114
The predictive role of sonographic clavicular length for cesarean section for labor arrest in nulliparous pregnants at term
Sonay Oztas, Gizem Durmaz, Esra Kartal, Burcu Dincgez Cakmak, Emin Ustunyurt
Department of Obstetrics and Gynecology, Bursa Yuksek Ihtisas Research and Training Hospital, Bursa, Turkey
DOI: 10.4328/ACAM.20349 Received: 2020-09-17 Accepted: 2020-11-12 Published Online: 2020-11-26 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S115-119
Corresponding Author: Burcu Dincgez Cakmak, Bursa Yuksek Ihtisas Research and Training Hospital, Department of Obstetrics and Gynecology, Mimar Sinan Mah. Emniyet Cad. No:35 Yıldırım, Bursa, Turkey. E-mail: email@example.com P: +90 (530) 544 88 28 F: +90 (224) 294 4499 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2697-7501
Aim: Fetal sonographic measurement of clavicle enables obstetricians to evaluate fetal growth, congenital anomalies and shoulder dystocia. In this study, we aimed to determine the role of clavicular length obtained in the latent phase of labor to predict cesarean section for labor arrest in nulliparous term pregnan- cies.
Material and Methods: From October to December 2019, 500 nulliparous term pregnants were included in the study, who were divided into two groups as vaginal delivery (n=441) and cesarean section (n=59). Sociodemographic characteristics, neonatal outcomes, obstetric features and clavicular length were compared between the two groups. Receiver operating curve analysis was performed to determine the predictive role of clavicular length for the cesarean section. The relationship between clavicular length and delivery features was examined by correlation analysis.
Results: There was no difference between the two groups in terms of age, body mass index, gestational week, birth weight, conjugata obstetrica, APGAR scores and neonatal intensive care unit admission rates. The clavicular length was 43.73±2.01mm in vaginal delivery and 45.1±1.73 mm in the cesarean group. The fetal clavicular length was longer in the cesarean section group compared with the vaginal group (p=0.040). The mean length of the second stage of labor was 29.20±23.93 minutes in the vaginal delivery group. In ROC analysis, the area under the curve for fetal clavicular length was 0.584 with a sensitivity of 79.7% and a specificity of 35% with a threshold value >43.45 milimeter and with p=0.040.The fetal clavicular length was correlated with the gestational week in all groups (r=0.752,p<0.001) and positively correlated with the length of the second stage of labor in the vaginal delivery group (r=0.566,p<0.001).
Discussion: The obstetric societies established guidelines for the management of labor arrest to reduce primary cesarean section rates. It is a challenging is- sue to determine the delivery mode in nulliparous pregnants, and we suggest that sonographic clavicular length could help obstetricians to predict labor arrest and cesarean delivery in nulliparous term pregnants.
Keywords: Cesarean section; Clavicular length; Labor arrest; Nulliparous; Sonography; Term
Cesarean section, which is performed on nearly 1.3 million pregnant women per year in the United States, is the most common surgical procedure in obstetric practice . Cesarean deliveries are related to a high risk of uterine rupture and maternal complications in subsequent pregnancies, and a high infection risk when performed at low levels of the birth canal in a recent pregnancy . Thus, choosing the optimal delivery mode and time is crucial for maternal and fetal well-being. Previous studies have reported that labor arrest is the most common indication for primary cesarean section [3,4]. The arrest of labor, which is a challenging issue for obstetricians all over the world, is commonly followed by cesarean section and instrumental interventions that are tightly related to an increased risk of perinatal complications . Maternal age, nulliparity, gestational week at delivery, birth weight, abnormal fetal head position, epidural anesthesia, macrosomia, and premature rupture of membranes are well-known indicators of labor arrest [6-8]. Defining the arrest of labor and deciding the optimal delivery mode has a great variability and is not clear enough in current guidelines. Although the Society of Maternal- Fetal Medicine and the American College of Obstetricians and Gynecologists have established guidelines for the management of labor arrest disorders to prevent primary cesarean section, only a mild decrement in cesarean rates was detected in 2015 [9,10]. Sonographic visualization of the fetal head, body and long bones enables obstetricians to evaluate fetal growth and congenital anomalies . Moreover, sonographic measurements of those could be helpful in deciding on the delivery mode . Recently, there have been several studies investigating the effect of intrapartum sonography by evaluating the fetal position and descent of the head to predict the mode of delivery [13,14]. The clavicle is an early ossified, horizontally placed bone of the human body . It demonstrates a more linear growth pattern during the intrauterine period, thus it could be used to estimate gestational age. Another feature of this bone is the relationship between the ossification and the syndromes such as Holt Oram, cleidocranial dysplasia, Goltz and Melnick Needles. Furthermore, clavicular length, the representative of shoulder width, claimed to be a reliable marker for shoulder dystocia [16-18]. In a previous study, the fetal clavicular length was found to be significantly and strongly correlated with estimated fetal weight, biparietal diameter, abdominal circumference and femur length . There is no data in the literature about the intrapartum sonographic clavicular length. Here, we primarily aimed to evaluate the role of sonographic measurement of clavicular length, obtained in the latent phase of labor, for predicting cesarean section for the arrest of labor in nulliparous women at term.
Material and Methods
This is a prospective study that was performed at a large-scale university-affiliated research and training hospital between October and December 2019. It was approved by the local ethics committee of our center with a decision number 2011-KAEK-25 2019/10-01 and it was in accordance with the Declaration of Helsinki. Written informed consent was obtained from all study participants.
A total of 650 pregnant women were initially included in the study. The study groups were composed of nulliparous term pregnant women who were admitted to our delivery room and gave birth in our hospital. The exclusion criteria in our study were as follows: multiple pregnancies, preterm birth, nonvertex presentation, history of previous uterine surgery, intrauterine fetal death or fetal anomalies, macrosomia, premature rupture of membranes, and oligohydramnios. After patients were selected according to the inclusion and exclusion criteria, 591 pregnant women were followed up during labor.
The sociodemographic features such as age, gravida, gestational age at delivery, height and weight were recorded. Body mass index (BMI) was calculated by dividing weight by the square of height.
In the latent phase of the labor, the clavicular length was measured for each participant. The measurement was made as follows: at axial planning, the clavicles including the curvature and configuration were determined. The calipers were placed on the sternal and acromial ends of the clavicle. The maximum distance was measured three times in each patient and the mean value was recorded. All sonographic measurements were obtained by the same sonographer who was blinded to the patients’ characteristics.
In the delivery room, the results of the vaginal examination, including fetal head station, cervical dilatation and effacement, were recorded to evaluate the progression of the labor. The decision on the mode of delivery was made by the specialist in the delivery room, independently from the researcher. Then, 91 pregnants underwent cesarean section for any reason other than the arrest of labor, and they were excluded from the study. The remaining 500 patients were divided into two groups as vaginal delivery (n=441) and cesarean section (n=59). Sociodemographic characteristics, birth weight, APGAR scores of the first and fifth minutes of neonates, neonatal intensive care unit admission, and clavicular length were compared between the two groups.
The sample size of the study was calculated using power analysis with 80% power and 30% difference and α-value of 0.05 as 350. The Shapiro-Wilk test was carried out to determine whether continuous variables were normally distributed or not. Continuous variables were expressed as mean±standard deviation or median (minimum-maximum), whereas categorical variables were expressed as frequency and percentage. The independent t-test was used to compare two groups for normally distributed variables, the Mann-Whitney U test for non-normally distributed variables and the chi-square test or Fisher’s exact test for categorical variables. Receiver operating curve (ROC) analysis was performed to determine the predictive role of clavicular length for cesarean section. The relationship between the clavicular length and the delivery features was examined using Spearman correlation analysis. An α-value ≤0.05 was considered statistically significant. The statistical analysis of the study was performed with SPSS software, version 21.0 (IBM Corp. Released 2012. IBM SPSS Statisticsfor Windows, Armonk, NY, USA).
The mean age of the patients included in the study was 22.47±4.0 years, and the mean BMI was 30.21±2.27 kg/m2. The median gestational age at delivery was 39 (37-42) weeks, while the mean birth weight of the babies was 3204.23±449.66 grams.
The patients were divided into two subgroups as vaginal delivery (n=441) and cesarean section (n=59). There was no statistically significant difference between the vaginal delivery and cesarean section groups in terms of age, BMI, gestational age at delivery, birth weight, conjugata obstetrica, first- and fifth-minute APGAR scores, and neonatal intensive care unit admission rates. The fetal clavicular length was 43.73± 2.01 mm in the vaginal delivery group, whereas it was 45.1± 1.73 mm in the cesarean section group. The fetal clavicular length was significantly longer in the cesarean section group compared with the vaginal delivery group (p=0.040). The features of the groups are demonstrated in Table. The mean length of the second stage of labor was 29.20 ± 23.93 minutes in the vaginal delivery group.
The predictive role of fetal clavicular length for the cesarean section was evaluated using the ROC curve. The area under the curve (AUC) for fetal clavicular length was 0.584 with a sensitivity of 79.7% and a specificity of 35% with a threshold value >43.45 mm with a p-value of 0.040 (Figure 1).
Another finding of the study is the correlation between fetal clavicular length and obstetric parameters. In all groups, fetal clavicular length was found to be significantly correlated with the gestational week (r=0.752, p<0.001). Moreover, it was positively correlated with the length of the second stage of labor in the vaginal delivery group (r=0.566, p<0.001).
In the present study, we found that fetal clavicular length was significantly longer in the cesarean section group compared with the vaginal delivery group. Moreover, the fetal clavicular length was determined to be a predictor with a cut-off value >43.45 mm with a sensitivity of 79.7% and a specificity of 35% for cesarean section, and it was correlated with the gestational week in all study groups, and also it was positively correlated with the length of the second stage of labor in the vaginal delivery group.
There is limited information in the literature on the problem of measuring fetal long bones. Although computerized tomography is a gold standard technique for measuring long bones, the major limitations of this procedure are the radiation effect, time-consuming features and not being cost- effective . Thus, new effective methods to measure long bones have been introduced, one of which is sonography. Sonographic fetal long bone measurement can be a marker to evaluate fetal growth and inherited diseases [19,21].
The clavicle, a bone of the shoulder girdle, is one of the fetal bones used in sonography to follow fetal growth. Ossification of the clavicula begins at the fifth and sixth week of fetal life before all other bones . The measurement of the clavicle is useful not only in obstetrics, but also in archeological and orthopedic studies. In archeology, it can be used to determine age, sex, ethnicity, and posture of the body . In orthopedics, clavicular shortening of more than 2 centimeter is accepted as an indicator of clavicular fractures [24,25].
In obstetrics, the clavicular length was found to be an indicator of shoulder width and gestational age. Hence, studies have been focused on the reliability of clavicular length for predicting osseous congenital anomalies, macrosomia and shoulder dystocia [16,19,23].
Cleidocranial dysplasia, Goltz Syndrome, Holt-Oram syndrome and Melnick Needles syndromes are some of the congenital syndromes, including clavicular pathology [19,21]. Holt-Oram syndrome includes clavicular shortening and defects in the limbs and cardiovascular system . Cleidocranial dysplasia is a disease composed of clavicular aplasia, brachycephaly, and cranial defects, while Goltz syndrome consists of clavicular aplasia accompanied by skin anomalies, teeth hypoplasia, dystrophia of nails, and syndactyly. In Melnick -Needles syndrome, largely extended skeletal abnormalities, such as clavicular shortening, narrowed thoracic cage, curtsy in radius and tibia, and small facial bones, are present . Since the prevalence of these syndromes is rare, the measurement of clavicular length has been used in other fields of obstetrics. The first study evaluating the relationship between fetal clavicular length and obstetric parameters was performed by Yarkoni et al in 1985. They reported a linear correlation between clavicular length and gestational age and defined 1 mm equals to 1 week rule. Moreover, they suggested that it could be used in determining the congenital anomalies affecting the bones and macrosomia leading to shoulder dystocia or labor arrest. In the same study, the clavicular length was found to vary between 33-43 mm at 37 weeks of gestation and 36- 46 mm at 40 weeks of gestation . Similar to the previous study, the fetal clavicular length was found to be significantly correlated with the gestational week in all groups in our study. In a study of Sherer et al., the clavicular length was longer than the measurements achieved by Yarkoni et al. and was shown to vary with the logarithm of gestational age. They suggested that rule that 1 mm equals to 1 week is inconsistent and results in the overestimation of gestational age nearly 6 weeks. In this study, the clavicular length was found to vary between 38.4- 47.2 mm at 37 weeks of gestation and 41.9-52 mm at 42 weeks of gestation . The clavicular length of our patients was consistent with previous studies.
Macrosomia is another concern associated with clavicular length in previous studies. In macrosomic fetuses, it was thought that the shoulder girdle would be greater . Sherer et al. did not found any difference between diabetic and nondiabetic patients in terms of clavicle length . Furthermore, there are no data in the literature supporting the relationship between clavicular length, clavicular fracture, and shoulder dystocia. As a consequence, measuring the clavicular length is not recommended in all fetuses, but noting the presence and configuration is suggested . In our study, we excluded macrosomic fetuses, thus we have no idea about the role of clavicular length in predicting shoulder dystocia in macrosomic fetuses.
There is no study assessing the relationship between clavicular length and delivery mode in nulliparous women. We searched for this association and found that the clavicular length was 43.73±2.01 mm in the vaginal delivery group and 45.1±1.73 mm in the cesarean section group, which was longer in the cesarean section group compared to the vaginal delivery group. Moreover, it was positively correlated with the length of the second stage of labor in the vaginal delivery group. Another interesting finding of the study was the predictive role of clavicular length for determining the cesarean section. Although it has a fair sensitivity and specificity, it has been found to be a significant predictor with a threshold value >43.45 mm for cesarean section.
Primary cesarean section rate is a focused issue by governments all over the world. Many studies have been performed and societies established guidelines for the management of labor arrest, which is the most common indication for a primary cesarean section to reduce primary cesarean section rates. As a consequence, it is too important to determine the delivery mode in nulliparous pregnants, and we suggest that sonographic clavicular length could help obstetricians to predict labor arrest and cesarean delivery in nulliparous term pregnants.
The present study has some limitations. Firstly, it has a single- center design. Second, the clavicular length measurement is limited to term and nulliparous pregnants. Lastly, the nomogram of clavicular length for each ethnicity would be useful to claim that the length limit could predict a cesarean section for the Turkish population.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Kozhimannil KB, Arcaya MC, Subramanian SV. Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database. PLoS Med. 2014;11(10):e1001745
2. Allen VM, O’Connell CM, Baskett TF. Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour. BJOG. 2005;112(7):986-90.
3. American College of Obstetricians and Gynecologists; Society for Maternal- Fetal Medicine. Obstetric care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery. Obstet Gynecol. 2014;123(03):693-711.
4. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011;118(1):29-38.
5. Hellman LM, Prystowsky H. The duration of the second stage of labor. Am J Obstet Gynecol. 1952;63:1223-33.
6. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 49, December 2003: dystocia and augmentation of labor. Obstet Gynecol. 2003;102(6):1445-54.
7. Senecal J, Xiong X, Fraser WD. Effect of fetal position on secondstage duration and labor outcome. Obstet Gynecol. 2005;105(4):763-72.
8. Dahan MH, Dahan S. Fetal weight, maternal age and height are poor predictors of the need for caesarean section for arrest of labor. Arch Gynecol Obstet. 2005;273(1):20-5.
9. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol. 2012;120(05):1181-93.
10. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Mathews TJ. Births: final data for 2015. Natl Vital Stat Rep. 2017;66(1):1-10.
11. Hobbins JC, Winsberg F. Berkowitz RL. Ultrasonography in Obstetrics and Gynecology. Baltimore: Williams and Wilkins; 1983.p. 87-169.
12. Eggebo TM. Ultrasound is the future diagnostic tool in active labor. Ultrasound Obstet Gynecol. 2013;41(4):361-3.
13.Ghi T, Farina A, Pedrazzi A, Rizzo N, Pelusi G, Pilu G. Diagnosis of station and rotation of the fetal head in the second stage of labor with intrapartum translabial ultrasound. Ultrasound Obstet Gynecol. 2009;33(3):331-6.
14. Ghi T, Youssef A, Maroni E, Arcangeli T, Musso FD, Bellussi F, et al. Intrapartum transperineal ultrasound assessment of fetal head progression in active second stage of labor and mode of delivery. Ultrasound Obstet Gynecol. 2013;41(4):430-5.
15. Ellis H. Clinical Anatomy: a Revision and Applied Anatomy for Clinical Students, 10th ed.Oxford: Blackwell Synergy Publishing; 2002. p.181-2.
16. Yarkoni S, Schmidt W, Jeanty P, Reece EA, Hobbins JC. Clavicular measurement: a new biometric parameter for fetal evaluation. J Ultrasound Med. 1985;4(9):467- 70.
17. Yarkoni S, Holl M, Oram S. Familial heart disease with skeletal malformation. Br Heart J. 1960; 22(2):236-42.
18. Forla DM. Cleidocranial dysostosis.A review of the syndrome and report of a sporadic case with hereditary transmission. Am J Med. 1962;33:792.
19. Sherer DM, Sokolovskı M, Dalloul M, Khoury-collado F, Osho JA, Lamarque MD, et al. Fetal clavicle length throughout gestation: a nomogram. Ultrasound obstet gynecol. 2006;27:306-10.
20. Smekal V, Deml C,Irenberger A, Niederwanger C, Lutz M, Blauth M, et al. Length determination in midshaft clavicle fractures: Validation of measurement. J Orthop Trauma. 2008;22(7):458-62.
21. Jones KL. Smith’s recognizable patterns of human malformation, 5th ed. Philadelphia: PA: WB Saunders; 1997. p.807.
22. Williams PL, Warwick R, Dyson M, Bannister LH. Osteology. Osteology of the upper limb. In Gray’s Anatomy (37thedn), Williams PL, Warwick R, Dyson M, Bannister LH, editors. Edinburgh, UK: Churchill Livingstone; 1997.p.401-15.
23. Wiśniewski M, Baumgart M, Grzonkowska M, MałkowskiB, Flisiński P, Dombek M, et al. Quantitative anatomy of the growing clavicle in the human fetus: CT, digital image analysis, and statistical study. Surg Radiol Anat. 2017;39(8):827- 35.
24. Wick M, Müller EJ, Kollig E, Muhr G. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg. 2001;121(4):207-11.
25. Thorsmark HA, Chiara V, Ole MC, Soren TP, Soren O, Lars HF. Validation of Navigation Ultrasound for Clavicular Length Measurement. Ultrasound Med Biol.2017;43(8):1722-8.
Download attachments: 10.4328_ACAM.20349
Oztas Sonay, Durmaz Gizem, Kartal Esra, Dincgez Cakmak Burcu, Ustunyurt Emin. The predictive role of sonographic clavicular length for cesarean section for labor arrest in nulliparous pregnants at term. Ann Clin Anal Med 2021;12(Suppl 1): S115-119
Virtual screening and molecular docking studies of certain lead-like compounds from ZINC15 database against COVID-19 Mpro enzyme
Erman Salih İstifli
Department of Biology, Cukurova University, Faculty of Science and Literature, Adana, Turkey
DOI: 10.4328/ACAM.20389 Received: 2020-11-01 Accepted: 2020-11-30 Published Online: 2020-12-11 Printed: 2021-05-15 Ann Clin Anal Med 2021;12(Suppl 1): S120-125
Corresponding Author: Erman Salih İstifli, Department of Biology, Cukurova University, Faculty of Science and Literature, 01330, Adana, Turkey. E-mail: firstname.lastname@example.org P: +90 5374370567 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2189-0703
Aim: The COVID-19 epidemic, which first emerged in Wuhan in December 2019, rapidly affected the globe in the form of a pandemic, and currently millions of people are classified as active cases in terms of this infection, while tens of thousands of people are in serious or critical conditions.
Material and Methods: In this study, 100 lead-like chemical entities were downloaded from the ZINC15 database and subjected to structure-based virtual screening (SBVS) in terms of their potential to be used in combating COVID-19. In our molecular docking study, the Mpro (3CLpro) enzyme encoded by the COVID-19 genome was selected as the receptor molecule that could be targeted in the treatment.
Results: A total of 3 small molecules (ZINC000000011271, ZINC000000026220 and ZINC000000006645) were identified as potential inhibitors due to their high binding affinities to this enzyme. Physicochemical profiles of the top-ranked ligands, determined in our study, showed that these compounds were safe and had drug-like features. Furthermore, in molecular dynamics (MD) simulations, the top-ranked compound ZINC000000011271 was found to strongly bound to the Mpro enzyme and preserved its hydrogen bonding stability throughout the whole trajectory.
Discussion: In this study, three orphaned drugs (ZINC000000011271, ZINC000000026220 and ZINC000000006645) were found to strongly inhibit Mpro in molecular simulations. These compounds also displayed hit features according to the SwissADME database. Therefore, these hits defined in this study may be used in the development and advanced optimization of potent COVID-19 inhibitors.
Keywords: COVID-19; Structure-based virtual screening (SBVS); Molecular docking; ADMET; Molecular dynamics
Coronavirus disease (SARS-CoV-2, COVID-19) continues to be a major burden on global health since December 2019. Although 18 million active cases have been reported worldwide as of 2 December 2020, the disease has spread to 218 countries and territories in total according to real time world statistics (Worldometer). Vaccines targeting different protein structures of the virus have been developed in different countries, however, there is still no known effective cure for the disease, and the incidence of new cases continues to rise with daily and linear increases. Therefore, urgent intervention is needed to reduce the worldwide spread of the virus and to develop a universally effective anti-COVID-19 agent. In some early and recent studies targeting the coronavirus main protease (Mpro, 3CLpro), various novel inhibitors have been developed against this protein, or known drugs have been repurposed against this target [1-4].
The SARS-CoV-2 genome size is approximately 30,000 nucleotides in length, and the viral replicase gene encodes two overlapping polyproteins (pp1a and pp1b), which are functional in viral replication and transcription [5, 6].
The conversion of these polyproteins to functional polypeptides is predominantly performed by the 33.8-kDa Mpro (3CLpro) protein. The Mpro cleaves these polyproteins at least at 11 evolutionarily conserved sites, and this process starts with an autolytic cleavage of pp1a and pp1ab regions that reside on the protein sequence of the enzyme .
The fact that Mpro has such a functional importance and that it does not have a close homolog in humans makes Mpro an important target in the design of antiviral drugs or repurposing licensed drugs against this enzyme. Thus, by inhibiting viral replication and transcription, the recovery process can be effectively accelerated in patients suffering from COVID-19 infection. The crystal structure of COVID-19 main protease in complex with its specific inhibitor (N3) (PDB ID: 6LU7), uploaded to Protein Data Bank in February 2020, can be used as a suitable target in virtual screening of libraries of small molecules in order to stop viral replication and transcription. Since the emergence of the SARS-CoV-2 infection, molecular docking and target-based virtual screening studies as the computer-aided drug design tools are progressing at an even faster pace .
In our study, the potential of 100 lead-like molecules to inhibit SARS-CoV-2 main protease was investigated through virtual screening, molecular docking and ADMET profile analysis. Instead of randomly filtering quite a large number of small molecules from the ZINC15 database, in this study, it is envisaged to accelerate the drug discovery process by scanning a small molecule library with only lead-like features.
Material and Methods
In this study, one hundred (100) small molecules, which meet the following lead-likeness criteria, were downloaded from the ZINC15 (https://zinc15.docking.org/) database in order to speed up the drug discovery process: i. 250 ≤MW ≤350, ii. Log P ≤3.5, iii. The number of rotatable bonds was ≤7 .
The ligands downloaded from the ZINC15 database had a molecular charge of -1 to 0, were set up to have the dominate form at pH 7.4 and the highest reactivity.
Protein retrieval and ligand preparation
In our study, the crystal structure of COVID-19 main protease in complex with the inhibitor N3 (resolution: 2.16 Å) downloaded from Protein Data Bank (PDB ID: 6LU7) was used as receptor molecule. This enzyme consists of a single chain (chain A) and 306 amino acids.
The Mpro enzyme, ligands, and docking parameters were prepared using AutoDockTools-1.5.6 . Water molecules and other heteroatoms were removed from the receptor structure. One hundred (100) lead-like small molecules (ligands) in sdf format downloaded from the ZINC15 database were converted to pdb format using Open Babel . The energy of ligands in pdb format was minimized using the ‘steepest descent algorithm’ (2500 steps). Finally, the geometrically optimized ligands in pdb format were converted to pdbqt format using a specific script.
Structure-based virtual screening
Structure-based virtual screening (SBVS) or target-based virtual screening (TBVS) technique serves to predict the best interaction conformation of the complex that will occur between the ligand and its molecular target (receptor).
As a result, the ligands tested are ranked according to their binding affinity with the target molecule . AutoDock Vina has significant advantages in binding affinity and binding mode prediction compared to AutoDock, and is also two orders of magnitude faster than AutoDock 4 in binding affinity and binding mode calculations . The parameters used in the docking experiments of the Mpro are given in Table 1. To calculate the binding energy of the inhibitor (N3) with the crystal structure of Mpro, AutoDock Vina was used in our study. The value obtained as a result of this calculation was used to compare the binding energies of the lead-like molecules downloaded from the ZINC15 database. The docking score of N3 inhibitor against Mpro was found to be -10.04 kcal/mol, and this value was used as the ‘binding energy threshold’ in docking experiments with other candidate ligands. Thus, the search space for candidate ligands was considerably narrowed. As a result, this cut-off value (ΔGo ≤ -10.04 kcal/mol) that we determined gave a total of 3 molecules, and these showed the highest binding affinity against Mpro.
Molecular Docking using AutoDock 4.2.6.
The top-ranked ligands (hit compounds) obtained by us as a result of the SBVS study were subjected to further molecular docking against their respective receptor, Mpro, using AutoDock 4.2.6. The parameters used in the adjustment of the grid box are given in Table 1. The grid box dimensions were adjusted to cover all amino acids in the ligand binding pocket (Figure 1a). For each ligand, 2.500.000 energy evaluations and a total of 100 genetic algorithm runs were implemented. Lamarckian Genetic Algorithm (LGA) was used as the search parameter, and Gasteiger partial charges were added to the receptor. Drug-likeness analysis
In the pharmaceutical industry, clarifying the drug-likeness properties of hit compounds is a crucial step in reducing the side effects of these agents. Additionally, the drug-likeness concept is functional in optimizing the pharmacokinetic and pharmaceutical properties of drug candidate molecules such as solubility, chemical stability, bioavailability and distribution profiles . In our study, a web-based SwissADME tool was used to determine the drug-likeness properties of top-ranked ligands downloaded from the ZINC15 database [15-18]. Molecular dynamics simulation of the top-ranked receptor- ligand complex
Molecular dynamics (MD) is a computer simulation used to analyze the physical movements of atoms and molecules in a system and their conformational changes within a certain time interval. Atoms and molecules are allowed to interact within this specified time interval and thus provide information about the dynamic ‘evolution’ of the system. To confirm the binding mode of the top-ranked ligand (ZINC000000011271), the molecular dynamics (MD) simulations were performed using the GROMACS 2020.1 version based on the docked conformation of ZINC000000011271 and the Mpro protein . The hydrogen atoms of the ligand were added explicitly using the Avogadro program. The CHARMM36 force field was used to create the topology for the protein and CHARMM General Force Field (CGenFF; https://cgenff.umaryland.edu/) was used to build the topology for our top-ranked ligand, ZINC000000011271. The topologies and coordinates of receptor and ligand were then combined to construct the topology and coordinate of the protein-ligand complex. Four Na+ ions, corresponding to physiological concentration, were added to neutralize the system, and then the protein-ligand complex was solvated in a dodecahedral box with SPC water molecules . Before the MD simulation, the complexes were subjected to 50,000 steps of energy minimization to relieve any unfavorable interactions in the initial configuration of the system. Equilibration simulations were carried out in two steps: equilibration using NVT for 100 ps consisting of an energy minimization of 50,000 steps, and an NPT equilibration for 100 ps with 50,000 steps. After the completion of two equilibration phases, a 10-ns MD simulation was performed. During the MD run, the trajectories were collected every 10 ps to analyze protein-ligand interactions and dynamics. The trajectories were analyzed to quantify the structural stability (RMSD and RMSF) of the protein, ligand and the protein-ligand complex as well as to detect the number of intermolecular H-bonds formed between the complex during the simulation. Excel 2013 program was used to graphically visualize the generated results obtained using the in-built tools of GROMACS.
Top-ranked ligands with their calculated binding energies and estimated inhibition constants against Mpro in our study are given in Table 2. In this study, ZINC000000011271, ZINC000000026220 and ZINC000000006645 showed the highest binding affinities against Mpro among 100 lead- like small molecules downloaded from ZINC15 database. The binding energy of ZINC000000011271 to Mpro was found to be -10.91 kcal/mol with an estimated inhibition constant of 10.09 nM. ZINC000000011271 formed conventional H-bonds with Leu141, Gly143, Ser144, Cys145 and Glu166, carbon- hydrogen bonds with Phe140, His164 and His172, showed a π-sigma interaction with His41 and a π -alkyl interaction with Met165. Furthermore, this compound showed four van der Waals interactions with Asn142, His163, Arg188 and Gln189, respectively (Figure 1b). The binding energy of ZINC000000026220 to Mpro was found to be -10.46 kcal/ mol with an estimated inhibition constant of 21.39 nM. ZINC000000026220 showed three π-alkyl interactions with Met49, Leu167 and Pro168, one π-sulfur interaction with Met165, and three conventional H-bonds with His164, Gln189 and Gln192. This compound also shared many van der Waals interactions with several residues of Mpro (Figure 1c). The third compound ZINC000000006645 showed a binding energy of -10.43 kcal/mol and an estimated inhibition constant of 22.50 nM in its interaction with Mpro. ZINC000000006645 showed a π-alkyl and a π-π T-shaped interaction with the Met165 and His41 residues of the Mpro, respectively. In addition, this compound formed a non-classical carbon-hydrogen bond with Pro168, and three classical hydrogen bonds with Glu166, Arg188, and Thr190 (Figure 1d).
In this study, 10-ns MD simulation was carried out to evaluate the conformational changes, stability and the dynamic evolution of the Mpro-ZINC000000011271 complex. To determine how much the ligand binding pose has changed over the 10-ns simulation period, the root mean square deviation (RMSD) of protein and protein-ligand complex was computed (Figure 2). In Figure 2, the RMSD of unbounded Mpro enzyme remained stable between 1.4 ns and 10 ns time period at 0,15 nm. The RMSD of Mpro-ZINC000000011271 remained stable at 0.2 nm at 0.3 ns until 1.7 ns, then slightly increased to 0.32 nm between 1.8 ns – 3.4 ns, and finally reached its steady state at 0.65 nm between 3.5 ns and 10 ns (Figure 2). RMSF of the unbounded Mpro showed that the residues located in the active site (Phe140, Gly143, Cys145, His164, Glu166, His172, Gln189, Thr190 and Glu 192) of the enzyme remained stable between 0.05 nm and 0.1 nm (Figure 3a). The other residues of the enzyme also showed a rigid character in terms of RMSF which was between 0.03 nm and 0.21 nm. The RMSF of ZINC000000011271 during MD simulation (Figure 3b) showed that the ligand atoms had low fluctuations between 0.02 nm and 0.20 nm, indicating that the atom positions of the ligand did not significantly changed during the interactions with the binding pocket residues. Although the 29., 30. and 31. atoms of the ligand displayed high RMSF values, their fluctuations were limited to an acceptable value of 0.2 nm (Figure 3b). The H-bond plotting showed an average of 3.66 hydrogen bond interactions between Mpro and ZINC000000011271 throughout the 10-ns MD simulation with a maximum of 13 hydrogen bonds (Figure 3c). The resulting dynamic H-bond formation pattern in Figure 3c well illustrates the tight binding mechanism of ZINC000000011271 to Mpro and the underlying reason for its inhibition.
In this study, ZINC000000011271, ZINC000000026220 and ZINC000000006645 showed the highest binding affinities against Mpro among 100 lead-like small molecules downloaded from ZINC15 database. The binding energy of ZINC000000011271 to Mpro was found to be -10.91 kcal/mol with an estimated inhibition constant of 10.09 nM. ZINC000000011271 formed conventional H-bonds with Leu141, Gly143, Ser144, Cys145 and Glu166, carbon- hydrogen bonds with Phe140, His164 and His172, showed a π-sigma interaction with His41 and a π -alkyl interaction with Met165. Furthermore, this compound showed four van der Waals interactions with Asn142, His163, Arg188 and Gln189, respectively. ZINC000000011271 is an analogue of 3’-[4-Aryl- (1,2,3-triazol-1-yl)]-3’-deoxythymidine and it has been reported to inhibit thymidine kinase and deoxynucleoside kinase enzymes in Herpes virus 1 (HSV1), Homo sapiens and Drosophila melanogaster . The binding energy of ZINC000000026220 to Mpro was found to be -10.46 kcal/mol with an estimated inhibition constant of 21.39 nM. ZINC000000026220 showed three π-alkyl interactions with Met49, Leu167 and Pro168, one π-sulfur interaction with Met165, and three conventional H-bonds with His164, Gln189 and Gln192. This compound also shared many van der Waals interactions with several residues of Mpro. This compound is an analogue of 2’-deoxyguanosine, and 2’-deoxyguanosine has been proved to be inhibitory against thymidine kinases (TKs) encoded by Herpes simplex viruses type 1 (HSV1) and type 2 (HSV2)[22, 23]. The third compound ZINC000000006645 showed a binding energy of -10.43 kcal/ mol and an estimated inhibition constant of 22.50 nM in its interaction with Mpro. ZINC000000006645 showed a π -alkyl and a π-π T-shaped interaction with the Met165 and His41 residues of the Mpro, respectively. In addition, this compound formed a non-classical carbon-hydrogen bond with Pro168, and three classical hydrogen bonds with Glu166, Arg188 and Thr190. The compound ZINC000000006645 is an isomer of the compound 2-Anilino-6a-(hydroxymethyl)-4,5,6,6a- tetrahydro-3aH-cyclopenta[d][1,3]oxazole-4,5,6-triol and it has been reported to strongly inhibit lysosomal α-glucosidase, β-galactosidase and β-glucocerebrosidase enzymes in vitro .
In this study, 10-ns MD simulation was carried out to evaluate the conformational changes, stability and the dynamic evolution of the Mpro-ZINC000000011271 complex. To determine how much the ligand binding pose has changed over the 10- ns simulation period, the root mean square deviation (RMSD) of protein and protein-ligand complex was computed. The RMSD of unbounded Mpro enzyme remained stable between 1.4 ns and 10 ns time period at 0.15 nm. The RMSD of Mpro- ZINC000000011271 remained stable at 0.2 nm at 0.3 ns until 1.7 ns, then slightly increased to 0.32 nm between 1.8 ns – 3.4 ns, and finally reached its steady state at 0.65 nm between 3.5 ns and 10 ns. The root mean square fluctuation (RMSF) captures the fluctuation from the average position for each atom, and therefore gives information about the flexibility of regions of the protein or ligand molecules. RMSF of the unbounded Mpro showed that the residues located in the active site (Phe140, Gly143, Cys145, His164, Glu166, His172, Gln189, Thr190 and
Glu 192) of the enzyme remained stable between 0.05 nm and 0.1 nm. The other residues of the enzyme also showed a rigid character in terms of RMSF, which ranged from 0.03 nm to 0.21 nm. The RMSF of ZINC000000011271 during MD simulation showed that the ligand atoms had low fluctuations between 0.02 nm and 0.20 nm, indicating that the atom positions of the ligand did not significantly changed during the interactions with the binding pocket residues. Although the 29., 30. and 31. atoms of the ligand displayed high RMSF values, their fluctuations were limited to an acceptable value of 0.2 nm. The H-bond plotting showed an average of 3.66 hydrogen bond interactions between Mpro and ZINC000000011271 throughout the 10-ns MD simulation with a maximum of 13 hydrogen bonds. The resulting dynamic H-bond formation pattern well illustrated the tight binding mechanism of ZINC000000011271 to Mpro and the underlying reason for its inhibition.
One of the targets, which is important in the treatment of Coronavirus (COVID-19) and whose inhibition can be quite functional, is the Mpro enzyme. In this study, the structure- based virtual screening revealed the potential of three orphaned drugs (ZINC000000011271, ZINC000000026220 and ZINC000000006645) to inhibit Mpro. Two of these entities (ZINC000000011271, ZINC000000026220) have thymidine kinase inhibitory properties, while the third entity (ZINC000000006645) inhibits glucosidase, galactosidase and glucocerebrosidase enzymes. These compounds displaying hit features are drug-like, ADMET profiles were found to be harmless, and according to the SwissADME database (http://www. swissadme.ch/index.php#), their synthetic accessibility (ease of synthesis) scores fall within the acceptable range. Furthermore, among these three compounds, ZINC000000011271 proved its tight binding with Mpro in 10-ns molecular dynamics simulation and preserved its stable hydrogen bond formation until the end of the trajectory. For this reason, these hits defined in our study may be used in the development and advanced optimization of potent COVID-19 inhibitors.
Scientific Responsibility Statement
Animal and human rights statement
Conflict of interest
1. Anand K, Ziebuhr J, Wadhwani P, Mesters JR, Hilgenfeld R. Coronavirus main proteinase (3CLpro) structure: basis for design of anti-SARS drugs. Science. 2003;300(5626):1763-7.
2. Yang H, Xie W, Xue X, Yang K, Ma J, Liang W, et al. Design of wide-spectrum inhibitors targeting coronavirus main proteases. PLoS Biol. 2005;3(10):e324.
3. Jin Z, Du X, Xu Y, Deng Y, Liu M, Zhao Y, et al. Structure of M(pro) from SARS- CoV-2 and discovery of its inhibitors. Nature. 2020;582(7811):289-93.
4. Zhang L, Lin D, Sun X, Curth U, Drosten C, Sauerhering L, et al. Crystal structure of SARS-CoV-2 main protease provides a basis for design of improved alpha- ketoamide inhibitors. Science. 2020;368(6489):409-12.
5. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270-3.
6. Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. A new coronavirus associated with human respiratory disease in China. Nature. 2020;579(7798):265- 9.
7. Hegyi A, Ziebuhr J. Conservation of substrate specificities among coronavirus main proteases. J Gen Virol. 2002;83(Pt 3):595-9.
8. Amin SA, Ghosh K, Gayen S, Jha T. Chemical-informatics approach to COVID-19 drug discovery: Monte Carlo based QSAR, virtual screening and molecular docking study of some in-house molecules as papain-like protease (PLpro) inhibitors. J Biomol Struct Dyn. 2020:1-10.
9. Teague SJ, Davis AM, Leeson PD, Oprea T. The Design of Leadlike Combinatorial Libraries. Angew Chem Int Ed Engl. 1999;38(24):3743-8.
10. Sanner MF. Python: a programming language for software integration and development. J Mol Graph Model. 1999;17(1):57-61.
11. O’Boyle NM, Banck M, James CA, Morley C, Vandermeersch T, Hutchison GR. Open Babel: An open chemical toolbox. J Cheminform. 2011;3:33.
12. Maia EHB, Assis LC, de Oliveira TA, da Silva AM, Taranto AG. Structure- Based Virtual Screening: From Classical to Artificial Intelligence. Front Chem. 2020;8:343.
13. Vieira TF, Sousa SF. Comparing AutoDock and Vina in Ligand/Decoy Discrimination for Virtual Screening. Applied Sciences. 2019;9(21):4538.
14. Vistoli G, Pedretti A, Testa B. Assessing drug-likeness–what are we missing? Drug Discov Today. 2008;13(7-8):285-94.
15. Pires DE, Blundell TL, Ascher DB. pkCSM: Predicting Small-Molecule Pharmacokinetic and Toxicity Properties Using Graph-Based Signatures. J Med Chem. 2015;58(9):4066-72.
16. Daina A, Michielin O, Zoete V. SwissTargetPrediction: updated data and new features for efficient prediction of protein targets of small molecules. Nucleic Acids Res. 2019;47(W1):W357-W64.
17. Lipinski CA, Lombardo F, Dominy BW, Feeney PJ. Experimental and computational approaches to estimate solubility and permeability in drug discovery and development settings. Adv Drug Deliv Rev. 2001;46(1-3):3-26.
18.CLobell M, Hendrix M, Hinzen B, Keldenich J, Meier H, Schmeck C, et al. In silico ADMET traffic lights as a tool for the prioritization of HTS hits. ChemMedChem. 2006;1(11):1229-36.
19.CAbraham MJ, Murtola T, Schulz R, Páll S, Smith JC, Hess B, et al. GROMACS: High performance molecular simulations through multi-level parallelism from laptops to supercomputers. SoftwareX. 2015;1–2:19-25.
20.CBerendsen HJ, Postma JP, van Gunsteren WF, Hermans J. Interaction models for water in relation to protein hydration. Intermolecular forces: Springer; 1981. p. 331-42.
21.CPoecke SV, Negri A, Gago F, Daele IV, Solaroli N, Karlsson A, et al. 3’-[4-Aryl-(1,2,3-triazol-1-yl)]-3’-deoxythymidine Analogues as Potent and Selective Inhibitors of Human Mitochondrial Thymidine Kinase. J Med Chem. 2010;53:2902–12.
22. Hildebrand C, Sandoli D, Focher F, Gambino J, Ciarrocchi G, Spadari S, et al. Structure-activity relationships of N2-substituted guanines as inhibitors of HSV1 and HSV2 thymidine kinases. J Med Chem. 1990;33(1):203-6.
23. Hernandez AI, Balzarini J, Karlsson A, Camarasa MJ, Perez-Perez MJ. Acyclic nucleoside analogues as novel inhibitors of human mitochondrial thymidine kinase. J Med Chem. 2002;45(19):4254-63.
24. Uchida C, Kimura H, Ogawa S. Potent Glycasidase Inhibitors, N-Phenyl Cyclic Isourea Derivatives of S-Aminoand 5-Amino-l-C-(hydroxymethyl)-cyclopentane- l,2~,4-tetraols Bioorganic & Medicinal Chemistry Letters. 1994;4(22):2443-648.
Download attachments: 10.4328_ACAM.20389
Erman Salih İstifli. Virtual screening and molecular docking studies of certain lead-like compounds from ZINC15 database against COVID-19 Mpro enzyme. Ann Clin Anal Med 2021;12(Suppl 1): S120-125