February 2022
Simple predictors of obstructive sleep apnea in obese patients
Hakan Silek 1, Fatma Ferda Kartufan 2, Arzu Gunturk 3, Aysegul Gormez 4
1 Department of Neurology, Faculty of Medicine, Yeditepe University, 2 Department of Anesthesia and Reanimation, Hospital of Medistanbul, 3 Department of Internal Medicine Faculty of Medicine, Yeditepe University, 4 Department of Radiolgy, Faculty of Medicine, Yeditepe University, İstanbul, Turkey
DOI: 10.4328/ACAM.20869 Received: 2021-09-21 Accepted: 2021-10-27 Published Online: 2021-11-08 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):119-123
Corresponding Author: Fatma Ferda Kartufan, Yunus Emre Mah. Lütfi Aykac Blv. No:80/G, 34260, Sultangazi, Istanbul, Turkey. E-mail: mdferdakartufan@gmail.com P: +90 850 474 47 47 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5592-2366
Aim: The aim of this study is to investigate BMI>30kg/m2 patients for the frequency of OSA, and to determine the effect of HS, NC, and Mp on the severity of OSA. The secondary aim is to evaluate the relationships between sleep autonomic arousal index (AAI), obesity, and OSA severity.
Material and Methods: The data were collected from 68 patients (42 male), prospectively. A Somnocheck Micro-WM94530 portable device was used to diagnose OSA. Abdominal ultrasonography (USG) was performed to evaluate the hepatosteatosis degree. The main exclusion criteria were BMI<30kg/m2, having respiratory system diseases, or comorbidities affecting the respiratory system.
Results: The percentage of OSA in evaluated obese participants was 57%. The age, NC, Mp were found to be active contributing factors for predicting OSA in obese patients (p=0.024, p=0.045, p=0.01, respectively). The respiratory-sleep disturbance measurement AAI has a positive correlation with OSA’s severity in obese patients (p= 0.0001 and r= 0.414).
Discussion: The age and anthropometric evaluation (Mp and NC) in obese patients provides a quick evaluation of OSA. AAI increases with severity of OSA.In our opinion, the recorded data of sleep apnea/hypopnea index (AHI) and AAI indexes from the Somnocheck micro device could be used as a screening diagnosis method in centers where polysomnography is not available.
Keywords: OSA, Hepatosteatosis, Neck Circumference, Mallampati Score, Obesity
Introduction
Obesity is a predisposing risk factor for the development of obstructive sleep apnea (OSA). If OSA is associated with excessive daytime sleepiness, it is defined as obstructive sleep apnea syndrome (OSAS). The prevalence is 2% in females and 4% in males while it tends to be 30% in obese and 50-98% in morbidly obese people [1].
Neck circumference (NC) is more predictive of OSA than the body mass index (BMI) parameter [2]. OSAS is currently considered to be an inflammatory disorder and endothelial dysfunction in OSA is thought to be the responsible mechanism [3]. Therefore, the patients with OSA have a higher incidence of visceral obesity, and non-alcoholic fatty liver disease-hepatosteatosis (HS) than the healthy population. The patients with OSA should also be screened for the presence and the severity of HS [4].
Somnocheck Micro-WM 94530 (SC-micro) is considered as a home sleep apnea test device and also a reliable portable device in monitoring OSA patients [5]. Home sleep apnea testing (HSAT) monitoring devices, have disadvantages as well as advantages. Unlike polysomnography (PSG), they do not provide information about the stages of sleep and are not as sensitive as PSG in detecting the desaturation index and cannot record cortical sleep arousal. However, they are susceptible for detecting apnea and hypopnea index (AHI), and easy to apply and highly cost-effective [6]. The SC-micro device is capable of evaluating a volumetric finger plethysmography recording. It can demonstrate profound changes in finger pulse and pulse wave amplitude (PWA), which is determined by α-receptor-mediated changes of finger blood flow, suggesting that pulse amplitude changes reflect the capacity of the vascular endothelium under hypoxic stress [7]. In OSA evaluation, polysomnography is capable to record respiratory PWA drops during sleep and it has been shown that PWA drops occur simultaneously with EEG cortical arousal in sleep. It is estimated that PWA drop suggests a possible role of pulse wave amplitude as a marker of cerebral response to respiratory events [8]. Moreover sleep cortical arousals are generally associated with withdrawal of vagal activity and activation of the sympathetic nervous system, resulting in heart rate (HR) augmentation, vasoconstriction, and blood pressure rise. These manifestations have been indicated as autonomic arousals [9].
This study aims to determine the effect of HS, NC, and Mp in obese patients and to evaluate their influence in severity of OSA. The secondary aim is to evaluate the relationships between sleep autonomic arousal index (AAI), obesity, and OSA.
Considering the fact that many patients have to wait for a very long time for PSG recordings because of limited numbers of sleep labs, we wanted to draw attention to the possible use of HSAT techniques in screening pre-PSG evaluating for diagnosis of OSA.
Material and Methods
This current study was planned to be performed from September 2019 to July 2020 in Yeditepe University hospital in obese (BMI≥30 kg/m2) patients. Ethical approval for this prospective, randomized, consecutive controlled clinical trial (number: 1120) was provided by the Yeditepe University Clinical Trials Ethical Committee, Istanbul, Turkey (Chairperson Prof T. Celik) on 20/11/2019. The study was conducted in accordance with the Declaration of Helsinki.
The sample size of 68 was determined by the literature revealing that 27.9% of the subjects do not have OSA and 61,5% of them having BMI ≥30 kg/m2, were diagnosed with OSA within the inputs of α err prob=0.05, Power (1-β err prob) =0.80 [8]. Seventy participants were planned to be included in the study for compensation of the possible losses. Systematic random sampling was performed according to the number of patients admitted to Yeditepe University, Department of Endocrinology and Internal Medicine in Istanbul, Turkey. Participants with BMI ≥30 kg/m2 were diagnosed with obesity. The volunteers were picked among the odd-numbered ones who coded before starting the trial until they reached the sample size of 70. Written informed consent was obtained from all participants who had been assigned to the trial by the senior author.
Obese participants (BMI≥30 kg/m2) between 18-60 years of age, were chosen according to the trial eligibility criterias. Participants under the age of 18 and over the age of 60, patients with respiratory system diseases (such as; dyspnea, chronic obstructive pulmonary disease, interstitial pulmonary disease) or with comorbidities affecting the respiratory system (such as; congestive heart failure, chronic kidney disease, coronary artery disease), examined in a sleep disorder polyclinic with any respiratory symptom, and whose BMI is lower than 30 kg/m2 were planned to exclude from the study.
The participants’ demographic and anthropometric data were recorded (age, height, weight, BMI, gender, and neck circumference). The Mallampati Classification assessment was evaluated as another anthropometric parameter. The participants’ examination was made while the patient was sitting, the head in a neutral position, the mouth opened, and the tongue protruded maximally without phonation. Mp score was graded based on the visibility of the airway structures. Class I: The soft palate, uvula, pillars, and fauces visible; Class II: Mp pillars are not visible; Class III, soft palate can be visualized but can not in Class IV. An experienced Anesthesiology consultant evaluated Mallampati scores of the participants. Participants were then asked to complete the Epworth Sleepiness Scale (ESS) [10].
The somnographic data for the trial was obtained via a portable device, Somnocheck Micro-WM 94530 (Weinmann Medical Technology, Hamburg, Germany). This method of evaluating OSA was found to be nearly equal to polysomnography (PSG) in measuring the sleep apnea-hypopnea index (AHI), minimal and mean peripheral oxygen blood saturation (SpO2) during sleep. Participants were informed about the device and educated. The participants used the device for monitoring themselves just before bedtime at their homes. Participants who had achieved at least six hours of uninterrupted sleep were included in the study; two of the participants who had not achieved this time of uninterrupted sleeping interval or not adequately monitored themselves were excluded from the study. OSA was diagnosed by the AHI measurements recorded from the monitoring. AHI<5, AHI between 5 and 15, AHI between 15 and 30, AHI>30 were diagnosed as “simple snoring,” “mild OSA,” “moderate OSA,” and “Severe OSA” respectively [11]. The device also measures the autonomic arousal index (AAI) via pulse wave analysis (PWA); therefore, the AAI was also recorded and evaluated for each participant [12].
Participants were also evaluated for hepatosteatosis in the Radiology Department’s ultrasonography rooms, under the same conditions of darkness by the same radiology consultant who did not know the current trial’s aim. The same device and probe were used for each examination {General Electric LOGIQ E9 (CISPR11 Group 1 Class A), Wauwatosa, WI, USA,53226} (C1-5-D broad –spectrum convex transducer with bandwidth 1-6 MHz). The liver was evaluated in terms of steatosis. Hepatosteatosis has been graded visually as Grade 1: diffusely increased hepatic echogenicity, but periportal and diaphragmatic echogenicity is still appreciable. Grade 2: diffusely increased hepatic echogenicity obscuring periportal echogenicity, but diaphragmatic echogenicity is still appreciable. Grade 3: diffusely increased hepatic echogenicity obscuring periportal echogenicity and diaphragmatic echogenicity [13].
Statistical Analysis
Minimum-maximum, standard deviation, frequency, and levels evaluated from different data recorded from participants’ data (categorical values) and comorbidities (number and percentage) were included in descriptive statistics. The distribution of the variables was measured by the coefficient of variation, skewness – kurtosis, histogram, detrended, and the normality test of Shapiro-Wilk. Data determined as parametric if three or more over five positivity occurred in the tests mentioned above.
The age, NC, and AAI compared with the t-test of the independent sample between groups. The Mann-Whitney U test used to compare the data of the BMI, SpO2-min, and SpO2-mean groups. A Chi-square test was performed to evaluate the effect of ESS, Mp, and HS on groups. Correlations were evaluated via the Pearson Correlation test or Spearman Correlation test. SPSS 22.0 program (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for the analysis. A p-value of less than 0.05 was considered to be statistically significant.
Results
Seventy participants were evaluated from September 2019 to June 2020. Two of the participants were excluded from the study. One of them was excluded due to an interrupted sleeping interval, and the other was excluded due to inadequate monitoring. Out of 68 participants involved in the trial, 29 (42,65 %) were found to have simple snoring and 39 (%57,35) cases of OSA have been found. Seventeen patients in the simple snoring group and 25 patients in the OSAS group were male, with no significant difference between the groups (p>0.05). The mean age of participants was 42.3±9.1 years. The mean age was statistically significantly lower in patients with smple snoring (39.5±10.3) compared to those with OSAS (44.4±7.5) (p=0.024). No statistically significant difference was found between the simple snoring and OSAS groups in terms of BMI (35.5±5,2 vs 35.5±4,2, p>0.05). The mean neck circumference (NC) was statistically significantly lower in the simple snoring group (43.9±3.6 cm vs 45.8±4.1 cm, p=0.045).
When somnographic parameters were compared between the two groups; the mean AAI was significanly lower in the simple snoring group compared to the OSAS group (24.4±14 vs 30.9±12.6, p=0.049). The minimum (86,5±4,5 vs 79,7±8,1) and mean (95,0±1,5 vs 93,7±1,9) oxygen saturation values were statistically significantly higher in the simple snoring group compared to the OSAS group (p<0.001, p=0.004, respectively).
BMI, NC, and sonographic parameters are also compared between OSA subgroups (Mild, Moderate, and Severe). The comparison between the OSA subgroups of “Mild vs. Moderate” and “Mild vs. Severe” were shown in Table 1. There was no significant difference between the OSA subgroups of “Moderate vs. Severe.”
The categorical values, including ESS, HS score, and Mp score, were compared between Simple Snoring and OSA groups. According to groups, the Spearman correlation results with r values, and the evaluation of the data were presented in Table 2. The numbers with percentages were shown in Table 3, according to the subgroups of OSA. The comparison between the OSA subgroups of “Mild vs. Severe” and “Moderate vs. Severe” were also shown in Table 3. There was no significant difference between the OSA subgroups of “Mild vs. Moderate.”
Pearson Correlation test revealed a significant positive correlation between AAI and AHI data, which were used for predicting simple snoring and OSA subgroups (p=0.0001 and r=0.414). AAI had a moderately significant negative correlation with SpO2-min ( p=0.006 and r=0.333) but not correlated with SpO2-mean (p>0.05). Spearman’s correlation test between AHI and SpO2-min, SpO2-mean data revealed a strong significant negative correlation (p=0.0001, r=0.582 and p=0.0001, r=0.514, respectively).
Discussion
The OSA-related predictiveness rate was found to be directly correlated with the highest Mp measurements. Although HS and EDSS and NC were found to be independent predictors for OSA diagnosis, their predictivity rate was found minimal. An important sleep disturbance marker that was strongly associated with severity of OSA were AAI parameters detected with PWA. It is estimated from previous trials that predictivity/sensitivity rate of PWA for the detection of an cortical EEG-micro-arousal related to a respiratory event was 89.1% [14]. Although it is not possible to detect cortical arousals on portable devices, it has been observed in recent studies that EEGspectral analysis power density increases in almost all > 20% PWA drops even in absence of standard cortical arousal criteria and these data suggest that all PWA drops are related with subcortical brain activation that can be detected only with spectral EEG recordings [15, 16].
It is easy to diagnose OSA when the patient comes to a sleep disorder polyclinic with corresponding problems. What about obese patients who do not know that they are suffering from a sleep disorder? This current study investigates predisposing or contributing factors of OSA in obese participants who were not examined in a sleep disorder polyclinic before and usefulness of screening portable device for diagnosing of OSA in randomly selected obese subjects. Although we found that the OSA ratio in obese participants was 57,4%, there was no correlation between OSA’s severity and increased BMI in obese participants. However, age, neck circumference, and Mallampatia score were the contributing factors for the diagnosis of OSA in obese participants. The Mp score was also shown to be a strong contributing factor for predicting the severity of OSA in obese participants. Soylu et al. [17] and Öztürk et al. [18] had assessed the anthropometric indexes of OSA/OSAS diagnosed patients to examine possible relationships. According to a cross-sectional study published in 2019, Mp, age, and NC’s were essential factors in predicting moderate OSA, while Mp, BMI, age, and gender were more predictive in severe OSA. According to the trial, Mp was the most significant factor compared with age, BMI, and NC concerning AHI cutoffs [19]. Those findings correspond with our study, except gender and BMI, that were already high Tom et al. [20] revealed that NC measures correlate better than BMI according to AHI in BMI>30kg/m2 OSA participants. Several studies found the significant relationship between Mp and AHI [21, 22]. These findings were also in line with our study.
OSA patients are commonly known to have shorter sleep duration, short sleep latency, low sleep efficiency, and high arousal index, although the total sleep time was not different in patients without OSA. We assessed AAI, ESS, and HS grade in obese participants to examine OSA’s correspondence with sleep disturbance, daytime sleepiness. Several studies were pointing out the essential co-occurrence of poor sleep quality and quantity with obesity. Weight gain and a predisposing metabolic syndrome could cause non-alcoholic fatty liver; therefore, Arısoy et al. [4] examined HS’s co-occurrence with OSA and found a significant difference between the simple snoring and moderate and severe OSA groups. In this study, we did not find a significant HS grade difference between simple snoring and OSA groups. The examination of subgroups of OSA did not also reveal any difference. These findings could be explained by the BMI difference of participants who were invited to this study. In this study, all participants were obese patients, and only six of them didn show any comorbidity. A blinded radiologist evaluated 20 participants with Grade 1 HS, 17 with Grade 2 HS, and 17 with Grade 3 HS in our institute.
Daytime sleepiness was evaluated with Epworth sleepiness scale (ESS). In this study, we assess the correspondence of ESS with OSA and the severity of OSA. In clinical practice for day-time sleepiness evaluation most commonly used questionnaires are STOP, STOPBang (SB), Berlin Questionnaire (BQ), Epworth Sleepiness Scale (ESS), and 4-Variable Screening Tool (4-V) and among them SB has been shown to have the highest predictive sensitivity (%97,6) but the lowest specitivity, ESS has shown moderate predictive specitivity (%67) [23]. According to the American Academy of Sleep Medicine Clinical Practice Guideline 4; Berlin Questionnaire, ESS, STOP Questionnaire had a low quality of evidence across AHI cutoffs.
Technically adequate Home Sleep Apnea Testing (HSAT) devices are approved for use in diagnosis of OSA. In our study obese subjects that were found with AHI >30/h on follow- up were confirmed in local sleep labs and all of them AHI values was >30/h. All patients with AHI >15/h were referred to local sleep laboratories for confirmation of the diagnosis of OSA. In practice most sleep labs recommend PSG in patients only if a single home sleep apnea test is negative, inconclusive, or technically inadequate for OSA diagnosis [4]. According to those recommendations above, we decided to use an SC-micro device with 96.2% sensitivity and 91.7% specificity of analysis in our study [18]. This device not only gives detailed AHI results but also gives Autonomous Arousal Index (AAI) results by Pulse Wave Analysis (PWA). High values of AAI are known to be associated with hypoxia. It has been shown that AAI increases could have a negative effect on sleep fragmentation. According to this current trial’s AAI findings, we found a moderate negative correlation between AAI and SpO2-min and a moderate positive correlation between AAI and AHI. In line with the explanations above, this current trial reveals that increased OSA severity has a high impact on sleep AAI index values, which has a negative effect on sleep quality. Lack of waist circumference or visceral fat area measurement could be mentioned as a limitation of this trial. Another limitation could be the imbalanced number of obese patients according to gender. The last limitation that should be mentioned is using the Epworth Sleepiness Questionnaire rather than the STOP-BANG questionnaire. Although the study has some limitations, to the best of our knowledge, this is the first study that reveals AAI’s correspondence with obesity and OSA.
Conclusion
The age and anthropometric evaluation (Mp and NC) in obese patients provide a quick evaluation of OSA with HSAT devices’ concordance. AAI increases with OSA and the increscent severity of OSA. The recorded data of AHI and AAI indexes from the portable SC-micro device may be valuable to determine and evaluate in an uncomplicated patient with suspected OSA. HSAT devices are reliable, comfortable, easy to use, and cost-effective. More extensive scientific research needed to understand the effects of AAI in arousal . We think that the use of HSAT devices should be encouraged in the rapid screening of OSA patients, since they are a practical and inexpensive scanning method.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Hakan Silek, Fatma Ferda Kartufan, Arzu Gunturk, Aysegul Gormez. Simple predictors of obstructive sleep apnea in obese patients. Ann Clin Anal Med 2022;13(2):119-123
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Second hysterosalpingography in the evaluation of unilateral proximal tubal obstruction
Ramazan Ozyurt 1, Cemil Karakus 2
1 Istanbul IVF Center, 2 Vocational School of Health Services, Beykent University, Istanbul, Turkey
DOI: 10.4328/ACAM.20870 Received: 2021-09-22 Accepted: 2021-10-12 Published Online: 2021-10-19 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):124-126
Corresponding Author: Ramazan Ozyurt, Istanbul IVF Center, Istanbul, Turkey. E-mail: atasagun02@hotmail.com P: +90 532 748 34 90 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6822-2222
Aim: In this study, we aimed to test how often PTO persists in the second HSG of infertile patients with unilateral proximal tubal obstruction (PTO) in the first hysterosalpingography (HSG).
Material and Methods: One hundred patients who underwent HSG during the infertility work-up and were found to have unilateral PTO were included in the study. Forty patients who accepted our proposal of expectant treatment or intrauterine insemination (IUI) were excluded from the study. The remaining 60 patients underwent a second HSG in the next cycle, and the results were compared with the results of the first HSG.
Results: Bilateral tubal patency was detected in 35 of 60 patients who underwent a second HSG for PTO confirmation (58.3%). In the remaining 25 patients, unilateral PTO persisted (41.6%).
Discussion: In patients with unilateral PTO in the first HSG, performing a second HSG before planning further examination with laparoscopy or hysteroscopy provides bilateral tubal patency in more than half of the patients.
Keywords: Second HSG, Proximal Tubal Obstruction, Infertility
Introduction
Fallopian tube-related problems are one of the most common causes of infertility in couples applying to have a baby. Tubal pathology is found in at least one of three women diagnosed with primary infertility. Pelvic inflammatory disease, abdominopelvic surgery, ruptured appendix, a history of ectopic pregnancy, recurrent abortions or curettages may lead to injury of the tubes [1,2]. However, in many patients with tubal factor infertility, there is no clear underlying cause. Chlamydia antibodies are frequently encountered in this patient group [1,3].
Tubal pathology leads to infertility through the following mechanisms: it prevents sperm-egg meeting, the infected material in the tuba prevents implantation, healthy oocyte-pick-up cannot be done from the fimbrial tip [1-4]. Not every tubal pathology leads to equally serious infertility problems. The presence of two types of tubal pathology is accepted: distal or proximal. Distal tubal pathologies may be in the form of phimosis, incomplete or complete obstruction, or may be in the form of impaired tubal function despite healthy tubal patency [1,2]. Proximal tubal obstruction is not considered a true pathology by many authors. However, although there are established treatment protocols for distal tubal pathologies, there is no clear treatment for PTO. Therefore, the detection of PTO in hysterosalpingography (HSG) is a difficult situation to manage for both the clinician and the patient [1-4]. PTO may be a true pathology or it may be due to the following reasons: (i) Failure to inject radiocontrast material with sufficient pressure during HSG, (ii) insufficient traction to the cervix, (iii) involuntary contraction of the patient due to pain or pressure, (iv) reaction of the tubal ostia to the contrast injection in the form of contraction [1-4].
Whatever the underlying cause of PTO is, the reality of this pathology should be confirmed using other methods. Fallopian tube catheterization or laparoscopy are the two preferred methods for the evaluation of tubal patency in PTO cases [5]. However, since both methods are invasive and expensive, repeat HSG may be a more cost effective approach [4]. This study was planned to analyze whether PTO persisted in the second HSG in infertile patients with unilateral PTO in their first HSG.
Material and Methods
Primary infertile patients who applied to our IVF-clinic, who could not conceive spontaneously, were sent to HSG after anamnesis, routine hormonal evaluation and spermiogram analysis. One hundred patients with unilateral PTO as a result of HSG were included in the study. Patients with secondary infertility, with a history of previous ovarian or tubal surgery, pelvic inflammatory disease, hydrosalpinx, and bilateral or distal obstruction were not included in the study. One of three options was offered to all patients with unilateral PTO in their HSG; (i) expectant management, (ii) intrauterine insemination, (iii) second HSG. While 40 out of 100 patients accepted the recommendation of expectant management or IUI (40%), the remaining 60 patients requested a repeat HSG (60%). Sixty patients were given an appointment for the next cycle for the second HSG. The only primary outcome of our study was to find out if the PTO persisted. HSG details are detailed below. The study was started after obtaining patient consent and approval from the local ethics committee.
The same technique was used in both the first and second HSG so that the results were objectively comparable. The cervix of the patient in the supine position was visualized with a speculum. The anterior cervical lip was grasped with a single-toothed tenaculum and pulled. Following insertion of the metallic hysteroinjector into the cervical canal, 5 to 10 ml of radiopaque contrast medium was infused through the cervix into the uterine cavity, and three to six images were obtained to evaluate whether the infused contrast medium flowed through the endometrial cavity, fallopian tubes and subsequently into the peritoneal cavity. The first radiographic images were taken after the injection of 15-20 mL of oil-based contrast medium at low pressure into the patient in the supine position. An X-ray monitor was used to acquire images. If adequate opacification was not achieved or the PTO in the first HSG persisted, 15-20 mL of contrast medium was injected under high pressure. If necessary, the patient was turned from the supine position to the prone position. In the second imaging, the cervix was subjected to stronger traction with a single-tooth tenaculum. The images obtained from the first HSG and the images obtained from the second HSG were brought together and evaluated by the specialist radiologist and gynecologist, and it was recorded whether the PTO continued. Fallopian tube catheterization or laparoscopy is recommended in patients with persistent PTO in the second HSG. In both HSG procedures, no anesthetic or analgesic was used before or during the procedure. An oil-based contrast medium was used in both procedures.
Statistical analysis
Analyses of all data were performed on SPSS 21 (SPSS Inc., Chicago, IL, USA). The Mann-Whitney U test was used for analysis of continuous variables. Differences were considered statistically significant if the p-value was <.05.
Results
Sixty patients with unilateral PTO in the first HSG went to the second HSG. In the repeat HSG performed after one cycle, bilateral tubal patency was detected in 35 of 60 patients (58.3%). In 25 patients who underwent the second HSG, unilateral PTO continued (41.6%). In 35 patients in whom PTO persisted, the proximal passage could not be achieved, although the contrast agent injection was re-administered under high pressure. Again, it was determined that PTO was not resolved in HSGs performed by turning the patients in this group from the supine position to the prone position.
One of the following three methods was recommended to 25 patients with persistent PTO: (1) laparoscopy, (2) fallopian tube catheterization, (3) intrauterine insemination. As there are those who accept one of the three proposals as well as those who reject it the results of three interventions in our patients with persistent PTO were not presented in our study.
Discussion
The fallopian tubes are organs that allow bilateral germ cell transport and allow the maturing embryo to migrate back to the endometrium after fertilization. They keep the passage open with the help of tubal contractile properties and the ciliary cells lining them. However, changes in hormonal secretion according to the cycle may reduce both the contraction and ciliary activity of the tubes, leading to obstruction of the passage with mucus and debris. In addition, the access of peritoneal contents to the tubes or the passage of blood from the tubes into the peritoneum with retrograde menstruation may also cause temporary obstruction in the tubes. Pelvic infections, endometriosis, and ovarian cysts may also obstruct the tubabl passage. For all these reasons, obstruction of the passage at the proximal or distal level may be detected in one or both tubes during HSG. While distal occlusions are mostly due to an underlying disease, proximal occlusions may be transient [2-4,6].
Most of the proximal tubal occlusions detected on HSG scans develop due to debris and mucus plugs that occur in the tubes due to the physiological changes mentioned above. For this reason, in patients with PTO in the first HSG, the clinician should not be pessimistic and should inform the patient that the picture is not very important. In patients with PTO in the first HSG, it is of great benefit to perform a second HSG before confirming the obstruction with methods such as laparoscopy or tubal catheterization, which require technical experience and the use of a special set. Dessole et al [4] performed an HSG for the second time in their patients who had PTO in their first HSG and showed that the tubal passage was open in 60% of cases. Similarly, we found bialateral passage opening in the second HSG in 35 of 60 patients with PTO in their first HSG (58.3%). Lazer et al [7] performed tubal canalization in 58 patients with PTO in HSG and showed that the tubal passage was healthy bilaterally in 93.1% of cases. When all these studies and our study were evaluated together, performing a second HSG before invasive procedure in patients with PTO in their first HSG showed that the tubal passage was open in more than half of the cases.
However, tubal passage obstruction persisted in 41.6% of cases despite the second HSG. PTO persisted in patients whose passage could not be achieved, even when contrast agent injection was performed with high pressure. Changing the position of the patients and applying stronger traction to the cervix did not improve the persistence of PTO. Tubal canalization or laparoscopy was recommended for patients with persistence of PTO despite the second HSG.
Conclusion
As a result, in patients with unilateral PTO in the first HSG, approximately 60% of the passage opening is provided in the second HSG. Because of this high success rate, a second HSG should be performed before an invasive procedure can be confirmed in PTO cases. If PTO persists in the second HSG, tubal canalization or laparoscopy should be recommended. In addition, chlamydia antibody levels should be measured in these patients and positive cases should be treated.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
1. Yi G, Jee BC, Suh CS, Kim SH. Stimulated intrauterine insemination in women with unilateral tubal occlusion. Clin Exp Reprod Med. 2012; 39(2):68-72.
2. Miller JH, Weinberg RK, Canino NL, Klein NA, Soules MR. The pattern of infertility diagnoses in women of advanced reproductive age. Am J Obstet Gynecol. 1999; 181(4):952-7.
3. Veenemans LM, van der Linden PJ. The value of Chlamydia trachomatis antibody testing in predicting tubal factor infertility. Hum Reprod. 2002; 17(3):695-8.
4. Dessole S, Meloni GB, Capobianco G, Manzoni MA, Ambrosini G, Canalis GC. A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction. Fertil Steril. 2000; 73(5):1037-9.
5. Capitanio GL, Ferraiolo A, Croce S, Gazzo R, Anserini P, De Cecco L. Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure. Fertil Steril. 1991; 55(6):1045–50.
6. Sulak PJ, Letterie GS, Coddington CC. Histology of proximal tubal occlusion. Fertil Steril. 1987; 48(3):437–40.
7. Lazer T, Meltzer S, Saar-Ryss B, Liberty G, Rabinson Y, Friedler S. The place of selective hysterosalpingography and tubal canalization among sub-fertile patients diagnosed with proximal tubal occlusion. Arch Gynecol Obstet. 2016; 293(5):1107-11.
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Ramazan Ozyurt, Cemil Karakus. Second hysterosalpingography in the evaluation of unilateral proximal tubal obstruction. Ann Clin Anal Med 2022;13(2):124-126
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Clinical and laboratory characteristics of COVID-19 cases at the pandemic hospital of an anatolian province
Burak Kurt 1, Onur Acar 2
1 Republic of Turkey Ministry of Health, General Directorate of Public Health, Ankara, 2 Agri Provincial Health Directorate, Agri, Turkey
DOI: 10.4328/ACAM.20873 Received: 2021-09-27 Accepted: 2021-10-27 Published Online: 2021-10-31 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):127-130
Corresponding Author: Burak Kurt, Republic of Turkey Ministry of Health, General Directorate of Public Health, Ankara, Turkey. E-mail: kurtburak@msn.com P: +90 533 661 05 33 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8185-2146
Aim: Biochemical monitoring of COVID-19 patients is essential for assessing disease diagnosis, severity and progression, as well as monitoring therapeutic intervention. In this study, we aimed to investigate the clinical and laboratory characteristics of the cases followed up with the diagnosis of COVID-19.
Material and Methods: The study included 110 patients who admitted to Kastamonu State Hospital between 1-30 April, 2020 and diagnosed with COVID-19. Demographic, clinical and laboratory data of the patients were evaluated retrospectively.
Results: According to the presence of pneumonia, an increase in neutrophil, ALT and creatinine values, and a decrease in the leukocyte count were found to be statistically significant. When we took the cut-off value of 28.49 for CRP, 1.45 for NLR and 111.12 for PLR in our ROC analysis, all three values were found to be associated with pneumonia. In the logistic regression analysis, female gender, age over 50 years, and an NLR value above 1.45 increased the risk of pneumonia 2.6, 4.9, and 8.3 times, respectively.
Discussion: High NLR, CRP and PLR values were found to be associated with the presence of pneumonia.
Keywords: COVID-19, Pneumonia, Laboratory
Introduction
Coronaviruses are enveloped and single-stranded RNA viruses and are a large family of viruses that are infectious in humans and animals. At the end of 2019, a new type of coronavirus was first identified as the cause of pneumonia in Wuhan, China’s Hubei province. The disease caused by this virus, which spread rapidly and caused an epidemic throughout China, was named COVID-19 by the World Health Organization in February 2020, which means 2019 Coronavirus Disease [1].
COVID-19 is a global pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). As the number of individuals infected with COVID-19 continues to increase globally and its effects on health systems are observed, it is clear that clinical laboratories will play an important role, contributing to patient screening, diagnosis, follow-up and treatments [2].
Biochemical monitoring of COVID-19 patients is essential for assessing disease diagnosis, severity and progression, as well as monitoring therapeutic intervention. Defining laboratory tests that will contribute to the diagnosis and follow-up of COVID-19 patients is very important in terms of distinguishing between severe and non-severe cases, and identifying those at low or high mortality risk, in addition to the stage of diagnosis [3].
In this study, it was aimed to investigate the clinical and laboratory characteristics of cases followed up with the diagnosis of COVID-19 in April 2020 in the city of Kastamonu, located in Turkey in the western Black Sea.
Material and Methods
This study included 110 patients who admitted to Kastamonu State Hospital, which is the only pandemic hospital in Kastamonu, between 1-30 April 2020 and diagnosed with COVID-19. Demographic, clinical and laboratory data of the patients were evaluated retrospectively.
The data of the patients were accessed through the Public Health Management System. Approval for the study was obtained from the Turkish Ministry of Health, General Directorate of Health Services (Application number: 2020-05-09T13_45_21).
The diagnostic process in the study was carried out according to the diagnosis and treatment guidelines of the World Health Organization and the Turkish Ministry of Health. The patients were stratified into two groups: patients with and without pneumonia.
NLR and PLR were calculated as NLR = ratio of neutrophil count to lymphocyte count, PLR = ratio of platelet count to lymphocyte count.
Frequency and percentage were used as descriptive statistics for categorical data, and Chi-square, Fischer Exact and Cochran-Mantel-Haenszel tests were used for analysis of categorical data. Student T Test was used to analyze numerical data consisting of two groups. Logistic regression analysis was used for multiple variables. Receiver operating characteristic (ROC) analysis was performed to evaluate the cutoff values for continuous numerical variables. Statistical Package for the Social Sciences (SPSS) Version 20.0 (SPSS Inc., Chicago, IL, USA) program was used for statistical analysis. P <0.05 was considered significant.
Results
The mean age of the 110 patients included in our study was 40.2 ± 19.4 (min = 1, max = 90) years. The number of male patients was higher than the number of female patients (55.5% vs. 45.5%); 29.1% of the patients were healthcare personnel, 86.4% were urban residents, 13.6% were of foreign origin, 33.6% were in contact with a person previously diagnosed with COVID-19. Considering the clinical features, 56.4% of the patients were found to have pneumonia, only 3.6% of the 110 patients included in our study received intensive care treatment and 1.8% were intubated. Looking at the complaints at the time of application, 87.3% of the patients had at least one complaint. The most common complaints were dry cough (56.4%), fatigue (37.3%), muscle pain (36.4%), sore throat (23.6%) and shortness of breath (22.7%). While 98.2% of the patients were discharged with complete recovery, 1.8% of them died.
When the presence of pneumonia and biochemical parameters were compared, the presence of an excess of neutrophils (p <0.001), low lymphocyte count (p = 0.008), ALT elevation (p = 0.001), high creatinine (p = 0.028) and NLR elevation (p = 0.010) were statistically significant with the presence of pneumonia (Table 1).
In the ROC analysis, NLR (p <0.001), CRP (p = 0.001) and PLR (p = 0.002) values were found to be statistically significant. When the cut-off value is 1.45 for NLR, the area under the curve was 0.73, indicating a moderately useful diagnostic test. When the cut-off value for CRP was 28.49, the area under the curve was found to be 0.69, indicating a poor diagnostic test. When the cut-off value for PLR was taken as 111.12, the area under the curve was found to be 0.68, indicating a poorly useful diagnostic test (Table 2 and Figure 1).
When the relationship between the presence of pneumonia and NLR, PLR and CRP values were examined, a significant relationship was found between high NLR (p <0.001), PLR (p = 0.001) and CRP (p = 0.001) and the presence of pneumonia.
According to the Mantel-Haenszel Test Odds Ratio estimate, individuals over the age of 50, in women, and with an NLR ratio of 1.45 and above have a 6.41-fold risk of pneumonia (Common OR, CI: 2.32-17.72) (very significant level of significance (p <0.001)) than those who do not have these 3 characteristics.
Individuals with a CRP equal to or above 28.49 and an NLR of 1.45 and above are 4.18 times more likely to have pneumonia than those who do not have these three characteristics (Common OR, CI: 1.21-14). , 40) significantly (p = 0.023).
When the Odds Ratios for pneumonia risk were examined in logistic regression analysis, in women, the risk increased 2.62 times (95% CI 1.01-6.78), the age 50 years and over increased 4.85 times (95% CI 1.56-15.03), NLR 1.45 and over increased 8.25 times (95% CI 2.78-24.49) (Table 3).
Discussion
The average age of 110 patients included in our study was 40. The average age of patients according to a review study published in Turkey was 50 [4]. The low average age of the patients in our study was attributed to the general curfew above the age of 65 at the time of the study. Women accounted for 45% of our patients, and 55% were men. According to the same article, 48% of reported cases in Turkey were female and 52% were male [4]. Almost 30% of our cases were healthcare professionals. This high rate was attributed to the low number of daily tests performed at the time of our study and the healthcare personnel’s easier access to the tests. At the same time, healthcare professionals are regularly tested.
The most common complaints in our patients were dry cough (56%), fatigue (37%), muscle pain (36%), sore throat (24%), shortness of breath (23%). In a meta-analysis study, 58% of patients complained of dry cough, 31% of fatigue, 17% of muscle pain, 12% of sore throat, 23% of shortness of breath [5].
In the analysis performed according to the presence of pneumonia, an increase in neutrophil, ALT and creatinine values, and a decrease in the leukocyte count were found to be statistically significant. In a meta-analysis study on the subject, a 1.33-fold increase in neutrophil count, a 1.34-fold increase in ALT, a 1.09-fold increase in creatinine, and a 1.44-fold decrease in lymphocyte count were reported in severe patients compared to non-severe patients [6].
When we took the cut-off value of 28.49 for CRP, 1.45 for NLR and 111.12 for PLR in our ROC analysis, we obtained the highest sensitivity and specificity values. When we tested these cut-off values in our patients with and without pneumonia, all three values were found to be associated with the presence of pneumonia. In logistic regression analysis, female gender, age over 50 years, and an NLR value above 1.45 increased the pneumonia risk 2.6, 4.9, and 8.3 times, respectively. A study conducted in Denizli province in Turkey found that advanced age and high NLR values independently predict inpatient treatment [7]. In a study conducted in Sakarya province, statistical significance was determined between mortality and CRP, NLR and PLR values. The cut- off values calculated in that analysis were 67.78 mg / dl for CRP, 3.9 for NLR and 148.85 for PLR [8]. In a study conducted in China, the median NLR value in severe patients was dramatically higher than in non-severe patients (10.4 vs 2.6; P < 0.001). The NLR value equal to 5 was a boundary value worthy of reference, because more than 80% of severe patients had an NLR value greater than 5, and over 80% of non-severe patients had an NLR value less than 5 [9]. In another study conducted in Istanbul, the optimal NLR and PLR cut-off values for detecting prognosis were 6.27 and 312, respectively [10].
According to the COVID-19 guide published by the Turkish Ministry of Health, there is male dominance (male/female: 2: 1) in patients with severe disease (T.R. Ministry of Health, General Directorate of Public Health. Management of COVID-19 (SARS-CoV-2 Infection) Severe Pneumonia, ARDS, Sepsis and Septic Shock. Ankara, Turkey: T.C. Ministry of Health Publications, 2020: 6-7. In Turkish). In our study, we can attribute female dominance to the low amount of data.
Conclusion
In our study, high NLR, CRP and PLR values were found to be associated with the presence of pneumonia. It is thought that these parameters can help physicians to decide on the treatment planning of their patients due to their low cost, short time and easy operation. Considering the limitations of our study, the retrospective nature of our study may have caused selection bias. The small number of patients indicates the need for larger studies.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
1. Akgül, Ö. SARS-CoV-2/COVID-19 Pandemisi(SARS-CoV-2/COVID-19 Pandemic). Tıp Fakültesi Klinikleri Dergisi/ Journal of Medical Faculty Clinics. 2020; 3 (1):1-4.
2. Pourbagheri-Sigaroodi A, Bashash D, Fateh F, Abolghasemi H. Laboratory findings in COVID-19 diagnosis and prognosis. Clin Chim Acta. 2020; 510:475-82.
3. Memikoğlu O, Genç V. COVID-19. Ankara, Turkey: Ankara Üniversitesi Basımevi; 2020. p.29-35.
4. Üner S, Okyay P. Türkiye Sağlık Raporu 2020 (Turkey Health Report 2020). Ankara, Turkey: Hipokrat Yayınevi; 2020.p. 667-70.
5. Grant MC, Geoghegan L, Arbyn M, Mohammed Z, McGuinness L, Clarke EL, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): A systematic review and meta-analysis of 148 studies from 9 countries. PLoS ONE. 2020; 15(6):1-19.
6. Bao J, Li C, Zhang K, Kang H, Chen W, Gu B. Comparative analysis of laboratory indexes of severe and non-severe patients infected with COVID-19. Clin Chim Acta. 2020; 509:180-94.
7. Harbalıoğlu H, Genc O, Yıldırım A. COVİD-19 tanısı alan hastalarda yatarak tedavi görmeyi öngörmede 3 prediktör: yaş, laktat dehidrogenaz ve nötrofil/lenfosit oranı (3 predictors of inpatient care for patients diagnosed with COVID-19: age, lactate dehydrogenase and neutrophil / lymphocyte ratio). Pamukkale Tıp Dergisi/ Pamukkale Medical Journal. 2021; 14(1):57-62.
8. Güneysu F, Guner NG, Erdem AF, Durmus E, Durgun Y, Yurumez Y. Can COVID-19 Mortality be Predicted in the Emergency Room? J Coll Physicians Surg Pak. 2020; 30(9):928-32.
9. Liu L, Zheng Y, Cai L, Wu W, Tang S, Ding Y, et al. Neutrophil-to-lymphocyte ratio, a critical predictor for assessment of disease severity in patients with COVID-19. Int J Lab Hematol. 2021; 43(2):329-35.
10. Açıksarı G, Koçak M, Çağ Y, Altunal LN, Atıcı A, Çelik FB, et al. Prognostic Value of Inflammatory Biomarkers in Patients with Severe COVID-19: A Single-Center Retrospective Study. Biomark Insights. 2021;16:1-8.
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Burak Kurt, Onur Acar. Clinical and laboratory characteristics of COVID-19 cases at the pandemic hospital of an anatolian province. Ann Clin Anal Med 2022;13(2):127-130
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Comparison of the effects of ozone therapy and photobiomodulation on sciatic nerve injury in rats
Dilek Günay Canpolat 1, Türker Yücesoy 2, Halis Ali Çolpak 3, Özlem Tuğçe Çilingir-Kaya 4, Bircan Kolbaşı 5, Recep Saraymen 6, Habip Karatürk 6
Nükhet Kütük 2, Mehmet Canpolat 7
1 Department of Oral and Maxiloofasial Surgery, Anesthesiologist, Faculty of Dentistry, Erciyes University, Kayseri, 2 Department of Oral and Maxiloofasial Surgery, Faculty of Dentistry, Bezmialem Vakıf University, Istanbul, 3 Department of Oral and Maxiloofasial Surgery, Faculty of Dentistry, Alanya Alaaddin Keykubat University, Antalya, 4 Department of Histology and Embryology, Faculty of Medicine, Marmara University, Istanbul, 5 Department of Histology and Embryology, Faculty of Medicine, Medipol University, Istanbul, 6 Department of Biochemistry, Faculty of Medicine, Erciyes University, Kayseri, 7 Department of Pediatric Neurology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
DOI: 10.4328/ACAM.20877 Received: 2021-09-29 Accepted: 2021-10-27 Published Online: 2021-11-13 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):131-135
Corresponding Author: Dilek Günay Canpolat, Erciyes University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Kayseri, Turkey. E-mail: dgcanpolat@gmail.com P: +90 352 207 66 66 / +90 352 202 91 85 F: +90 352 438 06 57 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8985-6918
Aim: Studies on drugs or alternative therapies are still the main treatment options for PNI. In this study, we aimed to research the effects of PBM and OT on nerve repair in a rat sciatic injury model.
Material and Methods: 29 Wistar albino rats were divided into four groups: control (n = 2), sham (n = 9), OT (n = 9) and PBM (n = 9). After 30 days of surgery and treatments, tissue specimens and blood samples were taken for histological and biochemical processing. Histological evaluations were performed at light and electron microscopy levels. Myelin basic protein (MBP) and S100 from the rat serum were analysed also.
Results: The OT and PBM groups had a significant increase in regeneration of the sciatic nerve in light microscopic evaluation. In the PBM and OT groups, Schwann cells (SC) around the axons and also axons with a thin myelin sheath were seen, regarded as signs of the myelination process in transmission electron microscopy (TEM) examinations.
Discussion: OT and PBM both resulted in a good healing pattern for sciatic nerve injury in the rat model. Therefore, OT and PBM are considered to be simple and reliable alternative treatment methods for PNI.
Keywords: Ozone, Photobiomodulation, Sciatic Nerve
Introduction
Peripheral nerves cover a large distance before reaching the end organs and can therefore be damaged in several ways. The main cause of peripheral nerve injury (PNI) is trauma, but ischaemic events, infections, traction, compression, burn injury can also cause PNI. Unfortunately, the response to PNI does not involve mitosis or cellular proliferation as in other tissues of the body. After an injury, SC proliferate, co-migrate and regrow, thus providing a favourable substrate for axonal extension [1,2]. Regeneration differs according to the type of nerve injury or degree of damage. Motor and sensory function defects can lead to unwanted maladaptive clinical situations such as dysaesthesia, hyperreflexia and dystonia [3].
Management of neuropathic pain is a complex clinical condition for both the patient and the physician. Pharmacological treatment is generally the first step, which often includes several drugs. Nerve autografting has been the first choice and the ‘gold standard’ for repairing peripheral nerve defects. However, this technique has some disadvantages, such as a limited supply of available nerve grafts, permanent loss of the donor nerve function and potential differences in tissue structure and size. Although xenografts and allografts are common alternatives to autografts, they have lower success rates and may be subject to immune rejection [4-5].
Conservative therapies are thought to be useful for milder cases of PNI but a serious crushed nerve may result in Wallerian degeneration of the distal segment [6]. Ozone therapy (OT) and photobiomodulation (PBM) are two of the newer alternative therapies that have an advantage over treatments such as cryotherapy or acapuncture [7]. Ozone is an unstable gas with strong oxidizing power that has good antiseptic, disinfectant and antiviral properties for use on all surfaces. Ozone also works as an immunomodulator and shows long-term anti-inflammatory effects [8,10]. For a long time, OT has been used in numerous different areas of medicine for the treatment of: acute and chronic infections; ischaemic disorders; orthopaedic, dermatological, pulmonary, renal and haematological disorders; and neurodegenerative diseases [10,11
PBM, formerly known as low-level laser therapy (LLLT), has been performed to facilitate the regeneration of peripheral nerves for early recovery of patient functionality. LLLT was first used for this aim in the 1970s, with some inconsistency [12,13]. PBM has been shown to stimulate SC and increase myelin capacity, which is a good marker of axon healing [14]. Also, the positive effects of PBM shown on mental nerve injury and neuropathic pain have been reported in our previous study [7].
In the present study, the primary aim was to evaluate and compare the effectiveness of OT and PBM for treating sciatic nerve damage in rats histologically. A secondary aim was to evaluate the biochemical changes associated with sciatic nerve injury in rats.
Material and Methods
A total of 29 adult Wistar albino rats weighting 250–300 g were included in the study regardless of gender. Animals were given food and water ad libitum. Ethical consent was obtained from the ethical committee of Erciyes University (Erciyes University, Animal Local Etical Comity, 16/011).
Intramuscular xylazine was used for anaesthesia induction of the rats: 1 mg/kg (Ketalar, 50 mg/ml; Pfizer, New York, NY) and 0.5 mg/kg (Rompun, 23.32 mg/ml; Bayer, Mefar Ilac San. AS, Istanbul, Turkey). The dorsal third of the sciatic nerve was sutured according to Seltzer et al.’s [15], neuropathic pain model in rats. The skin incision of all rats was covered with resorbable 3-0 suture.
Rats were divided into four groups: in the control group (n = 2), intact nerve tissue from rats whose sciatic nerves were not ligated was collected as normal tissue; in the sham group (n = 9), the sciatic nerve was ligated surgically and no therapy was applied; in the PBM group (n = 9), sciatic nerve treated with PBM was collected; and in the OT group (n = 9), sciatic nerve treated with OT was collected.
PBM therapy
PBM group received the therapy with an OsseoPulse LED (Biolux Research Ltd, Vancouver, Canada) in contact mode to the sciatic nerve. PBM is applied at a 618-nm wavelength and with 20 mW/cm2 output power, during 21 days for 5 minutes daily. Total 6 J/cm2 dosage of the energy amount was used for the treatment of neuropathy which is suggested therapeuticdose for this situations [16].
Ozone therapy
In Group OT, treatment was appliedby a CA probes that contacted to the sciatic nerve area (MIO International Ozonytron GmbH, Munich, Germany) which was connected to the ozone generator (OzonytronXL, MIO International Ozonytron GmbH). The OT, during 60 seconds with 75% power, was applied as recommened. OT was applied once every 3 days, totaly 7 times to the rats’ sciatic nerves [16].
The rats sacrified just after taken 5 ml of blood samples from the heart for biochemical evaluations which was expected to support our study results. In the beginning, blood samples were taken to tubes and centrifuged 1200 (Rpm) rates during 12 minutes. The serum of the sample over the tube was taken with a pipet and stored into pellets at -20 oC. Before the ELİSA tests, serum samples which were frozen at -20 °C were defrosted for 2 hours at room temperature.
Histological evaluations:
In order to evaluate the specimens by transmissionelectron microscopy (TEM), the tissue samples obtained from animals were fixed in 2.5% glutaraldehyde solution in 0.1M PBS buffered (pH 7.2) for 4 hours at +4°C. Then the glutaraldehyde solution was washed with PBS and tissues were post-fixed with 1% osmium tetroxide solution during 1 hour at room temperature andpassed through rising alcohol series (%70-90-96-100) for dehydration. The samples were incubated bypropylene oxide/Epon mixture and embedded in Epon 812. The epon blocks were cut by ultramicrotome (Leica Ultracut R, Wetzlar, Deutchland) in semi-thin sections (900-1000um in thickness) and stained with toluidine blue. Sections were examined by BX-51(Olympus, Japan) light microscope for both semiquantitative analyses and determination of the proper areas which would be analyzed in TEM and then photographed with the DP-72 camera system attached to light microscope.
For Light Microscopic evaluation, photographs taken from at least three areas in x400 magnification were evaluated semiquantitativelyin terms of the presence of axons with thinmyelin layer and small diameter. The scoring system used as; ”0: None, 1: Mild, 2: Moderate, 3: Severe”. The observed scoring values were regarded as follows; ‘Axons with thin myelin layer and small diameter were accepted as myelinization begins and/or persists’ in the samples that had ‘’3-2: Severe-Moderate’’ score leveland ’Although the morphology of some of them is distorted, small-diameter thin myelinated axons are scattered between myelinated axons’. In the samples that had ‘’0-1: None-Mild’’ score level. In regards of the semiquantitaive evaluations, the specimens which had higher score level were accepted as having more regeneration activity than that of having lower score level.
For TEM examinations, the epon blocks were trimmed to get the proper areas. The thin sections in 80-100um thickness were cut by ultramicrotome (Leica Ultracut R,Wetzlar, Deutchland) on 200-mesh copper grids. Air-dryed grids were stained with uranyl asetate and lead citrate and evaluated in the TEM and photographed with SIS Morada camera system.
Biochemical Evaluations:
Rat MBP (Myelin basic protein S) Test and Rat S100 tests were performed as below with Wuhan Fine Biological Technology ELISA Kits. Absorbance values were obtained by reading in a 450 nm wavelength filter on an ELISA reader.
Statistically Analysis:
To summarize the biochemical data obtained from the study, descriptive statistics were given as a median-quarterly width for continuous variables. The normality test of numerical variables was checked with Kolmogorov Smirnov test. In independent group comparisons more than two groups, Kruskal Wallis H test was used in cases where the numerical variables did not show normal distribution. Statistical analysis was performed by Jamovi project (2018). Jamovi (Version 0.9.1.5) [Computer Software]. (Retrieved from https://www.jamovi.org) (open source), and the statistical analysis of the level of significance (p-value) was considered as p< 0.05.
Results
Clinical findings and observations
In this study, we observed that all of the animals for 24 hours after operation, showed that the rats were not completely paralysed.
Histological outcomes
Data from semi-quantitative evaluations obtained at the light microscopy level (Figure 1) showed that the OT and PBM groups had a significant increase in regeneration of the sciatic nerve.
Regular and normal myelin sheath morphology was seen in the control group and irregular myelin sheath morphology was detected in the sham group. Furthermore, axons with a thin myelin sheath were observed in both therapy groups.
In transmission electron microscopy (TEM) examinations, myelinated axons with regular morphology were seen in the control group whereas the structure of the myelin sheath was degenerated in the sham group. In the PBM and OT groups, SC around the axons and also axons with a thin myelin sheath were seen, regarded as signs of the myelination process (Figure 2).
Biochemical outcomes
There was no statistically significant difference between the groups when comparing the median values of two biochemical markers: myelin basic protein (MBP; p = 0.534, Table 1) and S100 calcium-binding protein B (S100B; p = 0.401, Table 1).
Discussion
According to our study results, PBM and OT were found to be reliable, promising and alternative treatment methods for PNI by improving regeneration of the sciatic nerve.
Several studies were performed to explain the pathophysiological mechanisms in PNI and histological differentiation. The goal of nerve damage treatment is to provide nerve integrity and conduction, along with restoration of the primary function of the nerve [17,18]. Actually, the human sciatic nerve does not damage easily. Rats are often preferred for studies into peripheral nerve regeneration because of the similarity of rat nerve branches to those of humans. Also, rat sciatic nerve includes axons of different sizes and types and is thus a multi-fascicular mixed-type nerve [19]. Although there are several behavioural tests for researching neuropathic pain in the literature, difficulty using these tests in practice for rats and also differences in sensibility of the researchers may affect the reliability of the measures [20,21]. Thus, we did not prefer behavioural tests in this study and aimed to show whether treatment-related improvement histologically could be supported by biochemical results.
Several treatment approaches have been applied to solve neuropathic pain, such as drug therapy alone or in different combinations or with interventional therapies [22]. Unfortunately, treatment success for neuropathic pain requires an interdisciplinary approach and this is not always possible. Pain reduction of at least 30% is generally accepted to be a clinically meaningful result [23]. PBM and OT are considered to be enhanced alternative therapy modalities [6]. In our study, PBM and OT provide healing in sciatic nerve damage histologically.
PBM has many constructive effects, such as reducing edema, inflammation and pain, and also has anti-inflammatory and analgesic effects with wound healing and bioactive properties. Furthermore, PBM (i.e. LLLT) has some of the healing effects on the nerve that are reported to increase myelin capacity and provide neural tube formation with SC stimulation [12]. LLLT is an energy that does not exceed 36.5°C is produced. This application is mainly non-thermal and biostimulatory due to its low energy output and density [22]. In this recent study, we preferred LED-mediated monochromatic infrared LLLT for obtaining the regenerative and biostimulant effect, at a wavelength of 618 nm and output power of 20 mW/cm2 for 5 min in each session over 21 days in rat sciatic nerve. In light microscopy semi-quantitative evaluations, regeneration findings were found. Also, in TEM examinations the structure of the myelin sheath was degenerated in the sham group where surgery was performed without any therapy. This result was an indication of the nerve damage that can be produced. We observed SC around the axons, and axons with a thin myelin sheath.
OT is thought to be based on the conversion of oxygen atoms in the environment to ozone following contact of a special type (probe) with the tissue [23]. Although the wound healing capacity of OT is known, studies in which neuronal regeneration has been followed with OT are rare in the literature. No clear information was found about the frequency of OT application, the power of the device or the duration of application in the literature. We administered OT once every 3 days over 21 days (totalling seven times) at 75% density and 60 s, as in our previous study performed in the mental nerve of rats, and found success for neuropathic pain [7]. In our previous study we found a higher number of SC after OT. In the present study we similarly observed SC around the axons as a myelination process in both light microscopy and TEM views.
As a result, PBM and OT were found to be effective for sciatic nerve injury in this study. At the beginning of the study we wondered if biochemical markers such as S100B and MBP may change with these treatment methods, which determined the basis of this study. In vitro and in vivo studies have shown that S100B has a neurotrophic effect on the regeneration of neurons after neuron damage and increases the neuronal protection properties during development [23]. S100B is a member of the S100 protein family and is responsible for the regulation of energy metabolism in brain cells. S100B is found not only in brain tissue and SC in the peripheral nervous system, under physiological and pathological conditions [24]. Iwasaki et al. [25] observed that neurons could maintain viability and that S100B reduced motor neuron loss. In this study, we researched S100B levels in control and other groups from blood. We detected that S100B was higher in the sham and treatments groups than the control group, although this result was not statistically significant. An increase in the level of MBP, the other main protein in SC in the peripheral nervous system, was also expected during nerve regeneration [26]. A meaningful increase or difference between the control and the sham or treatment groups didn’t observed. Healing in the sciatic nerve did not supported by biochemical findings. Perhaps if these markers were evaluated immunohistochemically from histological sections a different result would be obtained, because in some situations S100B cannot be detected in blood serum due to other cytokines released from T cells.
In current anaesthesiology settings, the sciatic nerve may be damaged during anaesthesiology application or with different surgeries, therefore improving new alternative therapeutic strategies for sciatic nerve damage and related neuropathic results is really important for anaesthesiologists and surgeons. There are many studies that have researched OT or PBM on sciatic nerve in the literature but this is the first original study to compare the effects of OT and PBM in rats with sciatic nerve injury using light microscopy and TEM.
A limitation of this study could be that we did not use behavioural tests; these may point out neuronal disorders in animal models by showing abnormal responses to sensory stimuli and supported neuropathy [27]. However, such stimulatory-mediated methods, applied with cold, warm or mechanical stimuli, are applicable to nerves that have more motor functions and also evaluation of the response of animals to physical or chemical stimuli can often be very subjective [27]. Thus, we did not use behavioural tests in this study, preferring more objective evaluations such as light and electron microscopy.
In conclusion, PNI that causes neuropathic pain is an undesirable, uncomfortable condition. Both OT and PBM are considered to be simple and reliable alternative treatments in the PNI model by partially suturing the sciatic nerve in the subject animals, although the superiority of OT and low-dose PBM is not proven in this study.
Acknowledgment
Because of the contributions he made to our study, we thank to Dr. Ozan Yaman from Kayseri City Education and Research Hospital.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: This study was financially supported by Scientific Research Council of Erciyes University, Project number: 6643.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20877
Dilek Günay Canpolat, Türker Yücesoy, Halis Ali Çolpak, Özlem Tuğçe Çilingir-Kaya, Bircan Kolbaşı, Recep Saraymen, Habip Karatürk, Nükhet Kütük, Mehmet Canpolat. Comparison of the effects of ozone therapy and photobiomodulation on sciatic nerve injury in rats. Ann Clin Anal Med 2022;13(2):131-135
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The effect of living areas on the mortality rates of the patients with hip fracture
Seçkin Özcan 1, Erdinç Genç 2, Abdurrahman Acar 3, Mustafa Fatih Daşçı 4
1 Department of Orthopedic Surgery, Yalova State Hospital, Yalova, 2 Department of Orthopedics, Bağcılar Education and Research Hospital, İstanbul, 3 Department of Orthopedic Surgery, Şırnak State Hospital, Şırnak, 4 Department of Orthopedic Surgery, Konya Cihanbeyli State Hospital, Konya, Turkey
DOI: 10.4328/ACAM.20883 Received: 2021-10-02 Accepted: 2021-11-04 Published Online: 2021-11-07 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):136-140
Corresponding Author: Seçkin Özcan, Department of Orthopedic Surgery, Yalova State Hospital, Yalova, Turkey. E-mail: seckinozcan1301@gmail.com P: +90 541 807 86 32 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9209-5865
Aim: This study aims to evaluate the postfracture short- and long-term mortality rates in patients with a hip fracture living in urban and rural areas.
Material and Methods: This study included patients with a hip fracture who underwent surgical treatment between January 1, 2014 and May 31, 2017 in two different cities. The pre- and post-operative living areas of the patients were determined using the hospital network and the national death information system. The clinical data of 522 patients treated for hip fractures caused by low-energy trauma who live in either the urban areas (212 women, 134 men) or rural areas (103 women, 73 men) were evaluated in this study.
Results: The age and gender distribution of the patients in urban and rural areas were similar. There was no statistically significant difference between the groups, according to side, fracture type and comorbidity. Although 1-month mortality rates were lower in patients living in urban areas than in patients living in rural areas, there was no statistically significant difference between the groups (p = 0.158). Mortality rates of 1-year and 3-year follow-up were significantly lower in the rural population (p<0.05).
Discussion: We concluded that living area, advanced age and the presence of multiple comorbid disorders are independent risk factors associated with post-fracture long term mortality in patients with hip fractures.
Keywords: Hip Fracture, Mortality, Urban, Rural
Introduction
Hip fractures, which are becoming more common due to the aging of the population, are one of the most important causes of mortality associated with orthopedics and traumatology in the elderly population. It has been estimated that the incidence of hip fracture patients will reach 2.6 million worldwide by 2025 [1-2]. Different factors such as age, gender, comorbidity, time to surgery, and treatment type have been detected to affect mortality rates in hip fracture patients. Individual factors (age, gender, and socio-demographic features) and the quality of the health care system are common reasons of morbidity and mortality [3]. There are important differences between urban and rural environments, such as social structure, education level, quality of the healthcare system, waiting times before surgery, and access to healthcare. Long waiting times before surgical treatment or the difficulty of accessing health care is an important risk factor that increases both complications and mortality rates in patients with hip fractures. Therefore, it is thought that urbanization affects mortality rates and complications after hip fracture [4, 5].
There have been studies examining the differences in hip fracture incidence between urban and rural living areas. However, the number of studies investigating the effect of differences in residence on mortality and complications following hip fracture is limited [6, 7].
In the present study, the effects of living in urban or rural areas on the mortality rates following a hip fracture were investigated. We hypothesized that the mortality rate is higher in the urban population and investigated the relationship between mortality rate and variables such as age, gender, duration before surgery, and comorbidity rate.
Material and Methods
This retrospective observational cohort study was conducted after the approval of our institution’s ethics review board and performed in accordance with the Declaration of Helsinki (Approval number: 2020.05.2.01.045.r1.57).
Hip fracture patients who underwent surgical treatment between January 1, 2014 and May 31, 2017 in two different cities were included in this study. Clinical records of patients were accessed with the International Classification of Diseases (ICD) code S72.0-1. The pre- and post-operative living areas of the patients were determined using the hospital network and the national death information system.
International standard definitions were used to compare rural and urban living areas. The Organization for Economic Development and Cooperation (OECD), which has been working on rural areas since 1988, classifies living areas as rural or urban according to population density. This classification system is used by the European Union and Turkey [8]. According to the Turkish Statistical Institute (TSI), living areas with population of more than 20000 are defined as urban areas [9]. The living areas of the patients included in our study were determined as rural or urban according to the definition of (TSI).
The clinical data of 522 patients treated for hip fractures caused by low-energy trauma who live in either urban areas (212 women, 134 men) or rural areas (103 women, 73 men) were evaluated in this study. Patients with incomplete medical or death records, under 65 years of age, treated conservatively, having contralateral hip fractures, having pathological fractures, open fractures, isolated trochanteric and subtrochanteric fractures, periprosthetic hip fractures and high-energy trauma fractures were excluded from the study.
All clinical data examinations included age, gender, fracture and treatment type, comorbidity (0-2, 3+), American Society of Anesthesiologists (ASA) scores (1-4), anesthesia type (general or regional), time to surgery. Demographic, clinical and survival data of the patients are presented in Tables 1 and 2. Patients were divided into two groups according to the type of fracture as pertrochanteric and transcervical groups. Patients diagnosed with pertrochanteric fracture were treated with proximal femoral intramedullary nail osteosynthesis; patients with transcervical fracture were treated with hemiarthroplasty surgery. Patients were also evaluated in two groups as having 2 or fewer diseases and 3 or more diseases according to the presence of comorbid disease. ASA scoring was determined as 1: healthy, 2: presence of mild systemic disease, 3: presence of severe systemic disease, 4: presence of severe life-threatening systemic disease, 5: patients without life expectancy without surgical intervention. During the follow-up of patients, the survival was checked from the national death information system; one-month, one-year and three-year survivals were determined.
Statistical Analysis
Numeric variables were given as mean ± standard deviation, categorical variables were given as frequencies and percentage. Statistical analysis was performed using SPSS 21.0 (SPSS Inc., IBM, NY, USA). Comparison of means was performed using Student t-test; comparison of frequencies was performed using the Chi-Square test or Fisher’s exact test. Then, significant variables with p-values <0.05 were inserted into a multivariate regression analysis to determine major predictors of 3-year mortality.
Results
Demographic and clinical data of the patients are presented in Table 1. The age and gender distribution of the patients in urban and rural areas were similar (p=0.544, p=0.150, respectively). There was no statistically significant difference between the groups, according to side, fracture type and comorbidity (p>0.05). Forty and thirty-nine percent of the patients who live in the urban and rural areas had 3 or more comorbidities, respectively.
The mean time to surgery was 2,95±1,27 days in the urban population, whereas it was 2,82±1,38 days in the other group (p=0.276). The average duration of surgery was 94,32±29,94 minutes for patients who live in urban area and 99,66±34,48 minutes for those who live in rural area (p=0.068). Although 1-month mortality rates were lower in patients living in urban areas than in patients living in rural areas, there was no statistically significant difference between the groups (p = 0.158). Mortality rates of 1-year and 3-year follow-up were significantly lower in the rural population (p<0.05) (Table 2). In logistic regression, living in urban areas was shown to increase the 3-year mortality risk as 1.8 times of the risks in rural life (p=0.04, OR 1.2-3.4, CI=95%). Three or more comorbidities and old age have been found as risk factors for 3-year mortality (p<0.01, p<0.01, respectively) (Table 3).
Discussion
Hip fractures are among the common fractures in the elderly population and generally require hospitalization and surgical treatment [2]. In worldwide, there have been few studies examining the differences in post-hip fracture mortality rates between urban and rural living areas [6, 7]. Our study is the first study on this subject in Turkey. In hip fracture patients, we examined individual data (such as age, gender, side, fracture type, comorbidity, ASA scoring, anesthesia type, duration of anesthesia, mean time until surgery) and survival states (1-month, 1-year and 3-year). According to our results, the risk of mortality after a hip fracture is higher in the long-term period among the urban population than among the rural population. These results were actually consistent with our hypothesis.
In the literature, it has been reported that there is an increase in the functional disabilities, complications and mortality incidences in the elderly population following a hip fracture [10]. Patients with hip fractures have been shown to have a 3-fold higher mortality rate than the normal population [11]. In several studies, the mortality rate following a hip fracture has been reported between 14-36% in a one-year follow-up [12, 13]. The main causes of high mortality rates are age, concomitant cardiac, pulmonary and renal diseases, smoking, and long waiting periods before surgery [10, 14]. Along with these factors, studies conducted in different countries/regions have shown that the urban-rural lifespan of patients affects the short and long-term mortality rates [6, 7, 15]. In the present study, we investigated the effect of living in urban and rural areas on mortality from hip fractures in the Turkish population. In addition to being the first study on this issue in Turkey, our study reported the highest number of hip fracture patients among long-term studies investigating the mortality rate in the Turkish population. The short-term mortality rate of patients was lower in urban life, while their mortality rates in the first and third years of follow-up were higher than the patients living in rural areas.
There are differences between urban and rural living populations in terms of environment, lifestyle, education level and access to the health services (The results of address-based population registration system, 2019. (2020, February). Turkish Statistical Institute Press Release. 33705) [16]. The risk of hip fracture in urban and rural populations has been investigated in many studies [17,18]. A detailed study by Tuzun et al. [19] examining the hip fracture incidence and the prevalence of osteoporosis in Turkey reported that the incidence of hip fractures was higher among urban population and among females. However, there are limited studies in the literature investigating the risk of mortality [3, 15, 20]. In our study, patients were evaluated in terms of age, gender, fracture side and type, duration until surgery, ASA scores, and anesthesia type. There was no significant difference in data of both groups, suggesting reliable, valuable and objective results of the study.
It has been shown that the rural population generally loses more time before the treatment of hip fractures than those living in the city [15]. Moreover, it has been reported in various studies that there is a disadvantage in reaching a physician lately in the rural population [16, 21]. The limited number of physicians in surgical branches in rural areas leads to concerns about delayed treatment planning and its adverse effects on the treatment outcomes [22]. In a study by Abrams et al, it was reported that access to high-quality cardiac care was more limited in the rural population, and lower revascularization and higher mortality rates were detected in this patient group [23]. In our study, we found that the 1-month mortality rate of the patients with hip fractures was higher among the rural population, but not statistically different from the urban population. Although we consider that this finding may be related to differences in delayed initial treatment and quality of early post-discharge care among urban and rural areas, more valuable results will be obtained from further nationwide cohort studies.
In the present study, in opposition to the results of early mortality rate, one-year and three-year long-term mortality rates were found to be significantly higher in the urban population compared to the rural population. The reasons of mortality following a hip fracture differ in early and late periods [11, 14]. Juhász et al. found a higher risk of developing contralateral hip fractures in the urban population than in the rural population, suggesting that this may be related to osteoporosis [20]. The lower long-term mortality rates in the rural population can be explained by the possible high level of physical activity. It has been shown that increased physical activity associated with daily and traditional lifestyles in rural life is associated with a lower mortality rate [6]. A better physical condition was also reported to be important in the rehabilitation process, which is very crucial in the treatment outcomes of a hip fracture [24]. On the other hand, in a two-year follow-up study by Mortimore et al., it was reported that a low social interaction was associated with high mortality rate following a hip fracture [25]. We suggest that increased physical activity and high social interaction in the rural population has a positive effect on long-term mortality rates of hip fracture.
The hip fracture patients who live in the city with the highest urban population and the city with a high rural population were included in this study (Turkish Statistical Institute Press Release. (2020, February). 33705). The results of our study indicate a public opinion for the urban-rural comparison in Turkey. Nevertheless, the main limitation of our study is that it is not a nationwide comparison of urban and rural populations, but a regional comparison of those living in two specific cities. Another possible limitation in our study is that patients were expected to live in the city where they were treated and evaluated accordingly. Finally, the mechanism of injury, BMI and bone mineral density that are effective in mortality among patients after a hip fracture were not taken into consideration due to the inadequate clinical records.
Conclusions
Although there was no statistically significant difference in mortality rates in the first month in patients living in urban and rural regions, mortality rates in 1 and 3 years were significantly higher in patients living in the urban area.
In conclusion, living in an urban area, presence of more than two comorbidities and old age increase the risk of mortality in patients with hip fractures in the long term.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Seçkin Özcan, Erdinç Genç, Abdurrahman Acar, Mustafa Fatih Daşçı. The effect of living areas on the mortality rates of the patients with hip fracture. Ann Clin Anal Med 2022;13(2):136-140
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COVID-19 infection in pregnancy: A single-center experience in Rize in the Eastern Black Sea Region
İlknur Esen Yıldız 1, İlkay Bahçeci 2, Unsal Bagın 1, Beril Gürlek 3, Ömer Faruk Duran 2, Uğur Kostakoğlu 1, Ayse Erturk 1
1 Department of Infectious Diseases, 2 Department of Medical Microbiology, 3 Department of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
DOI: 10.4328/ACAM.20888 Received: 2021-10-08 Accepted: 2021-10-27 Published Online: 2021-11-03 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):141-145
Corresponding Author: İlkay Bahçeci, Department of Medical Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey. E-mail: mdilkaybahceci@gmail.com P: +90 505 713 18 65 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3662-1629
Aim: In this study, it was aimed to share the clinical experiences of mothers and their babies (perinatal, natal) who encountered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy.
Material and Methods: The study was carried out retrospectively, 62 pregnant individuals were diagnosed with the 2019 coronavirus disease (COVID-19). Demographic characteristics, clinical course, laboratory and radiological findings and clinical results of the baby were evaluated by examining electronic and file records.
Results: The average age of the 62 pregnant women included in the study was 29.8±4.7 (19-42) years, and the average gestational week at the time of admission was 28.5±10.4 (5-40) weeks. More than half of the patients (80,6%) on admission were in their third trimester. The most common initial symptoms were cough (45.2%), myalgia (43.5%),) fever (21%). In total, 15 of the pregnant women had evidence of COVID-19 pneumonia in lung involvement. The PCR test results of all pregnant women were positive. There were three cases admitted to the intensive care unit, one of whom was due to gestational diabetes. No maternal mortality was recorded. One gestation ended in a miscarriage and two women gave birth prematurely. One stillbirth occurred at the 33h week of gestation. Among 22 neonates, two were admitted to the neonatal intensive care unit. Neonatal mortality, congenital malformation, and mother- to- child transmission were not observed in newborns.
Discussion: The results of our study suggest that the clinical course of COVID-19 infection in pregnant women was mostly asymptomatic/mild.
Keywords: COVID-19, Maternal Outcome, Pregnancy, Perinatal Outcome, SARS-CoV-2
Introduction
The 2019 coronavirus infection (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV 2) started as an epidemic and soon caused a pandemic all over the world and spread rapidly. Even though the COVID-19 virus usually causes non-symptomatic or mild, self-limited respiratory tract infection, it is more prominent in the immunocompromised patient group, including pregnancy. It causes more serious disorders such as viral pneumonia, acute respiratory distress syndrome (ARDS) and multisystem organ involvement, including gastrointestinal, cardiovascular and neurological (World Health Organization. Coronavirus Disease 2019 (Covid-19) Situation Report – 88. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation reports/. Accessed October 7, 2020). Today, its epidemiology, physiopathology and what kind of effects it creates in which type of patients are still not fully clarified, and research continues [1-3].
Pregnant women are prone to infections, especially respiratory diseases, both due to anatomical and physiological changes during pregnancy and due to immunosuppression. In addition, immature immune systems in the fetus and newborn make pregnant women vulnerable to infections. Outbreaks of coronavirus experienced in previous years, “Severe Acute Respiratory Syndrome (SARS) or Middle East Respiratory Syndrome (MERS)”, have been associated with serious consequences such as high mortality in pregnant women, their fetuses and newborns, and premature birth [4-9].
In the literature, the current COVID-19 outbreak is considered to pose a potential threat to pregnant women and their fetuses. However, data on the impact of COVID-19 infection on pregnancy are still limited, and clinical management algorithms and effective treatment of pregnant women infected with COVID-19 are not yet clear. Therefore, it seems that more data on the effect of the disease on pregnant women are needed. In this study it was aimed to share clinical experiences of mothers and their babies (perinatal, natal) who encountered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy.
Material and Methods
The study was conducted as a retrospective descriptive study. Patients who were followed up by the Department of Infectious Diseases and Clinical Microbiology of the XXXXXXXXXXX of Medicine with the diagnosis of COVID-19 in the first year of the pandemic and who had clinical symptoms and had compatible PCR positivity and tomography (CT) findings were included in the study. Demographic and clinical characteristics, laboratory and radiological findings and perinatal outcomes of the patients were analyzed with the data obtained from the patient follow-up and treatment form using the hospital registry system. Pregnant women were categorized according to the severity of the disease as asymptomatic, mild-moderate, severe-critical [10].
Pregnant women with mild to moderate pneumonia disease (fever, muscle, joint pain, cough, sore throat symptoms, respiratory rate<20/minute, SpO2>93%, lung involvement), pregnant women with severe-critical pneumonia disease (fever, muscle, joint pain, cough, sore throat symptoms and SpO2<90, respiratory rate ≥30/minute, diffuse lung involvement), pregnant women who are asymptomatic and who were followed up on an outpatient basis, pregnant women with clinical symptoms who did not accept treatment despite being offered treatment, and pregnant women diagnosed with respiratory tract pathogens other than COVID-19 were excluded from the study. The treatment protocol was chosen according to the Turkish Ministry of Health guidelines. Written consent was obtained from pregnant women for the examination and treatment protocols to be applied.
Ethical Approval
The study was approved by the Ethics Committee of Recep Tayyip Erdoğan University Faculty of Medicine Training and Research Hospital (protocol no 2021/110).
Statistical Analysis
Statistical analyses were done using SPSS version 21.0 (Chicago IL, USA). Data are presented as mean ± standard deviation, median (minimum-maximum), n (%) or n/N (%), where N is the total number of patients with available data.
Results
Among the patients examined within the scope of the study, 20 out of 82 pregnant women with a history of exposure to COVID-19 infection were excluded because their clinic was asymptomatic or they did not accept treatment. The average age of the 62 pregnant women included in the preliminary study was 29.8±4.7 (19-42) years, and the average gestational week at the time of admission was 28.5±10.4 (5-40). Most of the pregnant women (n=50 and 80.6%) were found to be infected with SARS-CoV-2 in the third trimester. When the application complaints were examined, it was determined that 45.2% (n= 28) cough, 43.5% (n= 27) myalgia, and 21% (n=13) fever were the most common complaints. The oxygen saturation of the patients at the time of admission was 92.42±7.51 (85-99). Five pregnant women had a pre-existing chronic disease (rheumatoid arthritis, renal failure, hypothyroidism, two chronic hepatitis B (HBV), respectively), one pregnant had a history of gestational diabetes and one of them had a history of gestational hypertension. The clinical features of the pregnant women, disease severity and treatment included in the study are summarized in Table 1.
At the time of admission, lymphocytes of the patients were 1399±598 (360-3350), neutrophil-lymphocyte ratio was 5.5±3.7(1.3-18.7), D-dimer (ng/ml) was 1.3±0.7(0-3.5) and CRP values were found to be 21.4±23.6 (0.4-110). Laboratory data are summarized in Table 2. Eight patients (12.9%) who had respiratory distress (oxygen saturation SpO2<93, respiratory rate ≥30/min) on hospitalization were screened for PAAC radiographs after obtaining their consent. Local infiltration was detected in two patients (3.2%) and bilateral infiltration in six patients (9.6%). Protected lung tomography was performed in seven patients (9.7%), and more than 50% pneumonic involvement was observed in all of them. In total, 15 of the pregnant women had radiological findings of COVID-19 pneumonia in lung involvement. COVID-19 PCR test of all pregnant women was positive.
Antiviral treatment was given to 23 pregnants, treatment was started in 15 pregnants during pregnancy and eight pregnants after birth. Hydroxychloroquine (HCQ) treatment was not applied to any of the pregnant women. Lopinavir-ritonavir treatment in 17.7% (n=11) of pregnant women (for a mean duration of 7.7±3.2 (2-10) days) and remdesivir treatment in 6.4% (n=4) of pregnant women (for five days). Favipiravir treatment was given to 14.5% (n=8) of the pregnant women followed immediately after birth (for five days for four, for ten days for four). Favipiravir treatment was administered in 75% (n=6) of the patients at 37 weeks and above, 25% (n=2) of them at a gestational age below 32 weeks after giving birth.
Low molecular weight heparin (LMWH) was administered to 73% (n=46) of the pregnant women (mean 17.1±11.9 (3-68) days) and followed up. During the follow-ups, 15.9% (n=10) of them were treated with steroids (on average 17.4±17.4 (2-60) days). Three pregnant women received 250 mg of pulse steroid for three days, followed by 6 days of low-dose steroid, and seven pregnants received low-dose steroids for five days. All pregnant women who were started on steroids received oxygen support. Diffuse bilateral infiltration and low Sat O2 (Sat O2 84 and 85) were present in CT scans of two pregnant women who had to perform premature labor.
Only three pregnants were followed up in the intensive care unit (ICU), two of them were intubated and connected to mechanical ventilation. One was followed up in the ICU for five days and the other for three days, and then she was taken to the service. Both pregnant women were discharged in good health, after 14 days and 70 days of hospitalization. Reservoir mask and continuous positive airway pressure (CPAP) treatment was applied to the other pregnant woman. The pregnant woman, who was hospitalized in the intensive care unit due to gestational diabetes complications, gave a stillbirth at 37 weeks of gestation. She was discharged after three days of follow-up in the ICU and seven days in the service. No maternal mortality was observed in any of the pregnant women.
During the research period, 23 (37.1%) of the pregnant women gave birth; 86.7% (n=20) of the deliveries resulted in cesarean section, 8.7% (n=2) were live births by vaginal route, and 4.3% (n=1) resulted in abortion. The mean gestational week of 22 live-born babies was 36.5±5.4 (28-40), mean birth weight was 3047±562 (1900-3940) gr, and the APGAR score was 8.1±1.3 (3-9). The number of births under 2500 g was four, and the APGAR score of a baby was three at birth. Fetal distress symptoms occurred in two babies and hospitalization in the Neonatal Intensive Care Unit was required. Both babies were discharged from the ICU after one week of follow-up with CPAP treatment without the need for mechanical ventilation. Neonatal mortality and congenital malformations were not observed in any of the 22 infants with available data. The SARS-CoV-2 PCR test was performed on postnatal nasopharyngeal swab samples from only eight infants and the result was negative.
Discussion
Although it is thought that COVID-19 infection may pose a potential threat to pregnant women and their fetuses, this situation has not yet been clearly clarified. Data on this subject are limited and research is still ongoing [11-15]. In the study, the clinical course of COVID-19 was very severe in only three out of 62 pregnant women and needed ICU admission. However, none of the pregnant women died. Almost all live-born babies did not need ICU and were discharged in good health, except for two. These findings showed that the course of SARS-CoV-2 infection was not unfavorable for the followed-up pregnant women and their fetuses.
It has been observed that there are not enough studies on the effects of COVID-19 on pregnancy, maternal and perinatal outcomes, and the existing ones are mostly descriptive [13,15]. Similarly, in our study, it was carried out descriptively. It has been reported that pregnant women are susceptible to many viral infections, especially respiratory tract, due to a suppressed immune system during pregnancy. It has been observed in studies and in our own experience that infections in previous years (SARS-CoV, MERS-CoV and influenza) were more severe and even mortal in pregnant women [9,10]. However, studies on how the course of COVID-19 progresses or will progress during pregnancy are limited, and it is thought that it will become clear in time.
It has been observed that pregnant women may present with asymptomatic and different symptomatic pictures due to COVID-19 infection. In the study of Khalil A et al., it was reported that the complaints of pregnant women infected with COVID-19 were primarily cough and shortness of breath, while in the study of Akhtar H et al, fever was the most common and cough was the second most frequent complaint [14,15]. In our study, although cough was the most common reason for admission, it was found that pregnant women applied with the complaints of widespread myalgia and fatigue. This situation may be caused by many reasons such as regional and immunological.
In the literature, different maternal, fetal and perinatal outcomes have been reported in studies on the course of COVID-19 during pregnancy. While positive clinical experiences were reported in some of the studies, others emphasized that the results were not good [16-21]. It has been reported that the most common adverse outcome is iatrogenic preterm birth, however, there is no or very little intensive care transfer, and the mortality of both pregnant women and their babies is rare (<1%). However, in some studies, on the contrary, it has been determined that there are no positive developments. It has been reported that pregnant women have more concomitant maternal comorbidities, and the prevalence of COVID-19 is high in studies reported to be accompanied by adverse effects. In our study, it was observed that the maternal and perinatal clinical course was positive, and no maternal deaths or serious consequences were detected. There was no infant death except for the stillbirth of the mother with a history of gestational diabetes. However, the low number of infected pregnant women and the fact that there are not many comorbid and accompanying predisposing diseases may be related to the positive results. Also, the study is not generalized as it reflects a small population. It should be supported by more comprehensive studies more data.
Although different antiviral treatment regimens are recommended in various guidelines for the management of pregnant women infected with COVID-19, there is still no proven efficacy and safe treatment option. However, it has been observed that there is often antiviral treatment experience in the studies in the literature. In our country, the treatment of pregnant women begins in line with the recommendations of the COVID-19 Diagnosis and Treatment Guidelines, which were created and constantly updated by the Ministry of Health of the Republic of Turkey for the management of COVID-19 patients, and according to the severity of the infection. In our study, antiviral drugs were given to less than half of the pregnant women, and unlike other studies, fewer antiviral drugs were used. In addition, empirical antibacterial therapy was not initiated.
It is not yet clear whether there is direct transmission from mother to baby in COVID-19 infection. However, it was observed that there was no transition in most of the studies in the literature. In the review that evaluated 2567 pregnant women, it was stated that neonatal SARS-CoV-2 PCR positivity is rare, but the issue will become clearer as the information on this subject accumulates, but the lack of a universal test for SARS-CoV-2 (90% of pregnant women infected with SARS-CoV-2) being asymptomatic) has been reported as the non-standardization of prenatal surveillance, management, timing, and mode of delivery of women with COVID-19 [14,15]. The PCR test was performed in only eight of the newborns in our study, and the results were negative in all infants, suggesting that the possibility of transmission from mother to infant may be quite low, but this should be supported by studies with more data. The results of our study and other studies may be related to the direct effects of SARS-CoV-2, as well as indirect effects of COVID-19 (changes in maternal care, screening, maternity care delivery) with changes in the immune system caused by pregnancy. In addition, conditions such as an insufficient number of PCR tests and a lack of interlaboratory standardization may also cause different results in studies. Measuring and reporting outcomes may allow for more objective effects of COVID-19 on maternal and perinatal outcomes.
In our study examining the effects of COVID-19 infection on pregnancy, a significant portion of pregnant women were infected with COVID-19 in the third trimester or after birth. For this reason, no meaningful interpretation could be made about the results of viral exposure in the early stages of pregnancy and after. It is thought that these time-consuming situations will be better clarified as data are shared in the future. Exposure of pregnant women to the virus in the late period may be effective in not worsening our maternal and perinatal outcomes.
Instudies in the literature, mother-to-child transmission could not be evaluated clearly with the available data. It is reported that more data and comprehensive studies are needed to answer questions about the possibility of vertical transmission, how often and how vertical transmission of the virus occurs [14-18,21-23]. In our study, it was not possible to say that there was no vertical transmission in a very small number of newborn babies, since the COVID-19 PCR test was not performed and direct testing was not performed for breast milk, cord blood or amniotic fluid to evaluate fetal transit. Today, information about the pregnancy and postpartum effects of COVID-19 infection is still not clear, and further studies are needed [21-23].
Limitations
Our study had important limitations such as being descriptive, single-center and not randomized. First of all, our data were small because we included only the patients we followed up and consulted, and there were missing data because the study was conducted retrospectively. In addition, there were ongoing pregnancies that precluded evaluating the outcome of all patients with COVID-19 infection. Another limitation of ours was that only eight newborns were tested for SARS-CoV-2, and no direct testing was performed for breast milk, cord blood, or amniotic fluid to assess possible maternal-to-fetal transmission.
Conclusions
In conclusion, most of the pregnant women in the study had a favorable clinical course of COVID-19 infection and no maternal death. We cannot rule out mother-to-child transmission with available data, therefore further studies are needed to answer the questions about possibility of vertical transmission. In the study, it was observed that clinical follow-up of the infection was positive in pregnant women and their babies infected with COVID-19. However, it is thought that the course will become clearer with studies in which more and standardized data are available and long-term follow-up results of infected mothers and their babies are shared.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20888
İlknur Esen Yıldız, İlkay Bahçeci, Unsal Bagın, Beril Gürlek, Ömer Faruk Duran, Uğur Kostakoğlu, Ayse Erturk. COVID-19 infection in pregnancy: A single-center experience in Rize in the Eastern Black Sea Region. Ann Clin Anal Med 2022;13(2):141-145
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Methylene blue ameliorates colonic injury in acetic acid-induced colitis model
Yusuf Tanrıkulu 1, Ceren Sen Tanrıkulu 2, Fahriye Kılınç 3, Murat Can 4, Furuzan Köktürk 4, Süleyman Kargın 1, Gökhan Yılmaz 5
1 Department of General Surgery, Faculty of Medicine, KTO Karatay University, Konya, 2 Department of Emergency Medicine, Health Sciences University, Konya Education and Research Hospital, Konya, 3 Department of Pathology, Faculty of Medicine, Necmettin Erbakan University, Konya, 4 Department of Biochemistry, Faculty of Medicine, Bulent Ecevit University, Zonguldak, 5 Department of General Surgery, Faculty of Medicine, Medipol University, Istanbul, Turkey
DOI: 10.4328/ACAM.20889 Received: 2021-10-09 Accepted: 2021-11-11 Published Online: 2021-11-13 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):146-150
Corresponding Author: Yusuf Tanrıkulu, Department of General Surgery, Faculty of Medicine, KTO Karatay University, 42020, Karatay, Konya, Turkey. E-mail: drtanrikulu@hotmail.com P: +90 505 657 97 09 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8432-2119
Aim: Inflammatory bowel disease (IBD) is a serious health problem affecting the quality of life. IBDs caused by various pathophysiological mechanisms, including genetic, immunological, inflammatory, and environmental factors. Although it has been widely investigated, treatment of IBDs remains a difficult clinical problem. We aimed to investigate the healing of mucosal damage and anti-inflammatory effects of methylene blue (MB) in experimental colitis model.
Material and Methods: Twenty-eight rats were randomly divided into four equal groups: group 1 (Sham), group 2 (control), group 3 (topical treatment), and group 4 (topical and systemic treatment). In groups 2, 3, and 4, acetic acid-induced colitis model was created. Normal saline to group 2, topical MB to group 3, and topical and systemic MB to group 4 were given.
Results: The levels of hydroxyproline were lower in the treatment groups than in the control group (p=0.017 for group 3 and p=0.004 for group 4). There was no difference between groups according to the TNF- α levels. The results of macroscopic scores were significantly lower in treatment groups (group 3-4) than in the control group (group 2) (p=0.005 for group 3 and p=0.002 for group 4). There was a significant difference between the treatment groups and the control group according to the epithelial loss and inflammatory infiltrate (p=0.022 for group 3, p=0.026 for group 4 for both histopathological values).
Discussion: MB ameliorates colonic injury in acetic acid-induced colitis model. This effect of MB was observed both locally and with local + systemic administration.
Keywords: Acetic Acid, Colitis, Inflammatory Bowel Disease, Methylene Blue, TNF-α
Introduction
Inflammatory bowel disease (IBD) – Crohn’s disease (CD) and ulcerative colitis (UC), a systemic disorder involving primarily gastrointestinal tract, may be affecting the quality of life of patient promptly. IBD is caused by various pathophysiological mechanisms such as genetic, immunological and environmental factors. Patients with IBD mostly admit to the health care centers with abdominal pain, diarrhea, with or without blood [1,2]. Sulfasalazine, mesalazine, and steroids are the conventional medications for IBDs. In cases where patients do not respond to these medications, immunosuppressive agents such as azathioprine and cyclosporin that have significant side effects are used [3].
Many experimental colitis models have been developed for IBDs. The most widely used models are using chemical agents such as trinitrobenzene sulfonic acid (TNBS), acetic acid, dinitrochlorobenzene, dextran sodium sulfate, peptidoglycan, and polysaccharide. These agents, used to create the colitis model can be administered through the, through drinking water or gastric lavage, or via multiple intramural injections [4]. Acetic acid (AA) administration is one of the models for experimental colitis in rats [5].
In the pathogenesis of IBDs, both the natural (macrophages and neutrophils) and acquired (T and B lymphocytes) immune responses and the loss of tolerance against the bacteria in the enteric flora play key roles. The main change seen in the natural immune response is increased number of macrophages and dendritic cells activation in the lamina propria [7].
Hydroxyproline is an important constituent of the major structural protein, and plays a key role in the synthesis and stability of collagen. A normal and stable cellular structure of the extracellular matrix is a sign of complete wound healing process after tissue injury. Increased hydroxyproline content in granulation tissue is the indicator of increased collagen turnover, which indicates better maturation and proliferation of collagen during wound healing [7].
Methylene blue [MB], identified by Ehrlich in 1981, is widely used for its anti-adhesive and anti-inflammatory features. The most common medical applications of MB are refractory distributive shock, carbon monoxide poisoning, methemoglobinemia, corrosive esophageal injury, and encephalopathy [8]. In inflammation, although the main effect of MB is still not fully clarified, it shows its effect by inhibiting nitric oxide synthesis, increasing the antioxidant capacity, and reducing fibrinolytic activity [9,10]. We aimed to investigate the anti-inflammatory effects of MB in experimental colitis model in rats.
Material and Methods
Study Design and Animals
The experimental procedures were made based on the Turkish Guidelines for Laboratory Animals after obtaining approval from the local Ethics Committee for Animal studies at Bülent Ecevit University (Date/Number: 2014/13). Twenty-eight adult male Wistar-Albino rats, weighing 260±30 g, were used in the study. The rats were individually maintained at normal room temperature (21±1 °C) and fed with a standard diet and water. The animals were deprived of food for 12 hours before anesthesia. However, no water restriction was performed 2 hours before anesthesia. No enteral or parenteral antibiotics were administered at any time.
Induction of Colitis
The rats were anaesthetized with intramuscular ketamine (50 mg/kg) and xylazine (6 mg/kg). After inducing anesthesia, 1 mL of acetic acid (AA) (5%) in isotonic saline was instilled using a soft 6-Fr pediatric catheter inserted into the anus up to 6-8 cm. Eventually, after 15-20 seconds of exposure, the fluid was withdrawn. Before the withdrawal of the catheter, 2 mL of air was applied to distribute AA in the colon. In the treatment groups, the MB was administered one hour after induction. This experimental model has been shown to have similar histopathological features in human colitis [11].
Experimental Groups
Twenty-eight rats were randomly divided into four equal groups. The colitis model was produced in all groups except the sham group.
Group 1 (Sham): After each rat was rectally given saline, 1 mL of saline was intraperitoneally applied.
Group 2 (Control): After the colitis model occurred, 1 mL of saline was intrarectally applied. No treatment was given.
Group 3 (Topical treatment): One hour after the colitis model was occurred, a dose of 2 mL of 1% MB (Blumet®, Defarma, Tekirdağ, Turkey) was rectally applied. The rats were incubated for 10 min in a Trendelenburg position to provide sufficient mucosal contact with the drug. Subsequently, 1 mL of saline was intraperitoneally administered.
Group 4 (Topical+Systemic treatment): One hour after the colitis model occurred, 2 mL/kg of 1% MB was rectally administered. The rats were kept in the Trendelenburg position for 10 minutes to ensure adequate drug-mucosal interaction. Subsequently, a 0.1 mL dose of 1% MB was administered intraperitoneally to each rat as a single daily dose for ten days.
On the tenth day, the abdomen and thorax were opened through a midline incision under anesthesia. Blood samples were taken by cardiac puncture method for biochemical analysis, and the rats were sacrificed by the same method. Later, the distal 8 cm of the colon was excised for histopathological evaluation.
Histopathological Evaluation
Mucosal injury was evaluated macroscopically using the grading scale of Morris et al. just after being washed with saline solution. According to this scoring system, no damage is calculated as 0 points, localized hyperemia, but no ulcers are 1 point, linear ulcers with no significant inflammation are 2 points, linear ulcer with inflammation at one site is 3 point, two or more sites of ulceration and/or inflammation are 4 point and two or more major sites of inflammation and ulceration or one more site of inflammation and ulceration extending >1 cm along the length of the colon is 5 points [3]. A single well-experienced pathologist who was also unaware of the study design, examined each specimen. For this examination, 8- cm distal colon sections were taken. In the colon tissue samples, 10% neutral formaldehyde was used and then followed by the paraffin embedding technique. Tissue samples were obtained with a thickness of 4 μm and stained using hematoxylin-eosin (H&E), and then analyzed under a light microscope (Olympus BX53, Tokyo, Japan). The degree of inflammation of the colon was graded semi-quantitatively from 0 to 11 according to the criteria defined by Özgün et al. (Table 1) [12].
Biochemical Analysis
Blood
Blood was collected into tubes at the time of death. Blood samples were centrifuged at 1000 g for 10 minutes at 4oC to remove plasma. Aliquots of the samples were transferred into polyethylene tubes to be used in the assay of biochemical parameters and were stored at -80oC until analysis. TNF-α levels were measured in the serum using a rat TNF alpha ELISA kit (Eastbiopharm, Hangzhou) on fully automatic devices.
Tissue
All tissues were washed twice with cold saline solution, placed into glass bottles, labeled, and stored in a deep freezer (-80oC) until processing. Colon tissues were homogenized in 10 volumes of 150 mM ice-cold KCL using a glass Teflon Homogenizer (Ultra Turrax IKA T18 Basic; IKA, Wilmington, NC, USA) after cutting the tissues into small pieces with scissors (for 2 minutes at 5000 rpm). The homogenate was then centrifuged at 5000 g for 15 minutes. The supernatant was used for analysis. Later, spectrophotometry was used to detect tissue hydroxyproline concentrations, and the results were denoted as micrograms per milligram of tissue [13]. First, the samples, standards, and streptavidin-HRP were added to the well. The antibodies were labeled with an enzyme and the plate was incubated for 60 minutes at 37ºC. The plate was washed five times and chromogen solutions were added. The plate was incubated for 10 minutes at 37ºC and stop solution was added into the wells. The optical density (OD) was measured at 450 nm wavelengths with a microplate reader.
Statistical Analysis
The analysis of the results was carried out with the SPSS (Statistical Package for Social Science) for Windows 19.0 package program. Data normality was determined using the one-sample Kolmogorov-Smirnov test, and then the Kruskal-Wallis variance analysis was used for continuous variables. While the continuous variables were given as mean± standard deviation, non-continuous variables were expressed as median (min-max). The Chi-Square test was used to compare non-continuous variables. A p-value of less than 0.05 was considered statistically significant for all tests.
Results
Comparison of the groups according to the hydroxyproline and TNF-α levels is shown in Table 2. The levels of hydroxyproline were significantly lower in the treatment groups (group 3 and 4) than in the control group (group 2) (p=0.017 for group 3 and p=0.004 for group 4). The levels of hydroxyproline were lower in the sham group than that in treatment ones (no statistically significant difference). In contrast, TNF-α levels were lower in the treatment groups than that in group 2 (p=0.176).
The results of the histopathological examinations are summarized in Table 3 and Figure 1. The method described by Morris et al. [3] was used to assess macroscopic injury in the colon wall. The sham group seemed to have numerous goblet cells in the mucosal surface and crypt epithelium and sparse mononuclear cells in lamina propria, and mucosal structure was similar to the normal colon mucosa. The macroscopic scores were found to be significantly lower in the treatment groups (group 3-4) than that in the control group (group 2) (p=0.005 for group 3 and p=0.002 for group 4). Microscopic damage was evaluated according to criteria defined by Özgün et al. [14]. There was no difference between groups in terms of integrity of crypts and stress to goblet cells (p=1.000 and p=0.261, respectively). There was significant difference between the treatment groups and the control group according to the epithelial loss and inflammatory infiltrate (p=0.022 for group 3, p=0.026 for group 4 for both histopathological values). Total damage score was significantly lower in the group 4 compared to the control group (p=0.006).
Discussion
There are few studies investigating the effect of MB on the colitis model, although there are many experimental and clinical studies on colitis in the literature. Our results showed for the first time in the literature that intraperitoneal (systemic) and intrarectal (local) application of MB may reduce the severity of underlying inflammation among the rats with AA-induced colitis model.
IBDs are a chronic inflammatory disease of the gastrointestinal tract that are diagnosed based on clinical, endoscopic and histological findings. Although the combination of environmental, genetic and immunoregulatory factors has been hypothesized in the pathogenesis of the disease, the pathogenesis is still unclear. The generally accepted opinion in the pathogenesis of IBD is an inappropriate response of the mucosal immune system to the intestinal flora and other luminal antigens, which leads to inflammation [14].
Many proinflammatory cytokines (TNF, IL-2, IL-6 or INF) are upregulated in IBD. TNF is the main mediator of intestinal inflammation, and it is synthesized by many cells and activates many genes with NFKB pathway. Oxidative stress and reactive oxygen products play key roles in the development of IBD as well as in inflammatory activation. Reactive oxygen products with pro-inflammatory mediators eventually lead to mucosal ulceration and disruption. Therefore, the effect of various antioxidants and anti-inflammatory agents was investigated in experimental models of IBD [10,15].
MB has both anti-adhesive and anti-inflammatory properties. Although the main mechanism of action of MB is currently unknown, it is thought that its primary effect is associated with the nonselective NO synthesis inhibitor. Namely MB acts on both constitutive NO synthase isoforms as well as on inducible NO synthase isoform (15). Using this effect, MB has been used as an anti-adhesive in many studies [9,10]. MB also inhibits the generation of oxygen radicals as an electron acceptor. The main effect of MB in inflammation is still not fully clarified today, but this effect of MB is thought to be associated with inhibition of NO synthesis [16]. A previous study [17] suggested that MB may reduce expressions of adhesion molecules and pro-inflammatory cytokines. Dinc et al. [16] found that MB given intraperitoneally may prevent the AA-induced colitis via attenuation of oxidative stress and inflammatory pathway. In our study, even though it was not statistically significant, we showed a lower level of TNF-α in treatment groups.
In experimental colitis models induced by acetic acid, hyperemia, edema, linear ulcers and inflammation in the colon tissues indicate macroscopically inflammatory bowel disease [13]. In microscopic examinations, disruption of mucosal barrier, decrease in goblet cells and crypts, widespread cryptitis and crypt abscess, inflammatory cell growth and loss of mucus in lamina propria are defined as important histopathological findings for the diagnosis of ulcerative colitis [18]. Dinc et al. [16] found that MB given intraperitoneally reduces microscopic and macroscopic injury. Similarly, Çetinkaya et al. [19] showed that acetylcysteine has beneficial effects on acetic acid-induced colitis in rats.
Hydroxyproline is an important constituent of the major structural protein, and plays a key role in the synthesis and stability of collagen. Hydroxyproline is an important indicator of collagen accumulation. Deficiency of protein during wound healing may diminish new capillary development, fibroblast proliferation, collagen and proteoglycans synthesis and remodeling and contraction of the wound. A normal and stable cellular structure of the extracellular matrix is a sign of complete wound healing process after a tissue injury. There are numerous reasons to support the use of hydroxyproline as a biomarker of the collagen content within tissues after the wound-healing process, as it is abundantly found in collagen and plays a vital role in wound healing [7]. Sadar et al. [20] found that hydroxyproline levels increased hydroxyproline level significantly correlated with the accumulated collagen in colonic tissue after TNBS administration, and ferulic acid treatment significantly reduced the colonic hydroxyproline activity. In our study, we found that hydroxyproline levels were significantly high in the control group and significantly lower in the treatment groups in accordance with the literature (p=0.017 for topical treatment group, p=0.004 for topical + systemic treatment group).
Macroscopic and histopathological examinations are the gold standard for evaluating inflammation in the colon. Appleyard and Wallace [21] found that the total histopathological damage score was higher in colitis group compared to the saline group in the original colitis studies in which they underwent histopathological evaluation. Balaha et al. [22] found that GO ameliorated the marked macroscopic and microscopic changes of colonic mucosa in a dose-dependent manner. In our study, we found that the total damage score was significantly lower in group 4 compared to the control group (p=0.006).
Conclusion
In conclusion, we found that MB ameliorates colonic injury in acetic acid-induced colitis model. This effect of methylene blue was observed both locally and with local + systemic administration. In addition, it reduced inflammation, although not statistically significant. Therefore, due to the clinic and pharmacologic properties of MB, it can be used to treat the IBD. However, it is obvious that further and comprehensive clinical studies are needed.
Limitations
Since this study was experimental, the number of cases was limited. Due to restriction in the number of animals, treatment results for 10 days for both group 3 and group 4 could not be evaluated.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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4. Rosenberg LN, Peppercorn MA. Efficacy and safety of drugs for ulcerative colitis. Expert Opin Drug Saf. 2010;9(4):573-92.
5. Pereira C, Grácio D, Teixeira JP, Magro F. Oxidative Stress and DNA Damage: Implications in Inflammatory Bowel Disease. Inflamm Bowel Dis. 2015;21(10):2403-17.
6. Sartor RB, Hoentjen F.. Mechanisms of Bacterial-Induced Experimental Colitis. In: Mestecky J, McGhee JR, Strober W, editors. Mucosal Immunology, 3rd ed.USA: Academic Press 2005,p.681-702.
7. Yun HM, Ban JO, Park KR, Lee CK, Jeong HS, Han SB, et al. Potential therapeutic effects of functionally active compounds isolated from garlic. Pharmacol Therapeut. 2014;142(2):183–95.
8. Wainwright M, Crossley KB. Methylene Blue–a therapeutic dye for all seasons? J Chemother. 2002;14(5):431-43.
9. Dinc S, Ozaslan C, Kuru B, Karaca S, Ustun H, Alagol H, et al. Methylene blue prevents surgery-induced peritoneal adhesions but impairs the early phase of anastomotic wound healing. Can J Surg. 2006;49(5):321-8.
10. Kalaycı MU, Eroğlu HE, Kubilay D, Soylu A, Sancak B, Uğurluoğlu C, et al. The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis. Ulus Travma Acil Cerrahi Derg. 2011;17(3):205-9.
11. Randhawa PK, Singh K, Singh N, Jaggi AS. A review on chemical-induced inflammatory bowel disease models in rodents. Korean J Physiol Pharmacol. 2014;18(4):279-88.
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13. Bergman R, Loxley R. Two improved and simplified methods for the spectrophotometric determination of OH-proline. Anal Chem. 1963;35(12):1961–5.
14. Xavier RJ, Podolsky DK. Unravelling the pathogenesis of inflammatory bowel disease. Nature. 2007;448(7152):427-34.
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16. Dinc S, Caydere M, Akgul G, Yenidogan E, Hücümenoglu S, Rajesh M. Methylene Blue inhibits the inflammatory process of the acetic acid-induced colitis in the rat colonic mucosa. Int Surg. 2015; DOI: 10.9738/INTSURG-D-15-00118.1.
17. Werner I, Guo F, Stock UA, Lupinski M, Meybohm P, Moritz A, et al. Methylene blue modulates adhesion molecule expression on microvascular endothelial cells. Inflamm Res. 2014;63(8):649–56.
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Download attachments: 10.4328:ACAM.20889
Yusuf Tanrıkulu, Ceren Sen Tanrıkulu, Fahriye Kılınç, Murat Can, Furuzan Köktürk, Süleyman Kargın, Gökhan Yılmaz. Methylene blue ameliorates colonic injury in acetic acid-induced colitis model. Ann Clin Anal Med 2022;13(2):146-150
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Prevalence of Hepatitis B virus and Hepatitis C virus among prison inmates in Istanbul, Turkey
Ahmet Melih Şahin 1, Ahmet Rıza Şahin 2, Alper Gunduz 3, Ayse Aktemur 4, Nuray Uzun 3
1 Department of Infectious Diseases, Medical Faculty, Giresun University, Giresun, 2 Department of Infectious Diseases, Adana City Training and Research Hospital, Adana, 3 Department of Infectious Diseases, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, 4 Department of Infectious Diseases, Kahramanmaras Necip Fazil City Hospital, Kahramanmaras, Turkey
DOI: 10.4328/ACAM.20892 Received: 2021-10-10 Accepted: 2021-11-03 Published Online: 2021-11-08 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):151-155
Corresponding Author: Ahmet Melih Şahin, Rektorluk Gaziler Mahallesi, Prof. Ahmet Taner Kislali Cd, 28200, Merkez, Giresun, Turkey. E-mail: ahmetmelihsahin44@hotmail.com P: +90 454 310 10 00 F: +90 454 310 11 19 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3670-7801
Aim: Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are major contributors to liver disease and can cause chronic hepatitis, cirrhosis and hepatocellular carcinoma. In Turkey prisons, the prevalence of HBV and HCV is not known. The objective of this study was to determine the seroprevalence of HBV and HCV in prison inmates and wardens in Turkey.
Material and Methods: A questionnaire form including questions about demographics, place of living, educational status, monthly income before prisoned, smoking and alcohol use, use of drugs and pleasure-inducing substance, intravenous drug abuse, tattooing, razors, nail clippers, toothbrushes shared with other inmates, sexual preference, condom use and a history blood transfusion was applied. Participants were tested for their HbsAg and HCV status.
Results: A total of 520 male participants were included in the study. HBV virus was detected in 24 (4.82%) inmates and HCV virus in 2 (0.4%) inmates. No statistically significant difference was found between the participants with and without hepatitis in terms of age, marital status, place of living, income before prisoned, and educational status (for all p>0.05). The rate of intravenous drug use was statistically significantly higher in HBV positive and HCV positive groups (p<0.05).
Discussion: Our results indicate that the serorevalence of HBV and HCV among prisoners was similar to the general population. Training on appropriate behavioral patterns, performing required health screening, and improving conditions in prisons are important not only for individual health but also for public health.
Keywords: HBV, HCV, Seroprevalence, Risky Behavior, Prison, Inmate
Introduction
Hepatitis B virus (HBV) is a major cause of liver disease and can cause chronic hepatitis, cirrhosis, and hepatocellular carcinoma; therefore, it is one of the most important global health problems [1]. According to the World Health Organization (WHO), in 2015, the global prevalence of HBV infection in the general population was 3.5%. In Turkey, the prevalence of HBV has been reported as 4.57% in 2018. Accordingly, 3.3 million people are infected with HBV in our country.
Hepatitis C virus (HCV) is the main contributor to chronic liver disease worldwide. HCV infection is associated with acute and chronic hepatitis and liver cancer [2]. According to the WHO, in 2015, 71 million persons were living with chronic HCV infection worldwide with a global prevalence of 1% and 399 000 died from cirrhosis or hepatocellular carcinoma. The prevalence of HCV in our country has been reported as 1.15% in the general population [3].
Both infections are transmitted both parenterally and sexually, most often through mucous membrane exposure or percutaneous exposure to infectious body fluids. Risk groups for the two pathogens include healthcare providers, sexually active individuals, men who have sex with men, illicit drug users, dialysis patients, prison inmates and all pregnant women. In Turkey, the seroprevalence among risky groups such as dialysis patients, sex workers and healthcare professionals has been studied previously [4].
Prisons are potential locations for transmission of HBV and HCV infections, and prison inmates are among the risky groups. Crime rates and therefore the number of detainees and prisoners are gradually increasing. According to the statistics of the Ministry of Justice, the number of detainees and prisoners as of 30/6/2021 is 287.094. Prison occupancy rate is 100% depending on the city. There are studies on HBV and HCV prevalence of inmates in prisons abroad; but in Turkey, the prevalence of HBV and HCV is not known. Therefore, the objective of this study was to determine the seroprevalence of HBV and HCV in prison inmates and wardens in Turkey.
Material and Methods
Before the beginning, the study protocol was approved by the Ministry of Justice, General Directorate of Prisons and Detention Houses with the number B.03.0.CTE.09.204.06.01-3706/151485 and 29/12/2010 dated permission and by the local ethics committee of our hospital ( decision number 29 and dated 15/12/2011). All participants were informed about the objectives of the study, read the participation forms and gave written consent. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.
In this cross-sectional study, the seroprevalence of HBV and HCV was investigated among prison inmates and wardens in Kartal and Maltepe Penal Institutions between January 2012 and October 2012. A questionnaire form prepared by the researchers in line with the relevant literature was conducted. The study was conducted on a volunteer basis.
The questionnaire form included demographics, place of residence, educational status, monthly income before prisoned, smoking and alcohol use, use of drugs and pleasure-inducing substances, intravenous drug abuse, tattooing, razors, nail clippers, toothbrushes shared with other inmates, sexual preference, condom use and a history of blood transfusion.
Five mL of blood samples were collected from the participants. Serum samples were stored at -80 °C until the day of analysis. All serum samples were analyzed for HBsAg and anti-HCV.
HBsAg was studied with third-generation RADIM enzyme immunoassay (EIA) (DIA.PRO, Italy) testing method. The HBsAg analysis was performed according to the manufacturing company’s instructions. Blood samples from subjects who have a minimum positive value, over positive value, or an intermediate value were studied a second time to verify the positivity of HBsAg. Intermediate results were confirmed with Liason (Dia-Sorin, Saluggia, Italy).
Anti-HCV was studied with RADIM EIA (DIA.PRO, Italy). Analyses were performed according to the manufacturing company’s instructions. Blood samples from subjects who have a minimum positive value, over positive value, or an intermediate value, were studied a second time to verify the positivity of HBsAg. Samples with an intermediate value were confirmed with Inno-Lia (INNO-LIA, HCV Score, Innogenetics, Belgium), a third-generation Line Immune Assay (LIA) testing method. HCV-RNA was reconfirmed, because it showed results with an intermediate value again.
Statistical Analysis
Data obtained in the study were statistically analyzed using SPSS version 20.0 (Statistical Package for Social Sciences, IBM Inc., Armonk, NY, USA) package software. Mean, standard deviation, frequency and percentage values were used in descriptive statistics of the data. ANOVA test was used in the analysis of quantitative data. The Chi Square test was used in the analysis of the qualitative data; when the Chi Square test’s conditions were not satisfied, Fischer Exact test was used. The p values <0.05 were considered statistically significant.
Results
A total of 520 male participants were included in the study. All participants were over 18 years of ageж 495 (95.2%) of all participants were inmates and 25 (4.8%) were wardens. The mean age of the participants was 31±10.35 (min-max: 18-71) years.
HBV virus was detected in 24 (4.82%) inmates and HCV virus in 2 (0.4%) inmates. None of the wardens had HBV and/or HCV.
No statistically significant difference was found between the participants with and without hepatitis in terms of age, marital status, place of living, income before prisoned, and educational status (for all p>0.05). The demographic characteristics of the participants are shown in Table 1.
Risky behaviors of the participants were evaluated. Accordingly, the participants were divided into three groups as negative, HBV positive and HCV positive. Results of the questionnaire are given in Table 2. No statistically significant difference was found between the groups in terms of the rates of smoking, alcohol consumption, drug use, sexual preference, unprotected sexual intercourse, tattooing, tattooing in the prison, razor blade sharing, nail clippers sharing and toothbrush sharing (for all p>0.05). The rate of intravenous drug use was statistically significantly higher in the HBV positive and HCV positive groups compared to the negative group (p<0.05).
Discussion
HBV and HCV seroprevalence studies conducted in Turkey included risk groups such as people living in nursing homes, healthcare professionals who are in close contact with blood and blood products and dialysis patients [5-7]. However, there is no study published in Turkey on places where people live together such as prisons where there are plenty of commonly used areas. Prisoners worldwide have an increased prevalence of HBV and HCV compared to the general population [8]. A complex interaction of individual, social, and environmental factors before, during, and after imprisonment results in an increased risk of these infections and diseases in prison inmates. This study is the first conducted on this subject in Turkey.
The high prevalence of HIV, HBV, HCV and other sexually transmitted diseases have been attributed to unprotected sexual relationships, high-risk partners, intravenous drug use and shared syringe [9]. In several studies conducted in prisons, syphilis was found in 8%, chlamydia in 8.7%, gonorrhea in 32%, HIV in 13%, and HCV in 20% of the inmates [10, 11]. It was found that approximately 30% of cases newly diagnosed with HBV have an imprisonment history [12]. In the present study, the seroprevalence of HBV and HCV detected in inmates in prison was (4.82%) and (0.4%), respectively, similar to that in thesociety.
In a study by Kebede et al. investigating seroprevalence of HBV and HCV in Southwest Ethiopia, the prevalence of HBV according to age groups was 2.38% (20 yo), 2.85% (21-30 yo), 4.25% (31-40 yo) and 18.80% (>40 yo). The prevalence of HCV was found as 10.7% (31-40 yo) and 6.3% (>40 yo) [13]. In a study performed by Pack et al [11], it was found that HBV, HCV and sexually transmitted diseases are seen more frequently in adolescent male inmates compared to adults. This finding was attributed to the fact that adolescent inmates do not have enough information about the protection methods against sexually transmitted diseases and that they change partners more frequently.
In our study, we do not find a significant difference between the ages of HBV and HCV- infected inmates. In Maltepe and Kartal Penal Institutions where we conducted our study, there are only adult inmates and the mean age of our participants was 31 years. The mean age of inmates who tested positive for HBV was 31 years, while the mean age of inmates who were positive for HCV was 39 years. Seroprevalence and age distribution show geographical variability due to cultural and lifestyle factors.
A study by Macalino, HBV and HCV infections were significantly associated with those who used intravenous drugs (odds ratio was 7.9 and 32.4, respectively) [14]. In another study by Treso et al., HCV positivity was found in 22.5% of prisoners who used intravenous drugs (p<0.05) [15]. In a study by Taleban et al., HBV positivity was found in 18% of intravenous drug users [16]. Similarly, in our study, intravenous drug use was observed in all cases with HCV infection and was found to be significant among all cases with hepatitis compared to the inmates without hepatitis (p < 0.05).
In the present study, there was no statistically significant difference between the hepatitis (+) and hepatitis (-) groups in terms of the other studied parameters, including age, education, and income status, marital status and number of partners, condom use, tattoo, cigarette and alcohol use and blood transfusion, consistently with the literature [17 – 20]. One of the two cases with detected HCV infection had a tattoo. However, the statistical calculation could not be performed due to insufficient numbers.
The rate of sharing of materials such as razor, nail clippers and especially a toothbrush was high. Six HBV and one HCV patient shared these materials, which is important for transmission risk in common living places.
Educational status was primary school in 70% of the inmates with hepatitis, suggesting that these cases have insufficient information on transmission ways. Similarly, in the study by Nokhodian, the majority of the participants were primary school graduates.
None of the twenty-five wardens included in our study were found to be infected with HBV and HCV. This finding conforms with the literature [19].
Crime rates and therefore the number of detainees and prisoners are gradually increasing. Prison occupancy rate is 100% depending on the city. Prison conditions are questioned and debated by the public and this situation increases the importance of the present study. Besides common living as a solely risk factor for HBV and HCV, other risky behaviors questioned in our study affect not just inmates and prison workers, but also whole society, because 96.1% of our participants will be released within the next three years.
Study Limitations
The main limitation is that this study was conducted only in Kartal and Maltepe Penal Institutions and the results should not be generalized. In addition, age groups were not taken into account in the analysis of the questionnaire. However, our number of participants is satisfying for such a cross-sectional study. Furthermore, since this study is the first on this subject in Turkey, we believe that our results will be guiding for future more comprehensive studies.
Conclusion
Our results indicate that serorevalence of HBV and HCV among prisoners was similar to the general population. However, Prisons present a high-risk environment for the transmission and amplification of several infections. Therefore, health education programs focusing on infection prevention and how to build low risk behaviors, and facilitating access to suitable treatment care, should be in place in prison settings. Training on appropriate behavioral patterns, performing required health screening, improving conditions in prisons and reaching broader data through similar studies are important not just for individual health but also for public health.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Collateral damage of the COVID-19 pandemic on lysosomal storage diseases: A single unit experience
Gonca Kılıç Yıldırım 1, Şengül Tosun Altınöz 2, Harun Olcay Sonkurt 3
1 Pediatric Nutrition and Metabolism Unit, Department of Pediatrics, Faculty of Medicine, Osmangazi University, 2 Department of Psychiatry, Private Practice, 3 Department of Psychiatry, Private Practice, Eskisehir, Turkey
DOI: 10.4328/ACAM.20893 Received: 2021-10-12 Accepted: 2021-11-01 Published Online: 2021-11-10 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):156-160
Corresponding Author: Harun Olcay Sonkurt, Sumer Mahallesi, Aksahin Sokak, Uydu Demirkent Sitesi, C Blok, Daire 8, Odunpazarı, Eskisehir, Turkey. E-mail: hosonkurt@gmail.com P: +90 542 803 05 26 Corresponding Author ORCID ID: https://orcid.org/0000-0002-9772-2637
Aim: COVID-19 epidemic caused significant problems in countries’ health systems. The direct and indirect effects of this unprecedented outbreak on patients with rare diseases are not clear. The aim of this study is to identify the pandemic-related problems encountered by adults with LSDs and parents who have children with LSDs and to evaluate the socio-economic and psychological effects of the COVID-19 outbreak in the lysosomal diseases community.
Material and Methods: Our study included 27 adult patients receiving ERT treatment and 19 parents of child patients who were followed up with LSD diagnosis. Sociodemographic Data Form and COVID-19 Traumatic Stress Scale were applied to patients and their parents.
Results: We found that treatment was disrupted in 44.4% of adult patients and 36.84% of child patients due to the COVID-19 outbreak. We found that 50% of adults and 80% of parents had a fear of going to the hospital due to the COVID-19 pandemic. Economic distress was higher in the treatment-disrupted group. Also, patients who had a fear when going to the hospital for ERT had higher “fear/threat of infection” scores.
Discussion: The pandemic brought wide-ranging changes in the treatment and follow-up of patients with rare diseases. Home therapy appears to be the most effective way to maintain access to treatment during a pandemic; however, the personnel involved should be monitored and much attention should be paid to the proper use of personal protective equipment. It is also of great importance to provide adequate social, economic and psychological support to individuals.
Keywords: COVID-19 Pandemic, ERT, Lysosomal Storage Disease, COVID-19 Traumatic Stress Scale
Introduction
The coronavirus disease-19 (COVID-19) epidemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global problem that has affected the entire world since March 2020. Concerns about infection, loss of income/employment, disruption of routines, physical isolation from friends and family, restriction of leisure activities and closure of schools and nurseries have created significant stress for patients and clinicians. The COVID-19 epidemic has caused significant problems in countries’ health systems and countries faced with an unprecedented health crisis [1]. Countries’ health systems have been overloaded by the burden of the pandemic due to the increase in the number of cases and the lack of a specific and effective treatment. The COVID-19 outbreak has caused growing concern around the world due to the fear of infection, especially in people with chronic diseases [2].
The direct and indirect effects of this unprecedented outbreak on patients with rare diseases are still not clear. People with rare metabolic disorders are at risk during a pandemic due to multisystemic involvement, including vital organs [3]. In particular, patients with lysosomal storage disease (LSD) are considered to be at high risk of severe COVID-19 infection, as they often suffer from a multisystemic disease that also includes respiratory and cardiovascular system involvement [4]. It is well known that SARS-CoV-2 uses the lysosomal system to infect cells [5]. Therefore, those with lysosomal storage disease may be considered at increased risk for COVID-19 infection and complications due to lysosomal dysfunction and activation of inflammatory cascades [6].
Lysosomal storage diseases are rare, inherited group of metabolic disorders characterized by the progressive accumulation of undigested substrates within the lysosome. Currently, many LSD’s, such as Gaucher, Fabry, Pompe diseases, can be treated with enzyme replacement therapy (ERT) [7]. Although many countries offer infusions at home, in Turkey, patients must go to hospitals every 1 or 2 weeks to receive treatment. Although treatments such as hematopoietic stem cell transplantation and substrate reduction therapy are available for a limited number of LSD’s, ERT is currently the only approved and the most effective treatment for most [8]. In a limited number of studies, it was noted that during the pandemic process, patients who received regular ERT prior to it disrupted their infusions [2, 9-11].
The risk of infection in a pandemic increases fear and stress in societies. Despite a large number of studies that have been conducted on the global epidemic, the number of studies on COVID-19 anxiety is limited. It is important to identify the problems faced by patients with rare metabolic diseases during the pandemic, as well as their attitudes towards ERT to ensure the sustainability of their treatment. To the best of our knowledge, the association of the COVID-19 pandemic with LSDs, which has previously been investigated in limited and non-face-to-face studies and mostly in the pediatric population, was not investigated in the adult patient group. The aim of this study is to identify pandemic-related problems encountered by adults with LSDs and parents who have children with LSD and to evaluate the socio-economic and psychological effects of the COVID-19 outbreak in the lysosomal diseases community, as well as health service and treatment disruptions. Also, we aimed to enrich the literature by investigating the traumatic effects of the COVID-19 pandemic using a structured traumatic scale.
Material and Methods
Study sample
The study included 27 adult patients receiving ERT treatment and 19 parents of child patients who were followed up with LSD diagnosis at XXX University Faculty of Medicine Department of Pediatric Metabolism.
Procedure
Adults and parents of children with LSD who were followed up by XXX Faculty of Medicine, Department of Pediatric Metabolism were reached via telephone and e-mail. The research related to human use complied with all the relevant national regulations, institutional policies, and in accordance with the tenets of the Helsinki Declaration, and ethics committee approval was obtained from XXX Ethics Committee, with a decision number 497, dated 09.03.2021. All patients and parents of patients have signed informed consent. The data were collected between March and May 2021. Participants’ compliance with ERT treatment during the COVID-19 pandemic was evaluated from hospital records.
Tools
The socio-demographic Data Form and COVID-19 Traumatic Stress Scale were applied to patients and their relatives. The application tools were applied face-to-face to the 16 adults and 14 parents who were continuing the ERT treatment, while the remaining 11 adults and five parents were reached online.
Socio-demographic Data Form: It is a 26-question data form created by researchers. It consists of three parts: the first part contains the socio-demographic data of the participants such as age, gender. The second part contains information about LSD and ERT treatments and the third part contains data on participants’ daily routine changes due to the COVID-19 pandemic. Problems encountered during hospitalization or access to medications for ERT were identified by evaluating hospital records.
COVID-19 Traumatic Stress Scale: A 12-point Likert-type scale was developed by Kira et al. in 2020 [12]. The COVID-19 Traumatic Stress Scale consists of three dimensions: “fear/threat of infection and death”, “economic distress”, and “disrupted routine/isolation”. The validity and reliability of the scale in Turkish was conducted by Altınöz et al [13].
Statistical Analyses
Continuous data were given as mean ± standard deviation. Categorical data were given as percentages (%). The Shapiro–Wilk test was used to investigate the suitability of the data for normal distribution. To compare the non-normally distributed groups, we used the Mann–Whitney U test for the data with two groups. IBM SPSS Statistics 21.0 was used for the analyses. A p-value of < 0.05 was considered statistically significant.
Results
Twenty-seven adults with LSD and 19 parents of children with LSD participated in the study. The mean age was 37.33±10.82 years (20-68). Among them, 27 (57.8%) were women and 19 (41.3%) were men. Regarding the most striking findings, we observed that most of the adult patients had Gaucher Type 1 (59.3%), and most of the children had mucopolysaccharidosis group diseases. We found that 44.4% (N=12) of adult patients and 36.84% (n=7) of children patients’ treatment were disrupted due to the COVID-19 outbreak. When the reasons of the disruptions were examined, we found that %50 of adult patients (n=7) and %80 of parents had a fear of going to the hospital due to the COVID-19 pandemic. Also, we found that 50% of adult LSD patients (n=7) and 20% of parents (n=1) were diagnosed with COVID-19, thus they discontinued the ERT treatment. We also found that 7.9% of patients received ERT treatment at home. Socio-demographic data of the participants are summarized in Table 1, the data regarding lysosomal disease are summarized in Table 2, and the characteristics associated with COVID-19 are summarized in Table 3.
We found that all of the LSD patients and their parents complied with the restrictions in the COVID-19 pandemic. When patient and parent groups were evaluated in terms of COVID-19 traumatic stress scale scores, there was no statistically significant difference found in fear/threat of infection, economic distress and disrupted routine/isolation (p>0.05). In the LSD patient group, a significant difference was found between patients whose treatments were disrupted due to COVID-19 and who continued the treatment as usual, in terms of “economic distress” scores (p=0.048). Also, patients who had a fear when going to the hospital for ERT scored significantly higher in COVID-19 traumatic stress scale in “fear/threat of infection” sub-dimension (p=0.019).
Discussion
Undesirable conditions associated with COVID-19 significantly affected the access of people with chronic diseases to health care [1]. This group of diseases affects a vulnerable population, not only because of the effects of the disease itself, but also because they are dependent on proper health care. As most hospitals focus on the treatment of patients severely affected by COVID-19, several problems aroused in the treatment and follow-up of patients with chronic diseases. In addition, the risk of contracting COVID-19 disease increases due to the fact that these patients have to go to medical facilities [10].
One of the most important findings of our study is that the rate of COVID-19 infection in adult LSD patients was 25.9% (n=7) and 10.5% (n=2) in parents. This rate is significantly higher than the total COVID-19 patient rate in Turkey, which is 6.06%, as of May 2021. Although our study sample fully complied with the restriction rules, this rate is significantly higher than that of the general population. This may be associated with the need for frequent admission to hospitals and increased exposure to COVID-19. In these individuals at high risk for COVID-19 infection due to lysosomal dysfunction and inflammatory sensitivity, home treatment options are of high importance to ensure the continuity of LSD treatment, the reduction of COVID-19-induced anxiety and the reduction of COVID-19-associated morbidity and mortality [6-8]. Having the freedom to choose the date and time for the infusion, the opportunity to maintain functionality and to plan daily activities in a much more comfortable and private environment for the patient increases compliance with the treatment and the quality of life. Brunelli et al. conducted a cross-descriptive study to evaluate the advantages and the disadvantages of a home care program for patients with LSDs [14]. In the patient group, 86.9% chose to continue the treatment at home, and 88.5% felt that their quality of life has improved. The authors reported the main benefits of home treatment are higher adherence to treatment and improved quality of life [14]. The possibility of avoiding going to the health center in special situations such as pandemics, the opportunity to reduce the risk of infection that may occur in the hospital are important advantages and should be taken into consideration when treating these vulnerable groups in pandemics.
Regarding the studies related to the treatment of patients with LSD during the COVID-19 pandemic process, Sechi et al. found that 49% of adult LSD patients receiving hospital treatment had a disruption in treatment [11], whereas Kahraman et al. found that this rate is 46.7% [9]. In our study, the similar rates of those who had a disruption in the treatment indicate that approximately half of the LSD patients have COVID-19-related disruptions in their treatment, even though they live in different regions in the world. Disruption in treatment increases morbidity and mortality rates in these individuals, also it can lead to the progression of the underlying disease and cause irreversible outcomes [10]. In the study by Drelichman et al., it was reported that splenomegaly, hepatomegaly and bone-related complications could be seen in individuals with LSD as a result of suspending ERT for more than 2 months, and it is stated that these complications may be irreversible [15]. Since there is no home treatment option available in Turkey today, 93.5% of all patients in our study cannot access it, even if they want to. Considering the possible adverse effects of treatment disruption, it seems to be important to identify individuals who have difficulty accessing treatment and to present alternative treatment options.
Considering the causes of treatment disruptions, we found that the most common reason for the treatment disruption was fear of going to the hospital (59.2%). Similarly, Kahraman et al. also found that the most common reason for the treatment disruption was “being afraid to go to the hospital” (74.3%) [9], and Sechi et al. found that 62.9% of patients whose treatments were disrupted had a fear of getting an infection [11]. In a study by Fiumara et al., they found that pediatric LSD patients had an increase in their COVID-19 related anxiety, and 60% of them had a treatment disruption, due to the fear of COVID-19 infection [2]. In our study, the fact that both the patient group and parents received similar scores in all sub-dimensions in the traumatic scale, especially the fear of infection and fear of death/threat sub-dimensions, shows that COVID-19 affects all groups in similar ways in sense of anxiety and social problems. Our findings show that patients who were continuing their treatments regularly also had higher anxiety levels, and that these levels increased the most while receiving treatment in the hospital. Similarly, Fiumara et al. also found that people who were treated regularly with ERT had a high level of anxiety about getting COVID-19 [2]. This indicates that the problem experienced by individuals with LSD is not only treatment disruptions and complications they have thereafter, it also shows that they are going on with their lives under a high anxiety burden. Although alternative treatment options may reduce these patients’ anxiety levels, psychological interventions may also help their anxiety and improve their quality of life.
Regarding the COVID-19 traumatic scale, we also found that the economic distress sub-dimension score was statistically significantly higher in the disrupted group. These data shows that the causes, which are disrupting the LSD treatment are not only related to disease anxiety and can be multi-factorial. Since the vast majority of the patients in our study are of low-to-middle income and about half of them are unemployed, these people may be even more affected by the additional economic difficulties caused by the COVID-19 pandemic. According to the International Monetary Fund’s report published in April 2021, Turkey ranks at one of the bottom among the world countries in terms of pandemic expenditure, with 1.5 percent of the Gross Domestic Product. The economic difficulties experienced by individuals who have very few employment opportunities due to COVID-19 and who cannot access adequate social and economic assistance may affect the treatment of chronic metabolic diseases and can cause irreversible problems in the lives of these individuals. Ensuring adequate economic support for these individuals and their families is of great importance to prevent permanent damage that may occur.
Limitations
Our study has a number of limitations. The COVID-19 traumatic stress scale was applied to patients and their relatives, and there were no control groups in our study. The identification of COVID-19-related problems that individuals with LSD specifically experience can be investigated further by including control groups. Although a significant number of the patients followed in our unit have been reached, the small sample size is another limitation of our study.
Conclusion
The pandemic brought wide-ranging changes in the treatment and follow-up of patients with rare diseases. The most effective way to maintain access to treatment during a pandemic appears to be home therapy; however, the personnel involved should be monitored and much attention should be paid to the proper use of personal protective equipment. When home therapy is not possible, safe infusion centers should be established in hospitals, which separates patients with COVID-19 and non-COVID-19. Ensuring the safe transfer of patients to health centers can also be helpful. It is also of great importance to provide adequate social and economic support to individuals who are economically disadvantaged. In order to reduce the negative health effects caused by the interruption of treatment, psychological support is of great importance.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Gonca Kılıç Yıldırım, Şengül Tosun Altınöz, Harun Olcay Sonkurt. Collateral damage of the COVID-19 pandemic on lysosomal storage diseases: A single unit experience. Ann Clin Anal Med 2022;13(2):156-160
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Leukocyte albumin ratio as an early predictor of mortality in critical COVID-19 patients
Ayşegül Altıntop Geçkil 1, Erdal İn 1, Nurcan Kırıcı Berber 1, Umut Sabri Kasapoğlu 2, Ercan Karabulut 3, Cengiz Özdemir 4
1 Department of Pulmonary Medicine, Malatya Turgut Ozal University Faculty of Medicine, Malatya, 2 Intensive Care Unit, Malatya Training and Research Hospital, Malatya, 3 Department of Medical Pharmacology, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara, 4 Department of Chest Diseases, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
DOI: 10.4328/ACAM.20895 Received: 2021-10-10 Accepted: 2021-11-16 Published Online: 2021-11-21 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):161-165
Corresponding Author: Ayşegül Altıntop Geçkil, Department of Chest Disease. Malatya Turgut Ozal University Training and Research Hospital, 44090, Malatya, Turkey. E-mail: aysegul.altintop@gmail.com Corresponding Author ORCID ID: https://orcid.org/0000-0003-0348-3194
Aim: The aim of this study is to analyze the effectiveness of the leukocyte albumin ratio (LAR) in predicting mortality in critical COVID-19 patients.
Material and Methods: In this retrospectively-designed study, we evaluated a total of 98 critical patients who were hospitalized in the intensive care unit. Patients were divided into two groups according to hospital mortality as survivors (n=43) and non-survivors (n=55).
Results: The non-survivors group was statistically significantly older (67.3±9.7 versus 62.5±10.9; p=0.023). HT and DM were detected more in the non-survivors group than in the survivors group (p=0.031, p=0.018, respectively). Mean LAR values were significantly higher in non-survivors than in survivors (5.9±3.5 versus 3.3±1.4; p<0.001). LAR values was positively correlated with urea (r=0.43, p<0.001), LDH (r=0.35, p<0.001), ferritin (r=0.25, p=0.015), procalcitonin (r=0.34, p<0.001), and pro-BNP (r=0.24, p=0.015) levels. A cut-off value of 3.71 ng/mL for LAR predicted mortality with a sensitivity of 76% and a specificity of 70% (AUC:0.779 95% Cl:0.689-0.870; p<0.001). Multivariable logistic regression analysis revealed that older age (OR:1.114, 95% CI:1.020-1.218; p=0.017) and increased ferritin (OR:1.003, 95% CI:1.001-1.004; p=0.002) and LAR (OR:1.583, 95% CI:1.073-2.337; p=0.021) values were independent predictors of mortality in patients with critical COVID-19.
Discussion: LAR can be a useful and prognostic marker that can be used to predict mortality in COVID-19 patients admitted to the intensive care unit.
Keywords: COVID-19, Leukocyte Albumin Ratio, Intensive Care
Introduction
In the city of Wuhan in the People’s Republic of China, an outbreak of pneumonia developed due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. SARS-CoV-2 infection causes Coronavirus disease 2019 (COVID-19) and can range in severity from asymptomatic to acute respiratory distress syndrome (ARDS), to multi-organ failure, and even death. In keeping with preliminary data from China, 81% of COVID-19 patients have mild or moderate illness, similar to colds and mild pneumonia, while 14% of patients have severe illness and 5% have life-threatening critical illnesses [2]. While the overall mortality rate of COVID-19 is estimated to be below 3%, it has been observed that the mortality rate in hospitalized patients is reported to vary between 6% and 34% [2,3-5]. Mortality rates in critical patients in intensive care units are quite high and can exceed 50% [6]. Biomarkers that can predict patients with high risk of mortality early are needed.
Leukocytes are associated with acute infections following an early inflammatory response. In previous studies, it has been demonstrated that increased leukocyte count is related to severe disease and mortality in COVID-19 patients [7]. Albumin is a negative acute-phase protein and systemic inflammatory response is independently associated with circulating albumin concentrations [8]. The mechanisms behind hypoalbuminemia in COVID-19 patients have not yet been fully understood, but one possible mechanism is a cytokine storm associated with severe disease. Hypoalbuminemia in cases of COVID-19 is thought to be due to increased capillary permeability, resulting in albumin escaping into the interstitial space, rather than a decrease in albumin synthesis [9-11]. It has been demonstrated in some studies that low albumin levels are predictors of severe disease and mortality in COVID-19 patients [11-13].
The aim of this single-center, retrospective study was to analyze the effectiveness of the leukocyte/albumin ratio (LAR) as a predictor of mortality in COVID-19 patients hospitalized in intensive care.
Material and Methods
Study Population
Ninety-eight patients with COVID-19 infections who were hospitalized in the Intensive Care Unit of Malatya Turgut Ozal University Training and Research Hospital between September 2020 and October 2020 were retrospectively included in the study. Patients included in our study were older than 18 years old and no gender difference was observed between patients.
COVID-19 diagnosis was defined as a SARS-CoV-2 positive real-time reverse-transcriptase polymerase chain reaction (RT-PCR) from a nasal and/or throat swab together with signs, symptoms, or radiological findings suggestive of COVID-19 infection.
Data collection
Patient characteristics, clinical features and laboratory data were collected from a digital archive system in our hospital. Routine hematological and biochemical tests included leukocyte count, C-reactive protein (CRP), procalcitonin, d-dimer, fibrinogen, cardiac biomarkers, and liver/kidney function tests. The LAR was measured by dividing the leukocyte count by the albumin value. The laboratory data of patients within the first 8 hours after admission to the intensive care unit were evaluated.
Laboratory Analyzes
Complete blood cell counts were analyzed via a high-volume hematology analyzer (SYSMEX, Automated Hematology, Wakinohama-Kaigondori, Chu-ku Kobe JAPAN). The blood samples were collected in potassium-ethylenediaminetetraacetic acid tubes and analyzed within one hour after venipuncture. The albumin levels were determined via a nephelometric analyzer (ARCHITECT, Toshiba, Abbott Park, USA) by the immunonephelometry method.
Ethics
The study was conducted in accordance with the Helsinki Declaration and was approved by the Ethical Committee of the Medicine Faculty of Firat University (issue:2021/02-31)
Statistical Analyses
IBM SPSS Statistics 25 software was used for statistical analysis, results were stated as mean ± SD. The level of statistical significance was regarded as p<0.05. To compare two independent samples, the student’s t-test was conducted. To compare multiple samples, the One-Way ANOVA test was used. Parametric variables were evaluated using Pearson’s correlation analysis. In the study, multivariate analyses were conducted using binary logistic regression to evaluate variables that could predict mortality. In the analysis, a 95% confidence interval (CI) was adopted while calculating the odds ratios (ORs). The “Receiver Operating Characteristic” (ROC) analysis method was used to determine the cut-off value for inflammatory markers. Additionally, the ROC value was used for determining the sensitivity and specificity values for inflammatory markers. The “Area under Curve” (AUC) value was determined with the ROC curve.
Results
Baseline characteristics of patients
In this study a total of 98 patients were included, 76 of them were men and 22 were women. While 55 (56.1%) of the patients died during the intensive care follow-up, 43 (43.9%) patients were discharged. The mean age of the patients was 65.1±10.4 years. There was no difference between the two groups in terms of gender (p=0.252, x2:1.31). Non-survivors were found to be statistically significantly older than surviving patients (67.3 ± 9.7 versus 62.5±10.9; p=0.023). While HT and DM were found statistically much more frequent in the non-survivors group (p=0.031, p=0.018, respectively), no significant difference was observed on the basis of other comorbidities. When patients first admitted to intensive care, 38 (38.8%) patients had invasive mechanical ventilation, 33 (33.7%) patients had noninvasive mechanical ventilation (NIMV), 27 (27.6%) patients had high flow oxygen (HFO). In the non-survivors group, invasive mechanical ventilation application was found to be significantly higher (p<0.001). On the other hand, in the survivors group, HFO application was found to be significantly higher (p<0.001) (Table 1). All patients had bilateral pneumonia findings consistent with COVID-19, confirmed by thoracic CT.
Comparison of laboratory tests between survivors and non-survivors
Analysis of complete blood count parameters demonstrated that the non-survivors group had a significantly higher leukocyte count than the survivors group (p<0.001). Analysis of basic biochemical markers showed that urea, creatinine, sodium and LDH levels were significantly higher (p<0.001, p=0.004, p<0.001, and p<0.001, respectively), and albumin and calcium levels was significantly lower in the non-surviving patients (p<0.001, p=0.025). Analysis of inflammatory markers of the patients revealed that the non-survivors group had higher CRP, fibrinogen, ferritin and procalcitonin levels in significant numbers in the comparison with the patients of the survivors group (for all; p<0.001). In the analysis of cardiac biomarkers, CK, d-dimer and pro-BNP levels were found to be significantly higher in non-surviving patients from a statistical standpoint (p<0.001, p=0.035 and p=0.036; respectively). Additionally, the mean LAR values were significantly higher in the non-surviving patients compared to the survivors (5.9±3.5 versus 3.3±1.4; p<0.001) (Table 1, Figure 1).
Correlation Analysis
Pearson’s correlation analysis was used to explore the relationship between LAR and biochemical markers. LAR values was positively correlated with urea (r=0.43, p<0.001), LDH (r=0.35, p<0.001), ferritin (r=0.25 p=0.015), procalcitonin (r=0.34, p<0.001), and pro-BNP (r=0.24 p=0.015) levels. Linear
correlation analysis graphs are given in Figures 2 and Figure 3.
ROC Curve Analysis
The efficacy of inflammatory markers for the prediction of mortality was evaluated using ROC analysis. Areas under the curve (AUC) of leukocyte, CRP, procalcitonin, fibrinogen, ferritin, albumin and LAR were found as 0.734 (p<0.001), 0.724 (p<0.001), 0.761 (p<0.001), 0.683 (p=0.002), 0.764 (p<0.001), 0.273 (p<0.001) and 0.779 (p<0.001), respectively. Among these parameters, LAR occupied the maximum area with 0.779 (AUC:0.779 95% Cl:0.689-0.870, p<0.001). When the cut-off value for LAR in predicting mortality was determined to be 3.71, the sensitivity was determined as 76%, while the specificity was 70% (Table 2).
Logistic Regression Analysis
Multivariable logistic regression analysis, which included age, sex, urea, LDH, CK, ferritin, fibrinogen, CRP, procalcitonin, LAR revealed that older age (OR: 1.114, 95% CI: 1.020-1.218; p=0.017) and increased ferritin (OR: 1.003, 95% CI: 1.001-1.004; p=0.002) and LAR (OR: 1.583, 95% CI: 1.073-2.337; p=0.021) values were independent predictors of mortality in patients with critical COVID-19 during hospitalization (Table 3).
Discussion
The results of the present study indicate that LAR values were significantly higher in the non-surviving patients compared to the surviving patients. Multivariable logistic regression analysis revealed that increased LAR values were predictors of mortality in patients with critical a COVID-19 infection during hospitalization. Additionally, LAR was found to have a reasonable sensitivity (76%) and specificity (70%) in predicting non-survival patients.
The mortality rate in critical COVID-19 patients hospitalized in intensive care is quite high, and in a cohort study, hospital mortality was found to be at 53.4% [7]. In accordance with the literature data, mortality was found to be 56.1% in our study. In our study, there was a high rate of mechanical ventilation during intensive care admission, and this may explain the high mortality rate. Additionally, in our study it was determined that advanced age is an independent risk factor for mortality, and DM and HT are more common in non-surviving patients.
In many previous studies, it has been observed that biomarkers such as CRP, D-dimer, ferritin, cardiac troponin, IL-6, leukocyte and lymphocyte count can be used in risk stratification to predict disease severity [15]. Similarly, elevated leukocyte levels have been found to be associated with severe disease and mortality [7,16]. On par with the literature, in our study leukocyte levels were found to be elevated in non-survivor patients compared to those who survived. Additionally, when the cut-off value for leukocyte count was taken as 10.75 in ROC analysis, it was observed that it predicted mortality with 70% sensitivity and 63% specificity.
Albumin is known as a negative acute phase reactant, and circulating albumin concentrations are inversely proportional to the magnitude of the systemic inflammatory response. In cases of acute inflammation, while the production and secretion of pro-coagulants such as C-reactive protein and fibrinogen rise, plasma concentrations of constitutive proteins such as albumin and transferrin fall [8,17]. Various studies have shown that low albumin levels are predictors of severe disease and mortality in COVID-19 patients [11-13]. Similar to the literature, in our study we found the level of albumin to be higher in non-survivor patients compared to those who survived. Additionally, when the cut-off value for albumin was taken as 2.85, it was found that it showed 67% sensitivity and 65% specificity in predicting mortality.
Upon examination of the literature, it was seen that there was no study analyzing the importance of LAR in predicting mortality in COVID-19 patients. Wang et al. showed in their study that the CRP-albumin ratio is an independent risk factor for predicting mortality at an early stage of COVID-19 infection [18]. It has been reported that the ratio of fibrinogen-albumin in COVID-19 patients is an independent risk factor for severe disease and that the increased fibrinogen albumin ratio may be related to cytokine storms [19]. In another study, it was observed that the ratio of neutrophil-albumin was higher in critically ill patients compared to noncritical patients, and this situation was found to be associated with a poor prognosis [20].
According to the results of our study, LAR had a stronger predictive value for predicting mortality than leukocyte alone or albumin alone, as well as other analyzed inflammatory markers (CRP, procalcitonin, fibrinogen, and ferritin). LAR was found to be an independent predictor of mortality and showed an important performance for predicting hospital mortality. In addition, it was found that LAR levels were positively correlated with urea, LDH, ferritin, procalcitonin and pro BNP levels. High LAR indicates an imbalance in inflammatory response, and may be a marker showing disease severity in conditions such as sepsis [21].
Some limitations should be interpreted with our study. Our study is a single center, retrospective, and partially includes a small number of patients. The death rate from COVID-19-related or other specific causes alone is unknown. Finally, only LAR levels at the beginning of admission to intensive care were analyzed in our study.
As a result, it was found that the LAR index is an important marker in predicting hospital mortality, and is also an independent predictor of hospital mortality. More research is needed to validate our findings, evaluate the predictive ability of baseline LAR values, and analyze changes in LAR values during follow-up/treatment.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
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2. Wu Z, McGoogan JM. Characteristics of and important lessons from the Coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases
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3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective
cohort study. Lancet. 2020;395(10229):1054-62.
4. Wang K, Zuo P, Liu Y, Zhang M, Zhao X, Xie S, et al. Clinical and laboratory predictors of in-hospital mortality in patients with COVID-19: a cohort study in Wuhan, China. Clin Infect Dis. DOI:10.1093/cid/ciaa538.
5. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052-9.
6. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a singlecentered, retrospective, observational study. Lancet Respir Med. 2020; 8(5):475-81.
7. Henry BM, Santos de Oliveira MH, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): A meta-analysis. Clin Chem Lab Med. 2020;25;58(7):1021-8.
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9. Huang J, Cheng A, Kumar R, Fang Y, Chen G, Zhu Y, et al. Hypoalbuminemia predicts the outcome of COVID-19 independent of age and co-morbidity. J Med Virol. 2020;92(10):2152-8.
10. Soeters PB, Wolfe RR, Shenkin A. Hypoalbuminemia: Pathogenesis and Clinical Significance. JPEN J Parenter Enteral Nutr. 2019;43(2):181-93.
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14. Serafim RB, Póvoa P, Souza-Dantas V, Kalil AC, Salluh JIF. Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review. Clin Microbiol Infect. 2021;27(1):47-54.
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21. Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis. 2020; DOI:10.1093/cid/ciaa248
Download attachments: 10.4328:ACAM.20895
Ayşegül Altıntop, Erdal İn, Umut Sabri Kasapoğlu, Nurcan Kırıcı Berber, Ercan Karabulut, Cengiz Özdemir. Leukocyte Albumin Ratio as an Early Predictor of Mortality in Critical COVID-19 Patients. Ann Clin Anal Med 2022;13(2):161-165
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Effects of a fixed-time feeding method on physiological parameters in preterm infants
Mesut Dursun 1, 2, Duygu Gözen 3, Müjde Çalıkuşu İncekar 4, Alfiya Vehbioğlu 5, Habibe Türk 6
1 Division of Neonatology, Department of Pediatrics, Memorial Bahcelievler Hospital, Istanbul, 2 Faculty of Health Sciences, Istanbul Gelisim University, Istanbul, 3 Department of Pediatric Nursing, Florence Nightingale Faculty of Nursing, Istanbul University – Cerrahpasa, Istanbul, 4 Department of Pediatric Nursing, Faculty of Health Sciences, Yuksek Ihtisas University, Ankara, 5 Department of Pediatrics, Medical Faculty, Biruni University, Istanbul, 6 Neonatal Intensive Care Unit, Medical Faculty, Biruni University, Istanbul, Turkey
DOI: 10.4328/ACAM.20898 Received: 2021-10-12 Accepted: 2021-11-01 Published Online: 2021-11-07 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):166-169
Corresponding Author: Mesut Dursun, Merkez Mah. Yaren Sok. No: 6H/4, 34406, Kagithane, Istanbul, Turkey. E-mail: mesutdursun@outlook.com P: +90 532 395 20 54 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8461-0863
Aim: This study investigated the effects of fixed-time (study group) and gravity (control group) feeding methods on respiratory rate, oxygen saturation, heart rate, and gastric residual volume in preterm infants.
Material and Methods: This study was conducted in the neonatal intensive care unit. Preterm infants were fed with fixed-time and gravity feeding methods. The physiological parameters of the preterm infants were recorded.
Results: Compared with the control group, preterm infants in the study group exhibited lower respiratory rate (p < 0.05), lower heart rate (p < 0.05) and higher oxygen saturation (p < 0.05) during feeding. There was no statistically significant difference between the groups in terms of gastric residual volume (p > 0.05).
Discussion: Lower respiratory and heart rates and higher oxygen saturation rate were observed in infants fed by a fixed-time feeding method. The fixed-time feeding method may be suggested for use by healthcare professionals during the treatment of preterm infants.
Keywords: Feeding Methods, Intermittent Feeding, Neonatal Intensive Care, Prematurity
Introduction
A systematic review of studies conducted in 107 countries showed a global preterm birth rate of 10.6% of live births; the incidence of preterm birth (< 37 weeks of gestation) is increasing [1]. Premature and low birth weight infants are more likely to develop nutritional deficiencies because of organ or system immaturity, metabolic disorders, limited nutritional reserves, high growth rate, and intensive catabolism [2].
Intermittent bolus feeding is defined as feeding for 10–20 min at 2–3-h intervals, usually by gravity or an electric pump [3]. Of these, the gravity method is often used in intermittent bolus feeding [4-6], with a feeding duration of 10–30 min [5-7]. However, it is unclear whether this is the most effective method for preterm infants, or whether it ensures quality care [8]. Intermittent bolus feeding is regarded as physiological because it causes cyclical fluctuations of gastrin, gastric inhibitory peptide, and insulin in the infant digestive system, thus supporting gastrointestinal system development [9]. Intermittent feeding increases protein synthesis and improves protein balance in infants, both of which play important roles in the regulation of nutritional disorders [10]. A previous meta-analysis confirmed the utility of intermittent feeding [11].
In neonatal intensive care units, the feeding duration of preterm infants who receive intermittent feeding must be evidence-based and appropriate. In the literature, a fixed time for intermittent feeding has not yet been reported. In the gravity feeding method used in our clinic, a single meal comprises 10–30 ml of food administered to the infant over a mean duration of 10 min with the aid of gravitation. The physiological parameters of the infants have been reported to change during feeding because of the rapid flow. In a study comparing kangaroo care and prone position, both groups were fed by a pump for 30 min [12]. To our knowledge, no published studies have examined differences in respiratory rate, oxygen saturation, heart rate, or gastric residual volume in preterm infants between feeding with a longer-duration fixed-time method and feeding with the gravity method. In this study, these parameters were compared in infants fed for a period > 10 min and infants fed for a fixed time.
Material and Methods
Design
This randomized controlled trial was designed to determine the effect of the fixed-time (study group) and gravity (control group) feeding methods on respiratory rate, oxygen saturation, heart rate, and gastric residual volume in preterm infants before, during and after the feeding period. Study approval was obtained from the Clinical Trials Ethics Committee of Biruni University (no: 2015-KAEK-43-18-09). Written informed consent was obtained from the infants’ parents.
Participants
The study was conducted in our neonatal intensive care unit between June 2018 and October 2019. Based on a power analysis (G*Power 3.1.9.2) calculated for this study and using the method established in a previous study [13], the number of samples determined for power: 0.80, β: 0.05 and α: 0.05 was identified as a total of 28 including minimum 14 for each group. To plan for possible losses, the sample size was set at 30 infants, with 15 infants per group. Figure 1 presents a CONSORT flow diagram [14] of the study.
The study population consisted of infants at a gestational age ≤ 32 weeks and a birth weight ≤ 1500 g. Infants who switched to full enteral feeding (minimum 150 ml/kg/day) were included in the study. The exclusion criteria for preterm infants were as follows: major congenital anomaly, multiple organ failure, central nervous system disease, history of birth asphyxia, ongoing need for invasive mechanical ventilation, hemodynamically significant patent ductus arteriosus, and proven sepsis during the study.
Infants who met the inclusion criteria were assigned to either the study group or the control group using urn randomization [15], with the white ball indicating the study group and the red ball indicating the control group. A nurse working in the unit made the selection with closed eyes, which ensured the random distribution of infants between the two groups.
Measures
An infant information form was prepared by the researchers and included questions regarding sex, gestational age, postmenstrual age, weight, length of orogastric tube, feeding amount, food type, and respiratory support during transition to full enteral feeding. A feeding monitoring program was used to record the respiratory rate, oxygen saturation, and heart rate of infants before, during, and after feeding. Before the start of the next feeding, gastric residual volume was measured and then recorded in the form.
Procedure
The first orogastric tube was inserted after birth using the NEMU method (measuring from mouth to the earlobe, then to the xiphoid appendix and middle point of the umbilicus). The correct length and correct positioning of the tube were confirmed during chest radiography, performed in the clinic for examination purposes. The tube length of each infant was recorded in the research form.
Fixed time feeding method (study group)
Infants were placed in the prone position before the initiation of monitoring with a device that recorded the data every minute for 15 min between 09:45 am and 10:00 am. Researchers administered food to the preterm infant via the orogastric tube within 20 min with the aid of a pump, beginning at 10:00 am. The variables were measured every minute for 20 min. After the feeding, monitoring was continued; data were recorded every minute for 15 min. The gastric residual volume was assessed for either 2 h (infants weighing < 1250 g were fed at a 2-h interval) or 3 h (infants weighing > 1250 g were fed at a 3-h interval) after the end of feeding until the next feeding was performed.
Gravity feeding method (control group)
Infants were placed in the prone position before the initiation of monitoring with a device that recorded data every minute for 15 min between 09:45 am and 10:00 am. The infants were fed via the orogastric tube at 10:00 am with the aid of gravity. The height of the tube from the stomach was set at 15 cm and the duration of feeding was recorded. Variables were measured every minute during feeding. After the feeding, monitoring was continued; data were recorded every minute for 15 min. Gastric residual volume was assessed as described above.
Statistical analysis
The Number Cruncher Statistical System (NCSS) 2007 (Kaysville, UT, USA) program was used for statistical analyses. Descriptive statistical methods (mean, standard deviation, median, frequency, ratio, and range) were used to analyze the data. The normal distribution of the quantitative data was tested using the Kolmogorov–Smirnov test, Shapiro–Wilk test, and graphical evaluations. Student’s t-test was used to compare normally distributed quantitative data between the two groups; the Mann–Whitney U test to compare non-normally distributed data. The Pearson chi-squared test, Fisher-Freeman-Halton exact test, and Fisher’s exact test were used to compare qualitative data. A repeated measures test (repeated measures analysis of variance) was used to evaluate normally distributed variables, and a Bonferroni test was used to perform pairwise comparisons. Statistical significance was defined as p < 0.05.
Results
The study flow chart is shown in Figure 1. The descriptive characteristics and some variables did not significantly differ between groups (Table 1). The mean duration of infant feeding in the control group was 5.47 ± 2.29 min (range, 3–12 min; median = 5 min). The respiratory rate during feeding was lower in the study group than in the control group (p = 0.040). The infants’ oxygen saturation values were significantly higher during feeding in the study group than in the control group (p = 0.036). During feeding, heart rate was lower in the study group than in the control group (p = 0.045). The data are shown in Table 2.
The mean gastric residual volumes of preterm infants in the study and control groups were 0.73 ± 1.07 ml (range, 0–3; median = 0) and 0.87 ± 1.54 ml (range, 0–6; median = 0.3), respectively. The difference was not statistically significant (p = 0.807).
Discussion
This study evaluated the effects of the fixed time and gravity feeding methods on respiratory rate, oxygen saturation, heart rate, and gastric residual volume in preterm infants. The methods used and variables that were monitored in this study were consistent with published literature.
Our results showed that, during the feeding of preterm infants, both respiratory rate and heart rate were lower in the study group than in the control group; oxygen saturation was higher in the study group. The effectiveness of push and gravity feeding methods in enteral feeding were compared in a previous study that examined oxygen saturation and heart rate in preterm infants. The mean feeding duration for both methods was 10 min, and the cardiopulmonary findings of infants placed in the prone position were similar between groups [7]. Khatony et al. [16] reported that the gastric residual volume was lowest when infants were placed in the prone position. In our study, all infants were placed in the prone position; however, there were differences between groups in terms of feeding duration. For infants fed by the gravity method, the mean duration of feeding was 5 min; for infants fed by the fixed-time method, the feeding duration was fixed at 20 min. Due to the infants’ slow food intake, oxygen saturation was higher among infants fed by the fixed-time method.
Another study comparing push and gravity feeding methods found that the respiratory rates of infants fed by the push feeding method were high at 10–30 min after feeding, whereas the heart rate was high among infants fed by the gravity feeding method; however, that study did not report the duration of feeding [8]. In the present study, respiratory and heart rates were significantly lower in infants fed by the fixed-time method than in infants fed by the gravity method; both rates remained lower within 15 min after feeding, although the difference was not statistically significant at this time point. These results are presumably related to the slower transport of food to the infant’s stomach using the fixed-time method, compared with the gravity method. The distance of the tube between the stomach and the injector was 15 cm, which corresponds to the distance reported in the literature [7].
In the present study, gastric residual volume did not significantly differ between groups. In a randomized controlled trial, gastric residual volume in preterm infants was lower in the gravity feeding group (food was administered within 15 min) than in the semi-continuous feeding group (one-quarter of the hourly feeding amount was provided by gravity at 15-min intervals throughout the day) [6].
A limitation of our study was its small sample size, although this size was determined via power analysis. In addition, the results were measured after a single meal. The findings of our study are limited to the clinic where the research was conducted.
Conclusions
Our study showed lower respiratory and heart rates, and higher oxygen saturation, in infants fed by the fixed-time method than by the gravity method during feeding. Thus, the fixed-time method may suggest for use by healthcare professionals during treatment of preterm infants. Our results should be confirmed in studies with larger sample sizes and after administration of more than one meal. They also require validation according to additional physiological variables, anthropometric measurements, and feeding tolerance during transition to full oral feeding.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
1. Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health. 2019;7(1):e37-46.
2. Sánchez-Tamayo T, Espinosa Fernández MG, Affumicato L, López MG, Romero VF, Algarra MCM, et al. Reduction of enterocolitis with an enteral nutrition protocol in preterm newborns. An Pediatr. 2016;85(6):291-9.
3. Bozzetti V, Tagliabue PE. Enteral nutrition for preterm infants: by bolus or continuous? An update. La Pediatria Medica e Chirurgica. 2017;39(2):67-70.
4. Corvaglia L, Martini S, Aceti A, Capretti MG, Galletti S, Faldella G. Cardiorespiratory events with bolus versus continuous enteral feeding in healthy preterm infants. J Pediatr. 2014;165(6):1255-7.
5. Richards R, Foster JP, Psaila K. Continuous versus bolus intragastric tube feeding for preterm and low birth weight infants with gastro‐oesophageal reflux disease. Cochrane Database Syst Rev. 2014;17(7): CD009719.
6. Rövekamp-Abels LW, Hogewind-Schoonenboom JE, de Wijs-Meijler DP, Maduro MD, Jansen-van der Weide MC, van Goudoever JB, et al. Intermittent bolus or semicontinuous feeding for preterm infants? J Pediatr Gastroenterol Nutr. 2015;61(6):659-64.
7. Joshi R, van Pul C, Sanders A, Weda H, Bikker JW, Feijs L, et al. A strategy to reduce critical cardiorespiratory alarms due to intermittent enteral feeding of preterm neonates in intensive care. Interact J Med Res. 2017;6(2):e20.
8. Dawson JA, Summan R, Badawi N, Foster JP. Push versus gravity for intermittent bolus gavage tube feeding of premature and low birth weight infants. Cochrane Database Syst Rev. 2012;11:CD005249.
9. Lucas A, Bloom SR, Aynsleygreen A. Gut hormones and “minimal enteral feeding”. Acta Paediatrica Scandinavica. 1986;75:719-23.
10. Gazzaneo MC, Suryawan A, Orellana RA, Torrazza RM, El-Kadi SW, Wilson FA, et al. Intermittent bolus feeding has a greater stimulatory effect on protein synthesis in skeletal muscle than continuous feeding in neonatal pigs. J Nutr. 2011;141(12):2152-8.
11. Wang Y, Zhu W, Luo BR. Continuous feeding versus intermittent bolus feeding for premature infants with low birth weight: a meta-analysis of randomized controlled trials. Eur J Clin Nutr. 2019;74(5):775-83.
12. Özdel D, Sarı HY. Effects of the prone position and kangaroo care on gastric residual volume, vital signs and comfort in preterm infants. Jpn J Nurs Sci. 2020;17(1):e12287.
13. Dani C, Pratesi S, Barp J, Bertini G, Gozzini E, Mele L, et al. Near-infrared spectroscopy measurements of splanchnic tissue oxygenation during continuous versus intermittent feeding method in preterm infants. J Pediatr Gastroenterol Nutr. 2013;56(6):652-6.
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16. Khatony A, Abdi A, Karimi B, Aghaei A, Brojeni HS. The effects of position on gastric residual volume of premature infants in NICU. Ital J Pediatr. 2019;45(1):6.
Download attachments: 10.4328:ACAM.20898
Mesut Dursun, Duygu Gözen, Müjde Çalıkuşu İncekar, Alfiya Vehbioğlu, Habibe Türk. Effects of a fixed-time feeding method on physiological parameters in preterm infants. Ann Clin Anal Med 2022;13(2):166-169
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Efficacy of diode laser therapy on osseointegration of dental implants: A split-mouth clinical study
Suheyb Bilge 1, Seyma Bayındır 2, Ahmet E. Demirbas 1, Emrah Soylu 1
1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri, 2 Private Clinician, Department of Oral and Maxillofacial Surgery, Kayseri, Turkey
DOI: 10.4328/ACAM.20900 Received: 2021-10-15 Accepted: 2021-11-09 Published Online: 2021-11-14 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):170-174
Corresponding Author: Suheyb Bilge, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, 38039, Kayseri, Turkey. E-mail: suheybbilge@hotmail.com P: +90 530 211 23 49 F: +90 352 438 06 57 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9282-7344
Aim: The purpose of the present study was to investigate the effect of low-level laser therapy (LLLT) on postoperative osseointegration and secondary stability in symmetrical dental implants.
Material and Methods: Patients with symmetrical missing teeth in the maxilla and mandible participated in the present study. Implants were reserved randomly into laser and control groups. Indium Gallium Arsenide Phosphide (InGaAsP) semiconductor diode laser with a wavelength of 940 nm (total array area 0.8 cm², contact probe diameter 1 cm, total power 200 mW, average power intensity 250 mW/cm², total energy 40 J, average energy intensity 50 J/cm²) was used in the study. The buccal, lingual, mesial, and distal sides of the dental implants were irradiated with a laser. Six sessions of LLLT were given to the laser group implants for 2 months. The stability of these implants was measured with Periotest®. The mean Periotest® values were recorded at baseline at 14, 30, and 90 days.
Results: No significant differences were observed among the groups in the Periotest® (Periotest®, Siemens AG, Bensheim, Germany) values at baseline (P=0.985). A larger decrease in the Periotest® values of the laser group was observed compared to the control group for 90 days. The Periotest® values on the 30th day (P=0.043) and the 90th day (P<0.001) were significantly lower in the laser group.
Discussion: LLLT application stimulates biological tissues and increases both the bone healing capacity and secondary stability of dental implants. LLLT enhances the long-term success of dental implants by strengthening osseointegration and allows early implant loading.
Keywords: Bone Density, Dental Implants, Diode Laser, Implant Stability, Osseointegration
Introduction
Dental implant treatment has an important place in the rehabilitation of missing teeth. Implant-supported prostheses have been accepted by patients because they are more successful in terms of stability, aesthetics and functionality compared to conventional prostheses, and the popularity of this treatment method has gradually increased over the year. Although implant therapy is the preferred and effective treatment modality, this treatment modality depends on successful osseointegration during the healing period. The notion of osseointegration was first defined by Branemark as the connection of the implant surface to the bone [1]. Implant morphology, implant surface roughness and topography affect osseointegration [2]. Many studies have reported that immediate loading or early loading yielded near-success results when the osseointegration period was expected [3,4]. LLLT is used more and more in both medicine and dentistry to treat many medical conditions such as pain, wound healing and nerve injury. Understanding the effect of LLLT on bone remodeling is crucial to knowing whether LLLT will enhance implant-bone interaction. The laser, whose abbreviation is “Light Amplification by Stimulated Radiation Emission”, supports the inflammatory response by providing cellular biostimulation, thus accelerating the healing of tissues [5].
Although LLLT is known to stimulate cellular activity and increase tissue regeneration through biostimulation, clinical studies on the impact of LLLT on implant osseointegration are limited. The purpose of the present clinical research is to evaluate the effects of LLLT on the osseointegration of implants.
Material and Methods
Study Design
To address the research purpose, the authors designed and implemented a split-mouth, prospective, randomized, and double-blind clinical study. The present study was carried out on partially or totally edentulous patients who presented at the Erciyes University, Department of Oral and Maxillofacial Surgery, between January 2018 and January 2019 with the approval of the ethics committee. Healthy patients aged over 18 years, of both sexes, with symmetrical edentulous areas were included in the study. The following patients were excluded: patients under the age of 18 years, the presence of metabolic bone diseases, taking any kind of drugs, and non-symmetrical edentulous areas. There were 66 implants in the 22 patients included in this study. All patients signed informed consent forms. The control group consisted of 33 implants (21 mandibular and 12 maxillary) and the laser group consisted of 33 implants (21 mandibular and 12 maxillary). The study design is presented in Table 1. Cone beam computed tomography (CBCT) was taken from all patients after an intraoral examination.
Hounsfield Units (HU)
Implant recipient sites were evaluated for bone classification using the Simplant software (Simplant Pro 2011, Materialize, Leuven, Belgium). For bone density evaluation using the Hounsfield index, the same clinician (SB) evaluated implant sites from every patient’s CBCT scan. The average of these readings represented the density of that site. Table 1 shows the mean HU values of the patients. The HU values of the mandibular bones were over 600 HU, while these values were below 600 HU in the maxillary bones. The density of the bones of the patients in the laser and control group were similar to each other.
Surgical Protocol
Implantation sites had bilaterally similar bone density based on the HU. Following the mucosal incision, the mucoperiosteal flap was elevated. Drilling was performed at 800 rpm in both groups. Implants of the same length and diameter were placed symmetrically (Figure 1). All implants were placed with the same torque (60 rpm) by the same surgeon (SB). All patients received oral hygiene and post-operative care instructions.
LLLT Application
After implants placement, the implants were randomly selected for the laser and control groups by one clinician (SB). In the laser group, an InGaAsP semiconductor diode laser (BİOLASE Epic 10, Inc., Irvine, CA, USA) with a wavelength of 940 nm (total array area 0.8 cm², contact probe diameter 1 cm, total power 200 mW, average power intensity 250 mW/cm², total energy 40 J, average energy intensity 50 J/cm²) was used. Diode laser irradiation parameters were selected based on previous studies [6,7]. Four points were irradiated by a laser: buccal, lingual/palatal, mesial and distal sides of the implants with the tissue probe (Figure 2). Each application point received a total of 800 seconds with 200 seconds per side on the operation day, 3rd, 7th, and 14th days and the 1st and 2nd months postoperatively. The same process was applied to the other group with a diode laser in the ‘off’ mode.
Implant Stability Measurements
The stability of each implant was measured with the Periotest® device. The Periotest® records 16 strokes, eliminating imprecise accuracy to achieve reliable measurements. The Periotest® system evaluates mobility between -8 and +50. Values between -8 and +9 are considered the limits for osseointegration in the implant [8]. While measuring with the Periotest®, patients were sitting upright without leaning back. The Periotest® device evaluates the stabilization with the healing cap of the implants. To standardize the Periotest® measurements, all healing caps were given 10 Ncm torque with a rotary instrument. Periotest® values were recorded immediately after implantation and on the 14th, 30th and 90th days postoperatively. The torque of the healing caps was checked before each measurement to avoid incorrect measurement. Each measurement was repeated three times by the same clinician (AED).
Statistical Analysis
Data normality was assessed using histograms, q-q plots, and the Shapiro-Wilk test. The variance homogeneity was examined using the Levene’s test. To compare differences among groups, either an independent two sample t-test and the Mann- Whitney U test, or the Kruskal-Wallis tests were applied for quantitative data. Fisher’s exact test was applied for qualitative data. Data values were expressed using mean ± standard deviation or frequencies (percentages). Coefficient of variation (CV) and intraclass correlation coefficient (ICC) were used for intra-examiner reliability. Analyses were conducted using Turcosa (Turcosa Analytics Ltd. Co., Turkey, www.turcosa.com.tr). A p-value less than 0.05 was considered statistically significant.
Results
CV values ranged between 3.7% and 4.4%, while ICC values ranged between 0.96 and 0.97, showing excellent agreement. Sixty-six implants were placed in the 22 patients (8 males and 14 females) enrolled in this study. The laser group consisted of 33 implants (21 mandibular, 12 maxillary) and the control group consisted of 33 implants (21 mandibular, 12 maxillary). Twenty-one mandibular and 12 maxillary implants received laser therapy. Patients were followed for 1 year both clinically and radiographically. On clinical examination, all implants in both groups were immobile and asymptomatic. None of the patients experienced implant failure.
Periotest® Value Results
No significant difference was observed between the Periotest® values at day 1 in the control and laser groups (p=0.985). On the 14th day, a decrease in the Periotest® values was observed in the laser group. However, these changes were not statistically significant (p=0.204). On the 30th day, the decrease in the Periotest® values of the implants in the laser group was statistically significant (p=0.043). According to Periotest® values, the stability of the implants was statistically lower in the laser group than in the control group on the 90th day (p<0.001) (Table 2).
Discussion
The long-term clinical success of dental implants is closely related to implant osseointegration. Implant failures mostly occur during the postoperative recovery period before the implant superstructure and mostly in the early period following the surgical procedure. It is considerable to control, direct and accelerate the healing that causes the implant to integrate with the bone in the postoperative period [9]. Osseointegration is an essential condition for dental implant success. Therefore, studies have focused on methods to improve healing at the bone-implant integration. Previous studies have reported positive effects of LLLT on bone healing [7]. LLLT exhibits analgesic, anti-inflammatory and healing properties, since its wavelengths and low energy densities can penetrate tissues. The laser energy provides direct biostimulation, by stimulating the molecules and atoms of cells. In experimental studies investigating the effectiveness of LLLT, it has been reported that the healing potential of the bone is promoted. However, there is little literature information about these impacts on implant osseointegration [10]. In animal studies in recent years, it has been shown that LLLT application after implant surgery increases osteoblast proliferation and thus has a positive effect on implant osseointegration [11]. In an in vivo study, an increase in intracellular ATP occurred in the group receiving laser therapy, and osteoblastic activity was also found to be increased due to increased intracellular metabolism. In another in vitro study, cells exposed to laser irradiation with therapeutic doses showed a significant increase in alkaline phosphatase, a marker of bone production, compared to control cells. All these studies demonstrate that LLLT increases osteogenic potential creating strong bio stimulation in cells [12,13].
Soleimani et al. concluded that the use of LLLT enhances the proliferation of mesenchymal stem cells and their differentiation into osteoblasts [14]. In Petri’s study, gene expression alkaline phosphatase, osteocalcin, bone sialoprotein, and bone morphogenic protein-7 was higher in LLLT treated cultures, while runt-related transcription factor 2, osteopontin, and osteoprotegerin were lower compared to non-irradiated cells [9]. In present study, based on the knowledge that LLLT stimulates osteoblastic cell differentiation and the idea that it will show possible benefits in implant osseointegration, LLLT was applied to the peri-implant bone area after implant surgery. The basis of the biostimulant effect of LLLT on tissues is that it increases tissue oxygenation and nutrition by increasing ATP, DNA, RNA synthesis, and this condition results in a faster tissue regeneration activity. Jawad et al. reported the optimal efficacy of a nine hundred forty nanometer (nm) diode laser in stimulating osteoblast cells for improved bone formation [15]. Romao et al. applied laser to an alveolar bone socket after molar tooth extraction, and the results suggested that laser phototherapy could accelerate alveolar bone repair, leading to a more homologous trabecular design indicated by thin and close trabeculae. In light of these findings, a diode laser device that produces 940 nm wavelength laser beam was used in the jaw bones of patients included in the present study [16].
In the literature, the parameter used in laser studies for biostimulation is joule/square centimeter (J/cm²) [6,7,10]. Although similar laser parameters were used in in vitro and animal studies, it was seen that each researcher used different parameters in human studies. The effect of laser on the tissue was determined by the power (watt) of the laser, the application time (second), and the spot width (cm²). The present study focused on the effect of LLLT using a 940 nm GaAlAs diode laser with an output power of 200 mW and an average energy intensity of 50 J/cm², on the osseointegration of implants placed into the maxilla and mandibula. The diode laser irradiation parameters were determined based on previous studies [6,7,10]. Although there are a large number of in vitro and animal studies on this subject, human studies are quite limited. The literature has shown that clinical studies on this subject have been conducted over the last 10 years. As far as we know, there are very few clinical studies about LLLT on the osseointegration of implants in the literature. In the study conducted by Garcia et al., LLLT was applied to implants in the mandible and the implant stability quotient was measured using resonance frequency analysis. It was found that implant stability quotient values gradually increased from week 6 to week 12 in the irradiated group. Gokmenoglu et al., used the light-emitting diode (LED) device at a wavelength of 626 nm and they found that the stability values of the implants in the LED group did not change, while the stability values of the implants in the control group decreased over time [6]. Mandic et al., applied LLLT to implants placed in the maxillary bone [17]. The irradiated implants achieved higher stability than the implants in the control group during the follow-up, and the difference was statistically significant at the 5th postoperative week. In the study by Torkzaban et al., seven sessions of LLLT were irradiated on the buccal and palatal sides of implants [7]. While an increase was observed in the implants in the laser group over time, there was no statistically significant difference between the laser and control groups. These research studies focused on the potential of the laser to reduce the healing period following implantation and to improve the potential for bone regeneration. Although the stability values of the laser groups were higher than the control groups, the results were not statistically significant. Gokmenoglu et al. used forty-six joule/square centimeters energy intensity extraorally. No significant differences were demonstrated in the ISQ values between groups [6]. This may be due to insufficient energy penetration into the tissues due to the lower wavelength of the laser used. Torkzaban’s study showed similar characteristics as the present clinical study [7]. They used nine hundred forty nanometers, and laser irradiation was applied at two points for forty seconds per point.
Implant stability values were measured using the Periotest® device due to its practical, non-invasive and simple nature. Clinicians prefer Periotest® because it provides accurate and repeatable measurements and ease of application. Implant stability values were measured and recorded during and after the operation on the 14th, 30th, and 90th days. In this study, the Periotest® values were almost the same in both groups at baseline (Laser Group: -3.91±2.92, Control Group: -4.02±2.63). On the fourteenth day, an increase was observed in the laser group, however these changes were not statistically significant (p=0,204). The mean values of the thirtieth day were decreased in the laser group and there were statistically significant differences between the groups (p=0,043). On the ninetieth day, the values were lower in the laser group, and the results were found statistically significant (p<0,001). In other studies, the difference in values in the laser and control groups was not significant. However, in this present study, statistically significant results were obtained [10,17]. The present outcomes can be explained as follows. A total of 6 sessions of laser were applied for 2 months. The wavelength of the diode laser device used was 940 nm. By using the laser device with a high wavelength, the penetration of the laser light into the tissues may have increased. Osteoblastic cell stimulation may be increased by applying the laser to 4 regions around the implants. Application of LLLT at optimal doses may increase the osseointegration of implants by promoting bone formation.
Conclusion
As a result of our findings, laser application stimulates biological tissues and accelerates bone healing. LLLT was found to be effective and successful in implant osseointegration. The weakness of this study is the limited study samples. On the other hand, the strengths of the present study are that it is split-mouth, prospective, randomized, and double-blind clinical study design. Implant stability values increased after six sessions of LLLT using the irradiation procedure in the present study. When the primary stability is insufficient, the secondary stability can be improved by using low-level laser. Although LLLT has been applied in the osseointegration of implants, there is no defined standard irradiation protocol and parameter. More studies are needed on this topic due to insufficient clinical studies.
Acknowledgment
The authors thank Dr. Ahmet Ozturk, a statistician of the University Erciyes, Institute of Health Sciences, Department of Biostatistics for reviewing and confirming all the statistical analyses and results.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Suheyb Bilge, Seyma Bayındır, Ahmet E. Demirbas, Emrah Soylu. Efficacy of diode laser therapy on osseointegration of dental implants: A split-mouth clinical study. Ann Clin Anal Med 2022;13(2):170-174
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Evaluation of a computer-based cognitive training program for early-stage Alzheimer’s disease
Büşra S. Arıca Polat 1, Omer Karadas 2
1 Department of Neurology, Gulhane Training and Research Hospital, 2 Department of Neurology, Gulhane Medical School, Health Sciences University, Ankara, Turkey
DOI: 10.4328/ACAM.20902 Received: 2021-10-12 Accepted: 2021-11-02 Published Online: 2021-11-10 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):175-179
Corresponding Author: Busra S. Arıca Polat, Gen. Tevfik Saglam Street, No:1, 06010, Etlik, Ankara, Turkey. E-mail: busrarica@yahoo.com P: +90 312 304 20 00 / +90 505 384 05 71 F: +90 312 304 27 00 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9337-4041
Aim: Previous studies have reported that computer-based cognitive training (CBCT) programs improve many cognitive functions, especially memory, attention, and executive functions in early-stage Alzheimer’s disease (AD) patients. In addition, these programs have been shown to improve patients’ mood and quality of life. In this study, it was aimed to investigate the effect of a CBCT program on cognitive functions, behavioral symptoms, and quality of life in early-stage AD patients.
Material and Methods: Twenty-nine patients with a diagnosis of probable AD were included in the study. Patients and their caregivers were examined neuropsychologically before and after (after 12 weeks) the CBCT program. Mini-Mental State Examination (MMSE), forward and backward digit span, clock drawing test (CDT), verbal fluency tests, and Trail Making Test A and B forms were used for cognitive assessment, and the Geriatric Depression Scale (GDS) was used for depression screening. In addition, patients and their caregivers were evaluated with the Quality of Life in Alzheimer’s Disease Scale, the Caregiver Burden Scale, the Caregiver Stress Scale, and the Reactions to Helping Your Family Member Scale.
Results: Forward and backward digit span tests at the end of the program were significantly better than those before the program (4.81 ±0.75, p=0.01 / 10.72 ±5.64, p=0.01, respectively). In addition, it was observed that the trail-making test form B was completed faster at the end of the program (308 ±166.66 s, 200 ±111.73 s; p=0.02). The reaction times of the patients at the end of the program were significantly shorter than those before (p=0.01).
Discussion: The results indicate that the 12-week CBCT program provides an improvement in simple and sustained attention, delayed recall, executive functions, and information processing speed in early-stage Alzheimer patients. Large-scale randomized controlled studies are needed to more clearly demonstrate the effects of such programs on cognitive and behavioral symptoms, quality of life, and caregiver burden of AD.
Keywords: Computer-Based Cognitive Training, Cognitive Functions, Quality of Life, Caregiver Burden
Introduction
Alzheimer’s disease (AD) is a progressive neurodegenerative disease that affects all cognitive domains, especially memory, and activities of daily living (ADLs) [1]. Difficulties in cognitive functions vary depending on the stage of the disease. In early-stage AD, which is considered the first stage, symptoms such as mild forgetfulness noticed by family members or friends, inability to learn new things, difficulty in finding words, losing belongings, and withdrawal from social life are seen. Despite difficulties in more than one cognitive domain, patients’ functionality is relatively good and they can live independently [2]. Even in early-stage AD, the quality of life of patients and caregivers is adversely affected [3].
Since the effects of acetylcholinesterase inhibitors and memantine used in treatment are limited, nonpharmacological methods have recently been focused on in addition to pharmacological treatment. It is thought that cognitive-based therapies may be effective in reducing cognitive deficit in AD [4]. Among these interventions is cognitive training, which involves performing a standard group task that reflects cognitive functions such as memory, attention, and problem-solving [1]. It is known that computer-based cognitive training (CBCT) programs, especially those personalized and gradually increasing in difficulty according to patient performance, are the most beneficial method in early-stage AD [5]. Similarly, these programs have been reported to improve many cognitive skills, including memory performance, compared to the traditional paper-and-pencil method [6].
Although the effectiveness of the exercises in these programs on which cognitive functions in early-stage AD is unclear, studies show that they can result in improvement in memory, executive functions, naming, attention, semantic fluency, and speed of information processing skills [7]. It is also known that they improve the quality of life of patients and their caregivers and do not increase caregiver burnout [8].
The aim of the present study was to investigate the effects of a CBCT program on cognitive functions and behavioral symptoms in early-stage Alzheimer’s patients. In addition, this program is intended to evaluate the quality of life of patients and caregivers and the burden on caregivers.
Material and Methods
Patients
Fifty-one possible AD patients who presented to the neurology outpatient clinic were evaluated. All patients were in the mild stage of dementia (Clinical Dementia Rating: 1). Patients who had severe hearing and vision problems that would prevent them from complying with the CBCT program, those with severe systemic or psychiatric diseases, and those who did not volunteer to participate in the program were excluded from the study. Twenty-nine early-stage Alzheimer’s patients who met the appropriate criteria were included in the study (Figure 1). Age, sex, educational status, marital status, systemic diseases, family history of dementia, disease duration (according to symptom onset), and anti-dementia drugs (donepezil, rivastigmine, memantine) used were recorded.
Ethics committee approval was obtained for the study (Scientific Research Ethics Committee of Gulhane Training and Research Hospital, Project/Decision No: 2020-511, Date: 29.12.2020) and necessary consents were obtained from the relatives of the patients that their data could be used for scientific purposes.
Neuropsychological evaluation
Neuropsychological tests were performed by a neuropsychologist specialized in this field before and at the end of the CBCT program (12 weeks after the initial evaluation). The patients’ global cognitive performance was evaluated using the Turkish version of the Mini-Mental State Examination (MMSE) [9]. Additional detailed neuropsychological tests were administered to assess the following areas: (1) visuospatial functions, sequencing, planning, and abstract thinking (clock drawing test) [10]; (2) attention (forward and backward digit span tests) [11]; (3) ability to produce words, short- and long-term memory, perseveration, and sustained attention (verbal fluency tests) [12]; (4) visual-motor tracking, psychomotor speed, mental flexibility, visual attention, and executive functions (trail making test forms A and B) [13].
The Turkish version of the Geriatric Depression Scale was used to evaluate the emotional state of the patients [14]. Their performance in terms of activities of daily living (ADLs) was established using the Barthel ADL Index [15].
In addition, patients and their caregivers were examined in terms of their quality of life, caregiver stress and burden [16-19].
The four-point (0-4 points) scoring system was used because it was relatively easier for the clock drawing test (CDT). In the four-point system, one point each is given for a closed circle, digits in the correct positions, all 12 digits, and the correct position of the clock hands to show 11:10. The highest score that can be obtained from this version of the CDT is 4 and the lowest score is 0.
In the digit span tests applied to evaluate simple attention, random 2- to 8-digit sequences were given for the forward span and 2- to 7-digit sequences for the backward span. One point was given for each item counted correctly.
In the verbal fluency tests, letter fluency (producing words starting with the letters K, A, and S in one minute) and semantic fluency (producing words from the animal category in one minute) were evaluated. The numbers of words produced were recorded.
In the trail making tests, completion times, totals, differences, and ratios of the times and the number of errors obtained from both forms (A and B) were calculated.
In the Barthel ADL Index, which examines ten activities of daily living, a score of 0-20 indicates full dependence, 21-61 points indicate severe dependence, 62-90 points indicate moderate dependence, 91-99 points indicate mild dependence, and 100 points indicate full independence.
The geriatric depression scale consists of 30 questions and evaluates mood over the last week. Scores of 0-10 indicate no depression, 11-13 probable depression, and 14 and above definite depression.
The Quality of Life in AD Scale and its family version assess five sub-dimensions (social interaction, self-awareness, affect and mood, enjoyment of activities, and interaction with the environment). A low score on the scale indicates the impaired quality of life.
The caregiver burden scale, on the other hand, is used to evaluate the stress experienced by caregivers. With this scale, caregivers’ relationships with their patients, general health status, emotional difficulties, social life, and economic difficulties during the care process are evaluated. It consists of 22 items that determine the effect of caregiving on a person’s life and each is scored between 0 and 4. A score of 0-20 points indicates little/no load, 21-40 moderate load, 41-60 severe load, and 61-88 overload.
The Caregiver Stress Scale is a 13-item scale involving job status, financial status, physical condition, social status, and time. Each question is scored as 0 or 1, with a higher score indicating a higher level of stress.
The Reactions to Helping Your Family Member Scale is a 15-item scale included in the Family Caregiving Inventory. The participants are requested to respond to the items in the scale as follows: 0 – Not at all, 1 – Very little, 2 – A little, 3 – Quite a lot, 4 – A lot. High scores obtained from the scale indicate that caregivers react more to their relatives during care.
NoroSOFT® Cognitive Training Program
The NoroSOFT® Cognitive Training Program includes exercises culturally appropriate for Turkey in Turkish that can be applied via the Internet that improve memory, attention and concentration, executive functions, visual–spatial perception, and conceptualization skills. As the total daily score (determined from the answers and reaction times) increases, the exercises become more difficult. In each session, lasting approximately 25-30 minutes, a total of ten exercises, two from each of these five cognitive domains, were applied to the participants (3 days a week for 12 weeks). The patients were permitted to continue taking their current medication.
In addition, the reaction times of all patients in the first and last sessions they performed in the CBCT program were recorded in seconds.
Statistical analysis
SPSS 21.0 (Statistical Package for the Social Sciences, Chicago, IL, USA) was used for statistical analysis. Descriptive statistics were expressed as mean ± standard deviation for continuous and discrete numerical variables and as number of patients and percentages for nominal variables. The data expressed as percentages were compared using the Fisher–Freeman–Halton test and the chi-square test, and continuous variables were compared using the Mann–Whitney U test. The p- values < 0.05 were considered statistically significant.
Results
In the present study, 51 patients diagnosed with early-stage AD were evaluated. Twenty-two of the patients were not included in the CBCT program for various reasons. The remaining 29 patients were eligible for the program. However, 18 patients were unable to complete the program due to infection; logistical problems or relatives not being available to bring the patient to the hospital; the patient and/or their relatives going on vacation during the program, or the lockdown for people over 65 years old during the pandemic. The data of 11 patients [9 males (81.8%), 2 females (18.2%)] who completed the program were analyzed. The mean age of the female patients was 66.50 ± 4.94 years and of the male patients was 72.77 ± 7.87 years. All patients were married. Only 2 patients (18.2%) had no systemic disease. Approximately half of them had a family history of dementia (n=5, 45.5%). The mean duration of education of the patients was 7.63 ± 2.76 years and the mean duration of the disease was 1.63 ± 0.80 years. All patients were treated with donepezil 10 mg/day.
The neuropsychological test scores of the patients and their caregivers before and after the CBCT program (approximately 12 weeks after the end of the program) are summarized in Table 1 and Table 2. It is seen that the forward and backward digit span tests at the end of the program were significantly better than before the program (4.81 ± 0.75, p=0.01 / 10.72 ± 5.64, p=0.01, respectively). In addition, the Trail Making Test form B was completed faster at the end of the program (308 ± 166.66 s, 200 ±111.73 s, p=0.02). As expected, due to this decrease in duration for the B form, the difference and total scores of the two forms of the Trail Making Test improved significantly at the end of the CBCT program (p=0.04 and p=0.01). The MMSE, CDT, verbal fluency, ADL, and GDS scores of the patients before and after the program were similar. No significant difference was seen in the quality of life of the Alzheimer’s patients or their family members, caregiver burden or stress, or reactions to family members.
The mean reaction time in the first session, when the patients started the CBCT program, was 82.05 ± 46.98 s. The mean reaction time in the last session of the 12-week program was 48.90 ± 16.35 s. Reaction times at the end of the program were significantly better than those before (p=0.01).
Discussion
The results of this study showed that a 12-week CBCT program improved simple and sustained attention, delayed recall, executive functions, and information processing speed in early-stage Alzheimer’s patients. However, the program did not affect the quality of life of patients and their caregivers, depressive mood, or caregiving burden.
Recently, it has been stated that cognitive training practices can be effective in reducing the progression of AD in addition to medical treatment. [4]. It is known that CBCT programs in particular are more effective than the traditional paper-and-pencil method [5,6]. Cinar and Sahiner reported that after at least a 1200-minute CBCT program, the scores of early-stage AD patients receiving rivastigmine treatment from the Montreal Cognitive Assessment (MoCA) Scale, which was developed for the screening of mild cognitive impairment, increased significantly, whereas MoCA scores of the patients in the control group decreased [20]. Similarly, a meta-analysis of 12 studies revealed that such computer-based programs had a moderately positive effect on cognition [5]. In a small review of randomized controlled CBCT study results, these interventions were found to be ineffective in terms of basic cognitive functions. However, it has been suggested that these exercises may provide some positive effects in improving behavioral symptoms as well as the learning and short-term memory performance of patients with mild cognitive impairment and/or dementia [21]. In our study, it was seen that the cognitive functions of the patients improved after the CBCT program, which was consistent with previous studies.
Although it is not clear which cognitive functions these exercises improve, it has been observed that they improve attention, delayed recall and working memory, semantic fluency, naming, visuospatial skills, and executive functions [7,22]. The results of our study similarly revealed improvements in attention, delayed recall, and executive functions in patients. Unlike previous studies, there was no difference in semantic fluency or visuospatial skills. This may have been due to the number of patients analyzed.
In addition, the patients in the present study exhibited a significant increase in information processing speed at the end of the program. This result is consistent with previous studies stating that CBCT programs increase information processing speed [7].
The CBCT program can improve the behavioral symptoms of early-stage AD patients and the quality of life of both patients and their relatives. With these treatments, depression and apathy in patients can be reduced [5,23]. A reduction in the neuropsychiatric symptoms of patients also has a positive effect on caregiver burnout and stress [24]. It has been reported that these programs do not increase caregiver emotional burnout compared to controls, and they even reduce caregiver burnout associated with daily activities one year later [8]. Cognitive training is an approach that also improves the quality of life of patients and their caregivers [25]. In our study, the patients’ depressive moods and quality of life and the caregivers’ stress levels, caregiver burden, and quality of life after the CBCT program were similar to those before the program. The fact that there was no change in these areas in the patients or their caregivers over the 12 weeks and there was no worsening suggests that the CBCT program is beneficial, even if there is no statistically significant difference.
The effects of these programs on the ADLs of early-stage AD patients varied between different studies. While it was reported that cognitive training increased independent activities, it had no effect on ADL in some studies [5,8,20]. Our results also indicated that there was no positive effect on ADLs.
Cognitive training creates changes in the structure and function of synapses, improving neuronal connections and increasing neurogenesis. Thus, it is thought that these exercises can improve cognition by altering brain functions at both the synaptic and molecular levels [1,3].
The present study had some limitations. Although patients were evaluated in detail before and after the CBCT program using standardized neuropsychological tests, the lack of a control group is the most important limitation. At the same time, the number of patients analyzed in our study is relatively small.
Conclusion
In addition to pharmacological treatment in early-stage Alzheimer’s patients, it is important to implement easily applicable and accessible CBCT programs without side effects. Large-scale randomized controlled studies are needed to more clearly demonstrate the effects of such programs on cognitive and behavioral symptoms, quality of life, and caregiver burden in early-stage AD.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Büşra S. Arıca Polat, Omer Karadas. Evaluation of a computer-based cognitive training program for early-stage Alzheimer’s disease. Ann Clin Anal Med 2022;13(2):175-179
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Assessment of risk factors for recurrence of febrile convulsion and subsequent epilepsy in children with febrile seizures
Cem Yenicesu 1, Capan Konca 2, Mehmet Tekin 1, Habib Almis 1, Ibrahim Hakan Bucak 1, Mehmet Turgut 1
1 Department of Pediatrics, 2 Division of Pediatric Intensive Care Unit of Department of Pediatrics, School of Medicine, Adiyaman University, Adiyaman, Turkey
DOI: 10.4328/ACAM.20905 Received: 2021-10-15 Accepted: 2021-11-06 Published Online: 2021-11-14 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):180-184
Corresponding Author: Capan Konca, Division of Pediatric Intensive Care Unit of Department of Pediatrics, School of Medicine, Adiyaman University, Adiyaman, Turkey. E-mail: dr.capan@hotmail.com P: +90 505 489 69 04 Fax: +90 416 225 26 60 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8625-9045
Aim: Febrile seizure (FS) is the most common type of convulsion seen in children, and the prognosis for FSs is quite good. However, families and physicians continue to be concerned about the risk of recurrences and development of epilepsy in children in the future. In this study, we aimed to determine the demographic, clinical and laboratory characteristics of children with FSs and risk factors for FS recurrence and epilepsy, as well as to contribute to the accumulation of knowledge on this subject.
Material and Methods: The study included 159 patients who were hospitalized with a diagnosis of FS. Demographic, clinical and laboratory data were recorded from the patients’ files. These patients were followed up for at least three years after discharge.
Results: The mean age of the children with FS was 23.9 ± 16.5 months, and the male/female ratio was 1.14/1. The first FS in children was most frequently observed at under 2 years of age (90.6%). Of the 159 cases, 142 were simple FSs and 17 were complex FSs. Recurrence was present in 60 of the patients (37.7%). A significant relationship was revealed between the presence of FSs in families and these recurrences. Epilepsy developed in eight patients (5%). There was a significant relationship between the development of epilepsy and complex FSs and the presence of epilepsy in patients’ families.
Discussion: The results of our study show that follow-up of patients with FS seems to be important because of its high recurrence rate and the high risk of epilepsy compared to the general population.
Keywords: Children, Epilepsy, Febrile Seizure, Outcome, Prognosis, Recurrence
Introduction
Febrile seizure (FS) is the most common type of convulsion seen in children and one of the most frequent neurological disorders in childhood. FS is generally a benign disorder. Studies have reported that the frequency of FSs is 2–10%, and the risk of developing epilepsy after FSs is higher than in the normal population (2–7%) [1-4]. Recurrence occurs in approximately 1/3 of patients.
During the first FS, most families worry that their children will die or will be permanently affected, and also wonder about the fate of their children over the long term. If physicians are to be able to provide satisfactory answers that will relieve the anxieties of these families, they should be able to make predictions based on the demographic, clinical and laboratory characteristics at the time of admission. For such predictions to occur, it is imperative to share knowledge and experience about this subject.
Therefore, to contribute to the knowledge of the subject and to identify recurrences of FSs and the risks of developing epilepsy in these patients, we aimed to determine the demographic, clinical and laboratory characteristics of patients with FS.
Material and Methods
This retrospective study included 159 children who were admitted to the pediatric clinic at the Education and Research Hospital at Adiyaman University’s School of Medicine from September 1, 2015 to August 30, 2016. Diagnoses of FS were made based on criteria according to which seizures typically occur in children 6 months to 5 years of age in association with a fever greater than 38°C, who do not have evidence of an intracranial cause, another definable cause of seizure, or a history of afebrile seizure [5]. Convulsions lasting more than 15 minutes, focal, or repetitive within 24 hours were regarded as complicated FS.
The files were scanned in detail for information on socio-demographic characteristics such as gender, age, educational level of the family, number of siblings and their health, history of FS and epilepsy in the family, clinical features such as the starting ages of FS, any disease accompanying FS, neuromotor development status, the frequency of FS, laboratory findings, FS and epilepsy risk factors, the number of convulsions passed up to the time of admission and electroencephalograms (EEG) results. Results were evaluated for all patients after tests, including whole blood counts, glucose, sodium, potassium, chlorine, calcium, phosphorus, magnesium, urea, creatinine, alanine aminotransferase (ALT), aspartate amino transferase (AST), serum iron, iron binding capacity and ferritin levels, urine analysis, and urine cultures.
For this retrospective study, approval was obtained from the Medical Faculty Biomedical Ethics Board (approval date: 18.10.2016, approval number: 2016/6-3) . The files were taken from the archives and evaluated with the approval of the chief physician. The study was conducted in accordance with the Declaration of Helsinki.
The statistical analysis SPSS (Statistical Package for the Social Sciences) 21 for Windows 10.0 program was used during the study. Descriptive statistical methods (mean, standard deviation, and frequency distributions) were used to evaluate the data, the Chi-square test and the Fisher’sexact test were used for comparison of categorical variables; p< 0.05 was considered statistically significant.
Results
The study included 159 children, 53.4% of whom were male and 46.6% female. The mean age of the patients was 23.9±16.5 months (range: 6 months–5 years). Considering the age distribution of cases, 28.3% were under 12 months of age, 33.3% were 12–24 months, 23.9% were 24–36 months, 5% were 36–48 months, and 9.4% were over 48 months. The average age of the first FS was 20.88 ± 8.59 months (5–36 months). There was consanguinity between the parents in 32 cases (20.1%), while in 127 cases (79.9%) there was no consanguinity. In 6.3% of the cases, there was a history of FS in the family. In addition, 16 patients (10%) had siblings who had not survived because of miscarriage, and 5 patients (3.1%) had siblings who had died for other reasons. The files that were examined also contained information about the levels of education of 64 mothers and 70 fathers (Table 1).
Rectally examined body temperature levels of children with febrile convulsions ranged from 36.6 degrees Celsius (°C) to 39.9°C, and the mean value was 38.3 ± 0.64°C at emergency room admission. There were 28 children (17.6%) with body temperature measurements below 38°C; 71 children (44.7%) with temperatures between 38 and 38.5°C; 48 children (30.1%) with temperatures between 38.5 and 39°C; and there were 12 children (7.5 %) with temperatures at 39°C above. There were patients whose fever was below 38°C at the time of admission to our emergency department because families had done fever-reducing interventions at home. Eighty-eight cases (55.3%) had upper respiratory tract infections, 53 cases (33.3%) had lower respiratory tract infections, 13 cases (8.2%) had acute gastroenteritis, four cases (2.5%) had urinary tract infections and one case (0.6%) had acute otitis media (AOM).
Biochemical tests (glucose, electrolytes, urea, creatinine, ALT and AST) revealed normal values in all of the patients. Hematologically, hemoglobin, hematocrit, iron, total iron binding capacity and ferritin levels were studied. Iron deficiency anemia was detected in 41 patients (26.5%). One hundred fifty-two patients had c-reactive protein (CRP) results, and 62 of them (40.7%) had high CRP levels for their age. In our study, EEG was performed in all patients with complicated FS and in 27 patients with recurrence (total 44 patients), and abnormal epileptic form activity was detected in 11 patients (multifocal in 5 patients, focal in 3 patients, and generalized in 3 patients). Patients in the emergency room received antipyretics (100%), midazolam (24.5%), phenytoin (16.9%) and phenobarbital (1.26%), respectively.
The number of our simple FS cases was 142 (89.3%), and the number of patients with complicated FS was 17 (10.7%). The statistical significance of many parameters that may be related to the type of febrile convulsion was investigated. There was a significant relationship between the presence of abnormal epileptic form activity in the EEGs and the type of FS (p = 0.04). The patients were followed for at least three years for the development of epilepsy and recurrence. The mean follow-up time was 3.9±1,2 years.
Sixty (37.7%) of 159 children had at least one FS recurrence. Only one recurrence was observed in 55/60 children, whereas 5/60 recurred for a second time. Three recurrences occurred in one child. The statistical significance of many parameters that may be related to recurrence was investigated (Table 2). There was no meaningful relationship between many parameters and recurrence. On the other hand, there was a significant relationship between the presence of a family history of FS and recurrence (p = 0.02).
Epilepsy developed in eight patients (5%). Seven of these patients were diagnosed with generalized tonic-clonic epilepsy, and one was diagnosed with focal myoclonic epilepsy. Levetiracetam was initiated in six patients and valproic acid in 2 patients. The statistical significance of many parameters that may be related to the development of epilepsy was investigated (Table 3). A statistically significant relationship was detected between the type of FS and the development of epilepsy (p < 0.001). No significant correlation was found between the limited number of EEG results and the development of epilepsy (p = 0.154). A statistically significant relationship was found between the presence of epilepsy in the family and the development of epilepsy (p = 0.035). A statistically significant relationship was also found between the number of FS and epilepsy development (p = 0.001). Neurodevelopmental retardation and the duration of fever, which are among the risk factors of epilepsy development after febrile convulsions, could not be evaluated because sufficient information could not be found in the patient files.
Discussion
Febrile seizures are the most common neurological problem in childhood; they are also the most common type of convulsions in children. Although FS usually is a benign disorder, it is significant because of its consequences such as recurrence and epilepsy [5,6]. In this study, it was aimed to discuss useful information for predicting prognosis in patients presenting with FS.
Several studies have reported that FS is more common in male patients [7-8]. In addition, the average age of these patients was determined to be around 20 months. Byeon et al. [4] reported that the age at which the first episode of FS occurred must often was also 18–30 months. Similarly, in our study, the rate of boys was higher than that of girls (53.4%). The average age of our patients was 20.8 months, and 80% of the patients had their first FS attack when they were under two years of age. In many studies, the presence of FS history in the patients’ families ranged from 16% to 32% [5-9]. In our study, the incidence of FS in the family was found to be 6.3%. In children whose families have a high incidence of epilepsy, the incidence of FS is higher than in the normal population. A family history of epilepsy was 5.9% in the study of Canpolat et al [10]. In our study, a family history of epilepsy was found in 8.2% of cases in accordance with the literature.
There are two types of febrile seizures simple and complicated. The complicated FS occurrence rate was found to be 15.8 % and 18.4 % in studies performed by Sharawat et al. [9] and Canpolat et al. [10], respectively. In our study, the complicated FS ratio was found to be 10.7 %. There are a limited number of studies in the literature that examine the factors associated with seizure type. In our study, a single factor associated with seizure type was an EEG abnormality. Although EEGs are often performed in children with FS, their diagnostic value is quite limited. The EEG abnormality was found to be 10 % and 44.6 % in studies performed by Yilmaz et al. [11] and Yucel et al. [12], respectively. EEG abnormalities were more common in patients with complicated FS in all of these studies. Similarly, in our study, EEG abnormalities were found in 25 % of patients, and the frequency of EEG abnormalities was higher in complicated FS.
FS recurs in 30-55 % of children who have had an initial case [13-17]. Although mostly a single recurrence is observed, two, three and more recurrences can be seen. Pavlidou et al. [13] reported that 44.2% of children had at least one FS recurrence. Only one recurrence was reported in 52% of these children, whereas 48% of them recurred for a second time. Additionally, three recurrences occurred in 48 children, and 31 children had four or more recurrences. Numerous factors have been identified associated with these recurrences. Factors that increase the risk of recurrence include: the first seizure is seen under the age of one year, a history of FS in first-degree relatives, low fever during the first FS episode and short duration of fever before the seizure. Bessisso et al. [18] examined the risk factors for recurrence and reported that risk factors for recurrence noted were male sex, and complex febrile seizures. Agrawal et al. [14] found male gender and age <1year to be significant risk factors for recurrences. Tosun et al. [17] reported that a family history of FS was a risk factor for recurrence, but family history of epilepsy was not a significant risk factor for recurrence. A study reported that abnormal EEG was not predictive of febrile seizure recurrence [19]. However, Ojha et al. [16] stated that low temperature at onset of FS, short duration of fever before the onset of FS, and atypical FS were the risk factors for recurrent FS. In our study, recurrence was observed in 60 (37.7%) patients, and a significant correlation was found between the presence of a family history of FS and recurrence (p = 0.02). In addition, two recurrences occurred in 5 children, and from those one child had three recurrences. Although recurrence was more common in patients with several risk factors, these differences were not significant except for the presence of a family history of FS.
Although the risk of epilepsy development after FS is a controversial issue, this risk has increased slightly compared to the general population. In various studies, this risk has been found in rates ranging from 2 to 7%. Several studies reported that risk factors for the development of epilepsy include shorter duration of fever (<1 hour) before the seizure, first-degree relatives have a history of epilepsy, an existing neurological or developmental anomaly before the appearance of FS, complicated FS, an onset of febrile seizures before the age of 1 year or after the age of 3 years and epileptiform discharges on EEG [5,10,13]. Pavlidou et al. [13] reported that positive family history of epilepsy of first- and second-degree relatives was found to be a major prognostic factor for the development of epilepsy after FS. In a recent study, it was reported that the risk of developing epilepsy was 4.5 times higher in children with pathological EEG after FS and 21.1 times higher in those with neurodevelopmental abnormality [10]. In our study, epilepsy developed in 8 (5%) patients in accordance with the literature. Complicated FS and the presence of epilepsy in the family were significantly associated with an increased risk of the development of epilepsy. As the number of attacks increased, the risk of developing epilepsy increased significantly.
Limitations
The most important limitation of our study is that it was designed retrospectively. Since some data could not be obtained from files, reliable analysis could not be made on some issues. In addition, since there was not enough information in the files about neurodevelopmental retardation and duration of fever before FS episode, which are among the risk factors of epilepsy after FS, comments on this subject could not be made.
Conclusions
The results of our study show that it appears to be important to follow FS patients because of its high recurrence rate and the high risk of epilepsy compared to the general population. Presence of a family history of FS was related to recurrence and complicated FS, a family history of epilepsy and a high number of FS episodes were found to be associated with the development of epilepsy.
Acknowledgment
The authors would like to thank Head of the Department of Pediatrics, Adiyaman Medical Faculty to help us during 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.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20905
Cem Yenicesu, Mehmet Tekin, Habip Almis, Ibrahim Hakan Bucak, Mehmet Turgut, Capan Konca. Assessment of risk factors for recurrence of febrile convulsion and subsequent epilepsy in children with febrile seizures. Ann Clin Anal Med 2022;13(2):180-184
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Urinary excretion of heat-shock protein 70 in patients with familial mediterranean fever
Eren Yıldız 1, Arife Uslu Gökceoğlu 2, Nermin Dindar Badem 3, Bülent Alioğlu 4
1 Department of Pediatrics, University of Health Sciences, Ankara Training and Research Hospital, Ankara, 2 Department of Pediatric Nephrology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, 3 Department of Medical Chemistry, Kırıkkale University Faculty of Medicine, Kırıkkale, 4 Department of Pediatric Hematology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20909 Received: 2021-10-19 Accepted: 2021-11-04 Published Online: 2021-11-14 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):185-188
Corresponding Author: Eren Yıldız, Department of Pediatrics, University of Health Sciences, Ankara Training and Research Hospital, Ulucanlar Street, No: 89, Altındağ, Ankara, Turkey. E-mail: eren70@gmail.com P: +90 312 595 32 68 / +90 530 141 46 84 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8056-5727
Aim: In this study, we aimed to determine the urinary excretion of HSP70 in patients with familial Mediterranean fever (FMF).
Material and Methods: Children with FMF attack-free period and FMF attack and healthy controls were enrolled in the study. Characteristics of patients and laboratory results were recorded. Urine HSP70 levels, urine creatinine were studied, and urinary excretion of HSP70 was calculated.
Results: Mean levels of urine HSP70 in patients with FMF attack-free period were significantly lower than that of controls (p = 0.01). The mean urinary excretion of HSP70 was higher in patients with an FMF attack than that of patients with FMF attack free period, but similar with controls. The mean HSP70 and urinary excretion of HSP70 were not different in children with homozygous MEFV mutation, in children with M694V mutation and others (p > 0.05). There was negative correlation between urinary excretion of HSP70 and the age of patients and controls (r = -0.284, p < 0.01). There was no statistically significant correlation between urinary excretion of HSP70 and leukocyte counts, CRP, ESR, fibrinogen levels (p > 0.05).
Discussion: Urinary excretion of HSP70 increased in FMF patients during the attack period as it is a stress factor. Lower levels of urinary excretion of HSP70 in FMF patients with attack-free period may be related to the anti-inflammatory activity of colchicine. Urinary excretion of HSP70 was negatively correlated with the age of pediatric patients. MEFV mutation type as homozygous mutation and M694V mutation did not affect levels of urinary excretion of HSP70.
Keywords: Familial Mediterranean Fever, Heat Shock Protein, Colchicines, FMF Attack, MEFV Mutation
Introduction
Heat-shock proteins (HSPs) are a group of intracellular proteins and can be markedly upregulated by all cells under conditions of stress as increased temperature (fever); nutritional deficiency; exposure to pro-inflammatory mediators; oxidative stress; treatment with non-steroidal anti-inflammatory drugs and viral infection [1-4].
HSPs that are classified into about six families (including the HSP10, HSP40, HSP60, HSP70, HSP90 and HSP100 families) on the basis of their monomeric molecular weight, have crucial housekeeping functions and act as molecular chaperones that are important for the survival of cells [5-6]. HSP70 is predominantly an intracellular protein, which can be released to extracellular milieu as a result of tissue damage or cellular necrosis. Besides, active secretion of HSP70 may occur in trauma, sepsis, autoimmune diseases, and inflammatory conditions [7-10]. Extracellular HSP70 negatively regulates the production of pro-inflammatory cytokines of monocytes and contributes to dampen the inflammatory response [11]. HSP70 production localizes in renal tubular cells in the kidney [12]. Recently, various studies have shown that HSPs, particularly HSP60 and HSP70, constitute a group of ‘autoantigens’ with the potential to trigger immunoregulatory pathways, which can suppress immune responses that occur in human inflammatory diseases, such as rheumatoid arthritis (RA), type 1 diabetes, and possibly atherosclerosis and allergy [5-6]. Therefore, we aim to determine the urinary excretion of HSP70 in patients with FMF.
Material and Methods
The study design was prospective. The study was approved by the local ethics committee (date: 30.05.2017, number:13/07), and informed consent was obtained from all patients and controls. The study was conducted in accordance with the Declaration of Helsinki. Patients with a diagnosis of FMF due to Tel Hashomer criteria were enrolled in the study. The inclusion criteria for the patient group were as follows: <18 years old and receiving only colchicine treatment. The exclusion criteria were age >18 years, any other rheumatological disease, renal disease, and any other medication besides colchicine, active infection, and a history of infection 14 days before urine sampling. Characteristics of patients were recorded with the results of MEFV mutation type, follow-up period, FMF attack at the time of urine sampling, presence of proteinuria, presence of amyloidosis, results of leukocyte (count/mm³), erythrocyte sedimentation rate (ESR, mm/hour), C-reactive protein (CRP, mg/lt) and fibrinogen (mg/dl). FMF attack was determined with clinical symptoms as fever of unknown origin, abdominal pain, arthritis or arthralgia, chest pain, dyspnea and any increase of acute-phase reactants. Fever was determined as an axillary fever > 38°C.
The control group consisted of healthy children who were admitted to the general pediatric outpatient clinic for routine evaluation. The exclusion criteria were any systemic disease, any medication, active infection, and a history of infection 14 days before urine sampling.
Mid-stream urine samples from the patient and control groups were centrifuged at 2000G for 10 minutes and stored at -80 °C. Urine HSP70 level was determined using ELISA kits (ChemWell) and urine creatine levels were determined using the calorimetric Jaffe method (Roche). Excretion of urine HSP70 was calculated with the ratio of urine HSP70 to urine creatinine levels.
Statistical Analysis
IBM SPSS Statistics 20 program was used for statistical analysis. Mean, standard deviation, median, minimum and maximum values were given in descriptive statistics for continuous data and percentage values were for discrete data. Normality tests were performed using the Shapiro-Wilk test. Differences in proportions and continuous data were tested using the Pearson chi-square test and Mann–Whitney U test, respectively. Correlation analysis was evaluated using Spearman’s Correlation Coefficient. P < 0.05 was accepted as statistically significant.
Results
Characteristics of patients and controls
Fifty-five children in the patient group and 46 children in the control group were enrolled in the study. The mean age of the patient and control groups was 12.18 ± 4.06 years and 11.96 ± 4.11years, respectively (p > 0.05). Totally 50.9% (n = 28) of patient group and 47.8% (n = 22) of control group were male, respectively (p > 0.05). The mean duration of follow- up period in the patient group was 5.91 ± 4.01 years (range: 1 – 13 years).
Patients were categorized according to the presence of an FMF attack at the time of urine sampling. Group 1 consisted of 44 patients with FMF attack-free period and group 2 consisted of 11 patients with FMF attack. All patients have received only colchicine treatment. The follow-up periods of patients in groups 1 and 2 were similar (respectively 6.25 ± 3.98 years and 4.54 ± 3.95 years, p > 0.05). Group 2 had higher leukocyte, CRP, sedimentation and fibrinogen levels than group 1 (Table 1).
There were no patients with amyloidosis and proteinuria.
MEFV mutations in patients
Totally, 16 patients (32%) had a homozygous mutation, 10 patients (20%) had a heterozygous mutation, 20 patients (40%) had a compound heterozygous mutation, and 4 patients (5%) had triple MEFV gene mutation. Five patients had no mutation on MEFV gene. The most common MEFV mutation was M694V with 20% (n = 10) homozygous, 6% (n = 3) heterozygous, 32% (n = 16) compound heterozygous and 4% (n = 2) triple heterozygous characteristics (Table 2).
Urinary excretion of HSP70
Mean levels of urine HSP70 in group 1, group 2 and controls were 41.52 ± 27.02 pg/ml, 58.81 ± 65.12 pg/ml and 56.33 ± 27.67 pg/ml, respectively. Mean levels of urine HSP70 in group 1 were significantly lower than that of controls (Figure 1). The mean urinary excretion of HSP70 in group 1, group 2 and controls were 60.35 ± 60.24 pg/mg, 106.62 ± 86.76 pg/mg and 77.00 ± 53.48 pg/mg respectively. The mean urinary excretion of HSP70 was higher in group 2 than that of group 1, but similar with controls (Figure1 ). The mean HSP70 and urinary excretion of HSP70 was not different in children with a homozygous MEFV mutation, in children with a M694V mutation and others (p > 0.05, Table 3). There was negative correlation between urinary excretion of HSP70 and the age of patients and controls (r = -0.284, p < 0.01). There was no statistically significant correlation between urinary excretion of HSP70 and follow up period of patients, leukocyte counts, CRP, ESR, fibrinogen levels (p > 0.05).
Discussion
In this study, we analyzed urine HSP70 levels and urinary excretion of HSP70 in FMF patients. Interestingly, we demonstrated lower HSP70 levels in FMF patients with attack-free periods than in healthy controls, and higher urinary excretion of HSP70 in FMF patients with attacks than that of patients with attack-free periods. There was no difference in urinary excretion of HSP70 due to MEFV mutation type. Urinary excretion of HSP70 was negatively correlated with the age of patients. There was no correlation between urinary excretion of HSP70 and follow-up period of patients and laboratory parameters.
In addition to their physiological roles, heat shock proteins (HSP) have been presented to play a role in the pathogenesis of various immune-mediated disorders such as infections (tuberculosis and chlamydia), autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus and multiple sclerosis), vascular thrombosis (atherosclerosis), malignant disorders, dermatomyositis, inflammatory muscle disease, organ transplantation and cardiac surgery [5-6]. Serum levels of HSP70 were increased in patients with Behçet’s Disease (BD) [13]. In another study, free human HSP70 and anti HSP70 antibodies were both elevated in patients with BD, so the authors concluded that HSP70 mediated innate and adaptive immune responses may participate in pro-inflammatory cytokine activation and tissue destruction in BD [14]. In our study, it was noteworthy that urine HSP70 levels and urinary excretion of HSP70 were lower in FMF patients with attack-free period. Interestingly, urine HSP70 levels and urinary excretion of HSP70 in FMF patients with attacks were similar with healthy controls. FMF patients in our study received only colchicine treatment. Colchicine is one of the oldest medicines derived from the colchium autumnale plant. It inhibits neutrophil migration seen in many inflammatory diseases at the cellular level, and it is a vinca alkaloide connecting to tubulin [15-16]. Lower urine HSP70 levels and urinary excretion of HSP70 in FMF patients with attack-free period may be related to two reasons: one reason may be increase of HSP70 due to inflammation of attack, as it is a stress factor, and the second reason may be anti-inflammatory activity of colchicine in FMF patients with an attack-free period. It is known in the literature that a synthetic derivative of colchicine was found to have HSP70-inhibiting activity [17]. Loss of HSP70 function induced defects in mitotic spindles and resulted in altered mitosis progression and subsequent cell death. HSP70 was also required for the assembly of the mitotic centrosome and bipolar spindles [18].
The causative gene of FMF was first described in 1997 and named the Mediterranean Fever gene (MEFV), which encodes a protein named pyrin. The pyrin protein has functions in apoptotic and inflammatory pathways [19]. Mutations of the pyrin lead to upregulation of the inflammatory cytokines, especially interleukin-1B. Over 100 mutations related to FMF have been identified, and mutations located in exon 10 such as M694V, M694I, and M680I are related to a more severe disease phenotype [19,20]. M694V mutation was the most common mutation type in our study, and urine HSP70 levels and urinary excretion of HSP70 was similar in patients with homozygous mutations, M694V mutation type and others.
Aged organisms have a reduced ability to respond to stimuli or stress and to maintain homeostasis [21]. It was reported that induction of HSP70 expression is significantly reduced in cells from old rats and that the reduced expression is due to a deficit in the transcription of the hsp70 gene. Thus, it appears that changes in the induction of HSP70 transcription are closely associated with the aging process in rats [22]. In the literature, there have been no reports of age-related change in HSP levels in the pediatric age group. But our study demonstrated that urinary excretion of HSP70 was negatively correlated with the age of patients in the pediatric age group.
Limitations of our study were a small number of FMF patients with attack period and the lack of comparison of urinary excretion of HSP70 in the same FMF patients during attack and attack-free period. In order to demonstrate the effect of colchicine on urinary excretion of HSP70 more clearly, further studies can be planned before colchicine treatment and while receiving colchicine treatment in the same patient.
In conclusion, our study demonstrated that urinary excretion of HSP70 increased in FMF patients during attack period, as it is a stress factor. Lower levels of urine HSP70 levels and urinary excretion of HSP70 in FMF patients with attack-free period are interesting, and the reason for this result may be related to the anti-inflammatory activity of colchicine. Urinary excretion of HSP70 was negatively correlated with the age of pediatric patients. MEFV mutation type, as the homozygous mutation and M694V mutation, did not affect levels of urinary excretion of HSP70.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Eren Yıldız, Arife Uslu Gökceoğlu, Nermin Dindar Badem, Bülent Alioğlu. Urinary excretion of heat-shock protein 70 in patients with familial mediterranean fever. Ann Clin Anal Med 2022;13(2):185-188
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Mental health, hopelessness and quality of life in patients with retinitis pigmentosa
Ömür Günday Toker 1, Erman Şentürk 1, Duygu Akbulut Sağaltıcı 2, Dilek Güven 3, Dilek Sarıkaya 4, Ömer Akil Özer 5
1 Department of Psychiatry, University of Health Sciences, Bagcilar Training and Research Hospital, 2 Department of Ophthalmology, University of Health Sciences, Bagcilar Training and Research Hospital, 3 Department of Ophthalmology, University of Health Sciences, Şişli Etfal Training and Research Hospital, 4 Department of Psychiatry, Faculty of Medicine, Üsküdar University, 5 Department of Psychiatry, University of Health Sciences, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
DOI: 10.4328/ACAM.20943 Received: 2021-11-10 Accepted: 2021-12-21 Published Online: 2021-12-27 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):189-194
Corresponding Author: Erman Şentürk, Mustafa Yaşar Caddesi, Gençosman Mahallesi, No: 5/7, Bağcılar Training and Research Hospital, 34165, İstanbul, Turkey. E-mail: erman.senturk@hotmail.com P: +90 505 212 18 88 / +90 212 440 40 00 F: +90 212 562 69 22 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9208-7905
Aim: The aim of the study is to compare socio-demographic and clinical data, quality of life, psychiatric symptoms and hopelessness in patients with retinitis pigmentosa with healthy controls and to reveal factors associated with the quality of life and psychiatric symptoms in patients with retinitis pigmentosa.
Material and Methods: Seventy patients with retinitis pigmentosa and 70 age- and sex-matched healthy controls were admitted to this study. The Sociodemographic and Clinical Data Form, Brief Symptom Inventory, Beck Hopelessness Scale and Short Form-36 Quality of Life Scale were administered to all participants.
Results: Patients with retinitis pigmentosa had significantly higher unemployment levels, suicidal thoughts, and lower income compared to healthy controls. According to the Short Form-36 Quality of Life Scale results, lower mean scores were observed in patients with retinitis pigmentosa compared to controls in almost all domains. However, in almost all domains in Brief Symptom Inventory, higher mean scores were observed in patients with retinitis pigmentosa than in controls. Younger age of retinitis pigmentosa diagnosis, lower income and female gender were associated with lower physical quality of life, and lower monthly income, vision loss without blindness and higher depression levels were associated with lower mental quality of life in logistic regression analysis. Female gender and higher hope subscales scores of Beck Hopelessness Scale were associated with severity of psychiatric symptoms.
Discussion: The awareness of the factors associated with quality of life and psychiatric symptoms in patients with retinitis pigmentosa will increase the effectiveness of treatment options.
Keywords: Retinitis Pigmentosa, Mental Health, Quality of Life, Depression
Introduction
Retinitis pigmentosa (RP) is a group of inherited diseases characterized by progressive photoreceptor degeneration. RP is usually diagnosed in childhood or young adulthood and leads to progressive vision loss. RP is a leading cause of blindness in younger individuals, and most patients lose their sight by the age of 40 [1]. The prevalence of RP is approximately 1/4000 [2]. Males may be affected a little more than females because of the X-linked form of the RP [3].
Vision loss may be the one that causes the most serious social and psychological disabilities among all sensory losses [4]. The psychological impact of vision loss has been investigated in numerous previous studies on age-related macular degeneration, glaucoma, diabetes-related retinopathy and other age-related eye diseases, which are associated with poor quality of life, anxiety, depression, and suicide [5, 6]. However, relatively few studies have investigated the effects of early-onset progressive vision loss on mental health, whose sample is predominantly young adults. Most of the small number of studies addressing mental health in younger visually impaired patients were conducted as qualitative studies with limited sample sizes without controls. When we compare RP with other ocular pathologies, the importance of defining the relationship between RP and mental health becomes clearer. For instance, in a study comparing glaucoma and RP, patients with RP were found to have a higher prevalence of depression [7]. In this context, it is crucial to diagnose and treat psychiatric disorders so that they can maintain adequate follow-up and treatment for RP and adjust to rehabilitation processes. There have been very few studies evaluating RP cases from a psychiatric perspective in the literature. The aim of the study is to compare socio-demographic and clinical data, quality of life (QoL), psychiatric symptoms and hopelessness in patients with RP with healthy controls and to reveal factors associated with the QoL and psychiatric symptoms in patients with RP.
Material and Methods
Participants and study design
Data were collected between 17 August 2016 and 30 September 2016 from 70 patients diagnosed with RP, who were followed up in outpatient clinics of Şişli Hamidiye Etfal Training and Research Hospital Ophthalmology Retinitis Pigmentosa. The diagnosis of RP was based on family history, fundus examination, genetic testing, and electroretinogram recording procedure prepared by the International Society for Clinical Electrophysiology of Vision. The control group consisted of seventy age- and sex-matched controls without any ocular or systemic diseases. The inclusion criteria were as follows: age over 18 years, diagnosis of retinitis pigmentosa, minimum primary education, and voluntary participation in the study. Participants were checked for the following exclusion criteria: Current major psychiatric disorders and patients with systemic and ocular diseases that could cause irreversible visual impairment. The purpose of the study was explained to the participants and informed consent forms were obtained for all participants before participating in the study. All participants completed sociodemographic and disease-specific questionnaires, Brief Symptom Inventory (BSI), Beck Hopelessness Scale (BHS), and Short-Form 36 Quality of Life Questionnaire (SF-36). Since there were visually impaired individuals in our study, these scales were read by a psychiatrist. This study was approved by the Ethics Committee of Health Sciences University Şişli Hamidiye Etfal Training and Research Hospital (16.08.2016/701) and conducted in accordance with the Declaration of Helsinki Ethical Principles.
Measurements
Socio-demographic and Clinical Data Form was formed by the authors includes socio-demographic characteristics (age, gender, household members, marital status, employment status, educational status, monthly income, social support), suicidal thoughts and information about the disease (age of RP diagnosis, age of visual loss, visual impairment). According to International Council of Ophthalmology (ICO) standards, RP patients were divided into two groups as those with blindness and vision loss (limited visual impairment and low vision) [8].
Brief Symptom Inventory (BSI) [9] is a scale of 53 items selected from the Symptom Check List (SCL-90-R) in order to capture psychiatric problems in various medical conditions. Respondents indicate the degree to which they suffered from each symptom over the past week, with responses ranging from 0 (not at all) to 4 (extremely). Symptoms are divided into nine subscales representing the domains of psychopathology: Somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger–hostility, phobic anxiety, paranoid ideation, and psychoticism. Four additional items do not factor into any of the dimensions but are included because they are clinically important such as questions about sleeping problems or guilt. The BSI profile produces three global indices of distress, including the Global Severity Index (GSI), Positive Symptoms Total Index and Positive Symptoms Distress Index. The GSI is the most sensitive indicator of a respondent’s distress level, combining information about the number of symptoms and distress level. In this study, an average score for each scale was calculated. A higher score indicates more psychiatric symptoms. The Turkish version of BSI has good reliability and validity properties [10].
Short-Form 36 Quality of Life Questionnaire (SF-36) is a 36-item self-assessment scale that evaluates QoL based on eight health-related dimensions: physical functioning (PF), social functioning (SF), role physical (RP), role emotional (RE), mental health (MH), vitality (VT), bodily pain (BP), and general health (GH). The eight domains provide information on two main components: the Physical Component Summary (PCS; PF, BP, RP, and GH) and the Mental Component Summary (MCS; RE, SF, MH, and VT). Each subscale is scored between 0-100. Higher scores indicate higher levels of health and functionality. The reliability and validity of the Turkish translation have been established [11].
Beck Hopelessness Scale (BHS) [12] is a scale developed by Beck et al., which aims to measure the future expectations and pessimism level of individuals. It consists of 20 items related to emotions about the future, motivation loss, and hope. A total score is calculated by summing the pessimistic answers for each of the 20 items, with each optimistic response being scored as 0 and each pessimistic response as 1. High scores show that the hopelessness of the individual is high. The validity and reliability study of the scale for Turkey was performed [13].
Statistical Analysis
The collected data were analyzed using the Statistical Package for the Social Sciences version 20.0 (SPSS 20.0, Chicago, IL, USA). Descriptive statistics were presented as frequency, percentage, mean and standard deviation. The Chi-square test or Fisher Exact test were used to determine possible differences between groups in terms of categorical variables. The normality of distribution for continuous variables was tested with Kolmogorov–Smirnov test. Student’s t-test was used for comparisons of variables when parametric assumptions were met. The Mann–Whitney U test was used to compare not normally distributed variables. Multiple logistic regression models were generated by gender, age, age of RP diagnosis, age of visual loss, visual impairment, monthly income, BSI-Depression and BHS-Hope for SF-36-PCS, SF-36-MCS and BSI-GSI. The significance level for logistic regression analysis was set at p < .05. The variables assessed were determined by clinical experience and a review of the literature as significant variables derived from our results.
Results
Seventy patients with RP and 70 controls were included in the analysis. Among the 70 patients with RP, 29 were women and the mean age was 44.4±13.4 years. Among the 70 healthy controls, 29 were women and the mean age was 44.4±13.3 years. Patients with RP and control subjects did not significantly differ in gender, age, educational status, marital status, or social support (p>0.05). Patients with RP had significantly higher unemployment (p=0.004) level, suicidal thoughts (p=0.012), and lower monthly income (p=0.046) compared to healthy controls. Among the 70 patients with RP, 43 were blind. The mean age of RP diagnosis was 22.7±15.8, and the mean age of vision loss was 35.8±14.0 years. The socio-demographic and clinic characteristics of the participants included in the study are summarized in Table 1.
When the BSI subscales of the patient and control groups were examined, obsessive-compulsive (p<0.001), interpersonal sensitivity (p<0.001), depression (p<0.001), anxiety (p<0.001), hostility (p=0.005), phobic anxiety (p<0.001), paranoid thoughts (p=0.006) and psychoticism (p=0.011) were found to be significantly higher in patients with RP than in the healthy controls. There was no difference in somatization and additional items (Table 2).
There was no statistically significant difference in hopelessness total score between the patients with RP and healthy controls. When the BHS subscales were compared, the hope subscale scores were significantly higher in the patients with RP than the healthy controls (p=0.044) (Table 2).
When the SF-36 subscales were compared between patients with RP and control groups, participants patients with RP reported lower mean scores on PF (p<0.001), RP (p<0.001), GH (p<0.001), VT (p<0.001), SF (p<0.001), RE (p=0.003) and MH (p<0.001) than those controls (Table 2).
Regression analysis was performed for SF-36-PCS (physical QoL), SF-36-MCS (mental QoL) and BSI-GSI (severity of psychiatric symptoms) in patients with RP. The results are summarized in Table 3. Younger age of RP diagnosis, lower monthly income and female gender were associated with poorer physical QoL (R2=0.313, F(7,62)=4.03, p<0.001), and lower monthly income, vision loss without blindness and higher depression levels were associated with worst mental QoL (R2=0.541, F(7,62)=10.44, p<0.001). Female gender and higher hope subscales scores of BHS were associated with severity of psychiatric symptoms (R2=0.359, F(7,62)=4.88, p<0.001).
Discussion
This study aims to determine the differences between the patients with RP and the healthy controls in terms of psychiatric symptoms, hopelessness and QoL, and to reveal socio-demographic, psychiatric symptoms and clinical characteristics associated with QoL. To our knowledge, this is the first study to compare the mental health, hopelessness, and QoL of patients with RP with healthy controls in Turkey. The main findings of the study were that patients with RP had significantly higher unemployment, suicidal thoughts, and lower monthly income than control subjects. Patients with RP had significantly PF, RP, GH, VT, SF, RE, and MH lower scores than healthy controls. Higher hope subscale scores of BHS and female gender were associated with severity of psychiatric symptoms.
The socioeconomic inequalities of patients with RP emphasize the importance of rehabilitation. However, there is limited knowledge about education, employment, and income of patients with RP. A few studies focusing on socio-economic characteristics in RP patients have indicated that patients have low education levels and income [14]. Similar to these results, in this study, lower monthly income and employment were found in patients with RP. The lower income in patients with RP may be a direct consequence of the lower level of employment. However, the fact that lower monthly income in patients with RP is associated with both physical and mental QoL highlights the importance of socio-economic parameters. Consistent with the literature, findings from this study indicate that patients with RP are in an underprivileged position in terms of some socio-economic parameters.
Studies on the relationship between vision loss and mental health have revealed that irreversible vision loss has permanent negative effects on mental health [15]. However, there have been limited studies in the literature examining mental health in patients with RP. In this study, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thoughts and psychoticism scores were significantly higher in the patients with RP. These results corroborate the findings of a great deal of the previous studies in patients with vision loss in terms of mental health. In a study investigating psychiatric symptoms in 48 patients with inherited retinal diseases, increased phobic anxiety symptoms and paranoid thoughts were reported compared to healthy controls [16]. A study conducted with 417 RP patients revealed obsessive-compulsive disorder in 39.3%, hypochondriasis in 35.3%, depression in 31.2% of cases [17].
Visual impairment affects the daily life of patients, and it has been reported that the prevalence of depression is higher in visually impaired patients due to various reasons [18]. Depression in people with visual impairment often goes undetected and untreated. In these people, it is difficult to distinguish chronic depression from a normal part of the grieving process associated with vision loss. In the study by Papadopoulos et al. [18], 23.5% of participants with visual impairment had mild depression and 6.5% had moderate or severe depression. Another study by Moschos et al. [19] found that 23.5% of patients with RP had mild depression, 26.5% had moderate depression and 26.5% had severe depression . To our knowledge, there is only one study focusing on suicidal thoughts in patients with RP. In that study [20], patients with RP reported higher levels of depression and suicidal thoughts than the general population, similar to our findings. Since there is indirect evidence that depression can be successfully treated and improved vision-related functions in patients with RP, it is very important to detect and treat depression in these patients. In studies investigating the association of retinitis pigmentosa and anxiety, the prevalence of anxiety was found 37% in patients with RP [21]. This study confirms that anxiety is more common in patients with RP.
Hopelessness is defined as the presence of negative beliefs about the future, pessimism and loss of expectations about the future [22]. In this study, there was no difference between the patients with RP and the control group in terms of hopelessness, but hope, one of the subscales of hopelessness, was higher in the patient group. In addition, hope subscales scores of BHS were associated with the severity of psychiatric symptoms. Although there was no attempt to examine hopelessness in RP patients, in a study conducted with university students with vision loss, 14.6% felt hopeless and there was no statistically significant difference compared to the healthy group [23]. As a result of clinical observations, a sense of hope plays an important role in protecting individuals’ mental health. In this context, we suggest that the high hopelessness level in RP patients is associated with depression in this study. From this point of view, it can be said that depression and hopelessness in RP patients negatively affect the individual’s self-confidence and adjustment in social life, thus making it difficult to make a plan for the future.
This study supports findings from previous studies, which have demonstrated patients with RP had lower levels QoL compared to healthy controls. It has been suggested that there is a significant negative correlation between the QoL score and the degree of visual field loss [24]. To date, too little attention has been paid to explore predictors of QoL in RP. In this study, younger age of RP diagnosis, lower monthly income and female gender were associated with lower physical QoL, and lower monthly income, vision loss without blindness and higher depression levels were associated with lower mental QoL in logistic regression analysis. There have been different results regarding visual function and QoL due to the use of various measures. For instance, the visual field and visual acuity of patients with RP correlated with the National Eye Institute Visual Function Questionnaire (NEI-VFQ). However, the same variables did not correlate with the World Health Organization Quality of Life Scale-Short Form (WHOQOL-BREF) in patients with mixed retinal dystrophy [25]. Surprisingly, loss of vision without blindness was found to be associated with mental quality of life in this study. This finding might be associated with a loss of confidence due to progressive loss of vision, which causes a lack of independence.
A number of limitations need to be noted regarding the present study. First, this study has several limitations regarding its cross-sectional type and lack of a longitudinal follow-up. Therefore, only a relationship can be implied in the study, not causality. Second, self-assessment scales were used in the study. Participants may often be biased when they report on their own experiences.
Conclusion
This study showed that patients with RP had socio-economic difficulties, lower quality of life, and higher psychiatric symptoms compared to healthy controls. Moreover, female patients with RP were at greater risk for poor mental QoL and severe psychiatric symptoms. The quicker and easier diagnosis of factors related to the quality of life and psychiatric symptom levels in patients with RP will increase the effectiveness of treatment options. In addition, this study revealed the importance of regular psychiatric examination in RP patients in order to improve the quality of life of individuals in the process of progressive vision loss and to enable them to better adjust to social life.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20943
Ömür Günday Toker, Erman Şentürk, Duygu Akbulut Sağaltıcı, Dilek Güven, Dilek Sarıkaya, Ömer Akil Özer. Mental health, hopelessness and quality of life in patients with retinitis pigmentosa. Ann Clin Anal Med 2022;13(2):189-194
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Should echocardiography be performed in all acute ischemic stroke patients? Echocardiography in acute ischemic stroke
Ayse Caglar Sarilar 1, Mine Hayriye Sorgun 2, Anwar Rawandi 2, Muge Kuzu 2, Sabiha Tezcan 2, Sefer Rızayev 2, Inci Sule Ozer 2, Cagrı Ulukan 2
Volkan Yilmaz 2, Hafize Çotur 2, Canan Togay Isıkay 2, Busra Sumeyye Arica 3, Ozgur Ulas Ozcan 4, Cansin Tulunay Kaya 4
1 Department of Neurology, Erciyes University School of Medicine, Kayseri, 2 Department of Neurology, Ankara University School of Medicine, İbni Sina Hospital, Ankara, 3 Deparment of Neurology, Gulhane Training and Research Hospital, Ankara, 4 Department of Cardiology, Ankara University School of Medicine, İbni Sina Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.20906 Received: 2021-10-18 Accepted: 2021-11-20 Published Online: 2021-12-02 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):195-199
Corresponding Author: Ayse Caglar Sarilar, Department of Neurology, Erciyes University School of Medicine, Kayseri, Turkey. E-mail: acaglarsarikaya@gmail.com P: +90 505 571 68 35 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7818-1209
Aim: Echocardiography is one of the most commonly used diagnostic methods in the investigation of cardiac etiologies among patients with acute ischemic stroke (AIS). However, data regarding the diagnostic value of this method in patients with and without cardiac abnormalities are limited. The aim of this study is to determine the diagnostic yield of echocardiography in AIS patients with and without any cardiac disease.
Material and Methods: We retrospectively analyzed the data of patients with an AIS regarding medical history, cardiac examination, transthoracic echocardiography and transesophageal echocardiography. The patients were divided into two groups. Patients with a history of cardiac disease, cardiovascular risk factors, and abnormal findings in cardiac examination or ECG were allocated into Group A, while Group B included patients without cardiac disease with ischemic stroke.
Results: A total of 633 patients with acute ischemic stroke (327 females (51.7%); mean age: 68.9±13.4 years) were included in the study. There were 393 patients in Group A (62.1%), and 240 patients in Group B (39.9%). The diagnostic yield of echocardiography was significantly more frequent in Group A (41.2%) than in Group B (28.3%) (p=0.001). Antithrombotic treatment was changed among 24 (6.1%) patients in Group A and 19 (7.9%) patients in Group B as a result of the echocardiography findings (p=0.38).
Discussion: The diagnostic yield of echocardiography is low if it is used routinely in patients with acute ischemic stroke. Consequently, echocardiography could be performed for acute ischemic stroke patients with negative diagnostic work-up for other etiologic stroke subtypes
Keywords: Diagnostic Yield, Echocardiography, Ischemic Stroke
Introduction
Ischemic stroke is a heterogeneous disease with different mechanisms and etiologies [1]. Determination of the underlying etiological factor is essential to prepare an adequate preventive strategy [2].
Up to 15-30% of ischemic strokes are caused by cardiac sources of embolism [3,4]. Diagnosis of a potential source of cardiac embolism may be performed using 12-lead standard electrocardiography (ECG), cardiac rhythm monitoring at least 24-48 hours, and transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE) [5-7].
Echocardiography is the most commonly used diagnostic method for the detection of cardiac sources among patients with ischemic stroke. The European Stroke Organization guidelines recommend the use of echocardiography in selected patients while the American Stroke Association guidelines do not make any clear recommendation on the use of echocardiography [8]. In a study by Abreu et al., TTE was performed in all ischemic stroke patients with normal sinus rhythm [9]. Otherwise, some of the previous studies have reported that TTE and TEE should not be performed in all ischemic stroke patients, but they could be performed for only selected patients, such as no clear stroke etiology or younger patients [10-12].
The aim of this study is to determine patient characteristics that may increase the diagnostic value of echocardiography in ischemic stroke patients with and without any history of cardiac disease or risk factor in medical history and abnormal findings in cardiac examination or electrocardiography.
Material and Methods
Patients
The medical records of 633 consecutive patients who were admitted with acute ischemic stroke were retrospectively evaluated. Prior to the study, approval was obtained from the research ethics committee. The patients were divided into two subgroups: Group A included patients with any history of cardiac disease or cardiovascular risk factor and abnormal findings in cardiac examination or electrocardiography, while Group B included the patients with controlled hypertension and other remaining patients.
Patient demographics and cardiovascular risk factors, including history of hypertension, atrial fibrillation, congestive heart failure, coronary artery disease at admission were collected using a standard data collection form and entered into an institutional database. Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on repeated measurements or prior use of antihypertensive medication, atrial fibrillation, defined by the presence in the medical history or detection on ECG or Holter. Controlled hypertension was defined as systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg with antihypertensive drug treatment. The definition of controlled hypertension was then confirmed by ambulatory blood pressure monitoring or hospital observation forms. Coronary artery disease was defined as any presentation with angina pectoris, the existence of ischemic ECG changes, myocardial infarction suggested by pathological Q waves on ECG or confirmed by medical records, any history of coronary revascularization, or presence of coronary artery stenosis ≥ 50% in coronary angiogram or any history of coronary revascularization by percutaneous coronary intervention or coronary artery by-pass graft operation. Congestive heart failure was defined as the presence of symptoms such as dyspnea at rest or on exercise, fatigue and peripheral edema, along with structural heart disease, as confirmed by echocardiography or elevated natriuretic peptides. Abnormal findings of physical examination included distended jugular veins, thrill on palpation of precordium, presence of S3 or S4 gallop, any diastolic murmur or more than Levine 2/6 systolic murmur, crackles heard on lung fields, hepatomegaly, splenomegaly, ascites and extremity edema.
A single rater (MHS) determined etiologic stroke subtypes using the automated Causative Classification System (CCS, available at https://ccs.mgh.harvard.edu) [13]. The CCS subtypes included supra-aortic large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes, and undetermined causes. Etiologic work-up included vascular imaging studies, such as carotid Doppler ultrasonography, computerized tomography angiography, magnetic resonance angiography or digital subtraction angiography, TTE or TEE, 24-hour cardiac rhythm monitoring, and laboratory tests for hypercoagulability and vasculitis.
Cardiological Evaluation
Transthoracic and transesophageal echocardiographic examinations were performed using the Vingmed System 7 (Vivid 7; GE, Horten, Norway), according to the recommendations of the American Society of Echocardiography [14]. Patent foramen ovale (PFO) was considered by the appearance of microbubbles in the left atrial after intravenous injection of agitated saline, spontaneously or after the Valsalva maneuver, within 3 cardiac cycles and complete opacification of right atrium. Atrial septal aneurysm was defined as hypermobile thin-walled septum primum in the region of the fossa ovalis with a base at least 1.5 cm and an excursion during the cardiac cycle at least 1.5 cm [15]. Complex thoracic aortic atheroma was classified as mobile plaques or plaques protruding 4 mm or more into the lumen and/ or plaques with ulceration [16].
The diagnostic yield of echocardiography was defined as the detection of cardiac sources of embolism (high risk, low risk or uncertain risk for CCS) excluding patients with AF or paroxysmal AF. The diagnostic yield was considered to be the number of patients who had at least one cardiac source of embolism.
Statistics
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) 16.0 version (SPSS Inc. Chicago, Illinois, USA). Descriptive statistics were expressed as means/standard deviations for normally distributed continuous variables and median/interquartile range for variable with skewed distribution. Statistical analysis was performed to determine the diagnostic value of echocardiography in patients with ischemic stroke. The group rates were compared using a chi-squared test, and the means were compared using Student’s t-test; p<0.05 was considered to be statistically significant.
Results
A total of 633 patients with acute ischemic stroke (306 males (48.3%) and 327 females (51.7%); mean age: 68.9±13.4 (23-98) years) were included in the study. Patient demographics and medical risk factors are shown in Table 1. TTE was performed in 630 (99.5%) patients, and TEE was performed in 84 (13.3%) patients. Atrial fibrillation was detected in 191 (30.2%) patients using ECG.
There were 393 patients in Group A (62.1%) and 240 patients in Group B (39.9%). Atrial fibrillation was detected in 45 (11.5%) patients in Group A and 30 (12.4%) in Group B by using Holter.
TTE and TEE findings in both groups are shown in Table 2. Left atrium dilation, aortic stenosis, endocarditis, thrombus in the left ventricle, left ventricle dysfunction, left ventricle aneurysm, ejection fraction < 30% and vegetation were more frequent in Group A, other vegetation and atheroma in the ascendant aorta were more frequent in Group B (Table 2). The diagnostic yield of echocardiography was significantly more frequent in Group A (n=162, 41.2%) than in Group B (n=68, 28.3%) (p=0.001).
Antithrombotic treatment was altered in 43 (6.8%) patients as a result of the echocardiography [24 patients (6.1%) vs 19 patients (7.9%) in groups A and B, respectively, p=0.38]. There was no significant difference in changing treatment between Group A and Group B.
The etiological stroke subtypes are shown in Table 3. Cardio-aortic embolism was more common in Group A compared to Group B (p<0.001). Evident and probable cardio-aortic embolism was 83.7% in Group A and 25.3% in Group B (Table 3).
Discussion
Cardiac sources of embolism are segregated into high- and low-risk categories with reference to an objective 2% primary stroke risk threshold [1]. Cardiac sources with a high primary risk of stroke are left atrial thrombus, left ventricular thrombus, atrial fibrillation, paroxysmal atrial fibrillation, sick sinus syndrome, atrial flutter, recent myocardial infarction, rheumatic mitral or aortic valve disease, bio-prosthetic and mechanical heart valves, low ejection fraction <28%, symptomatic heart failure with ejection fraction <30%, non-ischemic dilated cardiomyopathy, nonbacterial thrombotic endocarditis, infective endocarditis, papillary fibroelastoma and left atrial myxoma. Cardiac sources with a low primary risk of stroke are mitral annular calcification, patent foramen ovale, atrial septal aneurysm, atrial septal aneurysm with patent foramen ovale, left ventricular aneurysm without thrombus, isolated left atrial smoke, complex atheroma in the ascending aorta or proximal arch and others (third-degree atrioventricular block, pre-excitation syndromes, etc.) in CCS [13[.
In our study, cardio-aortic embolic etiology was detected in 203 (51.7%) patients in Group A and 75 (31.2%) patients in Group B. Cardio-aortic embolic etiology was more common in Group A compared to Group B (p<0.001). High cardiac sources of embolism were more frequent in Group A, nevertheless, low cardiac sources of embolism were more frequent in Group B.
AF has been reported as the most common cause of embolic stroke [17]. Paroxysmal AF (PAF) is assumed to play also a dominant role in the pathogenesis of cryptogenic stroke [18]. PAF cannot be detected by standard ECG. Thus, it may be detected by a cardiac rhythm monitoring for at least 24 hours [19,20]. Gladstone et al. reported that they detected atrial fibrillation in one in six patients with ambulatory ECG monitoring for a target of 30 days. It was superior to an additional round of 24-hour ECG monitoring and clinical follow-up [21]. In this study, ECG detected AF in 191 (30.2%) patients in the Group A. AF was found in 45 (11.5%) patients in Group A and 30 (12.4%) in Group B by using Holter.
Other causes of evident and probable cardiac embolism and possible cardiac embolism could be diagnosed using TTE or TEE [8,9,22]. TTE is easier to perform, non-invasive, widely available and cheaper than TEE. However, it is clearly less sensitive for the detection of unknown cardiac sources of emboli [20]. The disadvantages of TEE are that it is semi-invasive, more expensive, and requires more experience to be perform adequately. TEE is more sensitive than TTE for detecting atrial septal aneurysm and defect, patent foramen ovale, atrial myxoma, atrial thrombus, atrial appendage thrombus, aortic arch atheroma, and mitral valve vegetations [6]. Atherosclerotic plaque thickness >4 mm within the aorta has been associated with a high risk of aorto-embolic ischemic stroke [23].
In some previous studies, only TTE was used to determine the causes of evident and probable cardiac embolism and possible cardiac embolism [9,24]. However, TEE combined with TTE was performed for the detection of cardiac sources in patients with ischemic stroke in some other studies [10-12]. In our study, TTE was performed in 630 (99.5%) patients, and TEE was performed in 84 (13.3%) patients.
After exclusion of patients with AF, common cardiac anomalies associated with ischemic stroke were dilated cardiomyopathy and severe heart failure following previous anterior wall myocardial infarction, left ventricular systolic dysfunction with an ejection fraction <35%, mitral valve stenosis with enlarged left atria, intracardiac masses, and valvular prosthesis determined by use of TTE [9,23]. In addition, PFO was the most common low-risk in potential source of cardiogenic embolism with ischemic stroke in most of previous studies which were examined by TEE [10,11]. Other cardiac anomalies were complex aortic plaques, atrial septal aneurysm and defect, atrial myxoma, atrial thrombus, and mitral valve vegetation in TEE [5,16].
In our study, left atrium dilation was the most common cardiac abnormality in both groups as measured byTTE and TEE. Other cardiac anomalies such as aortic stenosis, endocarditis, thrombus in the left ventricle, left ventricular dysfunction, left ventricular aneurysm, left ventricular ejection fraction < 30% and vegetation were more frequent in Group A according to TTE findings, otherwise vegetation and atheroma in the ascendant aorta were more frequent in Group B according to TEE findings (p<0.05). Total abnormal TTE and TEE findings were significantly more frequent in Group A (96.4%) than in Group B (41%) (p<0.001), and the diagnostic yield of echocardiography was significantly more frequent in Group A (41.2%) than in the Group B (28.3%) (p=0.001). Cardio-aortic embolism was more common in Group A compared to Group B (p<0.001). Previous studies have not compared diagnostic value of echocardiography in ischemic stroke patients with and without any cardiac disease or risk factor in medical history and abnormal findings in cardiac examination or electrocardiography. Only Cho et al. retrospectively evaluated 3112 consecutive patients with ischemic stroke who had normal sinus rhythm and no history of cardiac disease, but did not compare to other patients with a history of cardiac disease [12].
Anticoagulation therapy was indicated in 0-37.2 % of ischemic stroke cases after examination with TTE or/and TEE in ischemic stroke patients [25]. The therapeutic impact of echocardiography in previous studies has varied widely due to different methods [14,26]. We found that antithrombotic treatment was changed in 43 patients as a result of the echocardiography findings. There were no significant differences in changing treatment between Group A and Group B.
There are several limitations in our study, including its retrospective design and relatively short follow-up duration. In addition, this is a restriction of the cohort of a single medical center. However, all of our patients underwent a detailed work-up for determining the causative mechanism of ischemic stroke. Acute ischemic lesions were identified with diffusion-weighted imaging in all patients. In contrast to the previous studies, the etiologic subtypes of all patients with acute ischemic stroke have been determined systematically according to the CCS in our patients.
Conclusion
The diagnostic yield of echocardiography is low if it is used routinely in acute ischemic patients. Otherwise, there was no significant difference in changing treatment between Group A and Group B. Thus, echocardiography could be performed for acute ischemic stroke patients with negative diagnostic work-up for other etiologic stroke subtypes.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20906
Ayse Caglar Sarilar, Mine Hayriye Sorgun, Busra Sumeyye Arica, Ozgur Ulas Ozcan, Anwar Rawandi, Muge Kuzu, Sabiha Tezcan, Sefer Rızayev, Inci Sule Ozer, Cagrı Ulukan, Volkan Yilmaz, Hafize Çotur, Cansin Tulunay Kaya, Canan Togay Isıkay. Should echocardiography be performed in all acute ischemic stroke patients? Echocardiography in acute ischemic stroke. Ann Clin Anal Med 2022;13(2):195-199
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The predictive role of Troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia
Öznur Demiroluk, Yıldız Yiğit, Süheyla Abitağaoğlu, Zeynep Bayhan Arı, Arzu Yıldırım Ar
Department of Anesthesiology and Reanimation, University of Health Sciences, Fatih Sultan Mehmet Health Research and Application Center, Istanbul, Turkey
DOI: 10.4328/ACAM.20907 Received: 2021-10-15 Accepted: 2021-11-01 Published Online: 2021-11-14 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):200-205
Corresponding Author: Öznur Demiroluk, Anesthesiology and Reanimation Department, University of Health Sciences, Fatih Sultan Mehmet Health Research and Application Center, E-5 Highway, İçerenköy Street, 34752, Ataşehir, İstanbul, Turkey. E-mail: onrdemiroluk@hotmail.com P: +90 533 522 95 08 F: +90 216 575 04 06 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6427-5148
Aim: Troponin I is an important prognostic marker in critically ill patients with COVID-19, similar to cytokines and other inflammatory mediators. The aim of this study was to evaluate the predictive value of troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia according to age group.
Material and Methods: Seventy-four patients with COVID-19 pneumonia were grouped according to age (Group 1:65–74 years, Group 2: 75–84 years, and Group 3: ≥ 85 years) and retrospectively analyzed. Demographics, clinical findings, laboratory results upon admission to the intensive care unit, and outcomes were compared among the groups. Predictive value of troponin I levels upon admission to intensive care unit (Troponin Iicu), difference in troponin levels between general wards and intensive care unit (Troponin Idiff), C-reactive protein, ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, procalcitonin, and D-dimer levels for mortality were also investigated.
Results: The mortality rate was 74.3% for the patients overall, and increased, albeit insignificantly, with increasing age. Neither Troponin Iicu nor Troponin Idiff was predictive for mortality for any of the age groups or for the patients overall. Ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, and C-reactive protein levels were predictive for mortality for patients overall (p= 0.016, p= 0.001, p= 0.013, and p < 0.001, respectively).
Discussion: For geriatric patients, troponin I levels at the time of the first admission to the ICU are not sufficient to predict mortality alone and should be evaluated together with other parameters.
Keywords: COVID-19, Geriatrics, Intensive Care, Mortality
Introduction
The 2019 novel coronavirus (COVID-19), which is still prevalent in high numbers across the world, is considerably challenging to treat in the intensive care unit (ICU). The early identification of severe forms of COVID-19 disease, and appropriate use of markers for prognosis, assist with patient management and reduce mortality [1]. While the COVID-19 infection is predominantly asymptomatic or is accompanied by mild symptoms, in nearly 15% of patients, infection can progress to acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or severe interstitial pneumonia, all of which are associated with high mortality rates [2]. Patients with advanced age, comorbidities, and those who develop ARDS during the course of their disease are at a greater risk of mortality [3]. The reported mortality rates among those with COVID-19 disease across all age groups is currently 2.3%, while for those aged 70-79 years, the mortality is 8% and for those aged ≥80 years, it reaches 14.8% [4]. Infectious diseases are a significant cause of mortality in patients aged > 65 years. Infections can be more severe in patients with advanced age due to dysfunction of the immune system, malnutrition, impaired mucosal function, or the loss of the cough reflex [3]. Furthermore, geriatric patients with COVID-19 infection have a more marked decrease in lymphocyte counts along with a greater increase in leukocyte counts and C-reactive protein (CRP) levels, which are associated with a worse prognosis [5].
In addition to pneumonia, patients with COVID-19 disease can develop cardiac complications, which include myocardial damage, arrhythmia, acute coronary syndromes, and venous thromboembolism, all of which worsen the prognosis [2]. Elevated troponin I and creatinine kinase levels, which indicate cardiac damage, can occur due to viral proteins, hypoxia, thrombosis, immune activation, subendocardial ischemia, and a severe disease course [6]. Similar to high levels of circulating cytokines and inflammatory mediators associated with an excessive immune response to COVID-19 infection, high troponin I levels are considered an important marker for worse prognosis and mortality [1,7].
In this retrospective study, we aimed to investigate the predictive value of troponin I levels for mortality in geriatric patients admitted to the ICU for COVID-19 pneumonia according to three age groups.
Material and Methods
This was a single-center retrospective study conducted between April 2020 and March 2021. A total of 74 patients aged ≥ 65 years who were treated in the ICU with positive polymerase chain reaction (PCR) tests for COVID-19 were included. Approval for this study was obtained from the local ethics board (2021/20). PCR assays for COVID-19 testing were performed on nasopharyngeal swab specimens. Patients without COVID-19 pneumonia, those aged < 65 years, and those with negative PCR results for COVID-19 were excluded. Patients were grouped according to age as follows: Group 1, aged 65–74 years; Group 2, aged 75–84 years; and Group 3, aged ≥ 85 years.
Demographic data (age, gender, comorbidities, Acute Physiology and Chronic Health Evaluation II [APACHE-II] scores, and thoracic computed tomography [CT] results before ICU admission), clinical data (symptoms, electrocardiogram and CT findings upon ICU admission, cardiovascular complications prior to ICU admission, need for mechanical ventilation [MV], need for vasopressors or inotropes in the first 24 h, duration of MV, length of ICU stay, and mortality), and laboratory blood test results upon admission to the ICU (hemoglobin, white blood cell count, lymphocytes, platelet count, neutrophil-to-lymphocyte ratio [NLR], CRP, procalcitonin [PCT], albumin, creatinine, aspartate transaminase [AST], alanine transaminase [ALT], lactate dehydrogenase [LDH], Interleukin-6, ferritin, fibrinogen, D-dimer, creatine kinase, creatine kinase-MB, high sensitive troponin I upon admission to the general ward [Troponin Iw], high sensitive troponin I upon admission to the ICU [Troponin Iicu], difference between troponin Iicu and troponin Iw [Troponin Idiff], ratio of partial arterial oxygen pressure to fraction of inspired oxygen [PaO2/FiO2], and lactate levels (from arterial blood gas results) were recorded. Interleukin-6 levels were not included in the study due to missing data. Patients were intubated and continued on invasive MV when hypoxia (peripheral oxygen saturation < 92% or PaO2 < 60 mmHg), tachypnea (respiratory rate ≥ 28/min), dyspnea, hemodynamic instability, or decreased consciousness developed despite treatment with non-rebreather reservoir bag oxygen mask, high-flow nasal oxygen therapy, or non-invasive MV. Vasopressor treatment was initiated when patients had hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg) despite fluid administration.
The data were compared among the groups. The sensitivity and specificity of Troponin Iicu, Troponin Idiff, CRP, ferritin, LDH, NLR, PCT, and D-dimer levels were analyzed to evaluate their predictive value for mortality in geriatric patients according to age group.
Statistical Analysis:
Statistical analyses were performed using SPSS version 23 (IBM Corp., Armonk, NY, USA) and MedCalc version 16 (MedCalc Software bvba, Ostend, Belgium). Descriptive statistics were presented as the number (n) and percentage (%) for categorical variables, and as median and interquartile range (IQR) for numerical variables. The Pearson chi-square test and Fisher’s exact test were used to compare categorical variables, and the Kruskal-Wallis test was used to compare numerical variables among the study groups according to age group. Dunn’s post-hoc tests were carried out for pairwise comparisons. A receiver operating characteristic (ROC) analysis was used to predict the diagnostic accuracy of Troponin Iicu and Troponin Idiff, ferritin, CRP, LDH, D-dimer, NLR, PCT, and fibrinogen levels in predicting mortality. The area under the ROC curves (AUCs) with 95% confidence intervals (CIs) for Troponin Iicu, Troponin Idiff, ferritin, and CRP were calculated using the method proposed by Delong et al [8]. The Youden J index was used to predict the best cut-off values. Sensitivity and specificity with 95% CIs were calculated. Statistical significance was set at p < 0.05.
Results
We retrospectively reviewed 115 patients during the study period. After excluding 41 patients according to the inclusion and exclusion criteria, 74 patients were included in this study. Table 1 presents the patients’ demographics and clinical features before admission to the ICU and ICU outcomes. The median age was 78 years, with an IQR of 70–85 years, and 51.4% of the patients were female. The presence of dementia significantly increased with age (p = 0.035), and a low Glasgow coma scale was observed statistically less frequently in those aged between 65 and 74 years (p = 0.040). The distribution of acute thromboembolic events during follow-up in the ward was similar among the groups. Ventricular extrasystoles were observed only in three patients, all aged ≥ 85 (p = 0.024). CT features were statistically similar among the groups, and bilateral ground-glass opacities were the most common finding. Concerning the patients’ ICU outcomes, the need for vasopressors or inotropic drugs in the first 24 h of ICU admission was significantly lower in the group aged 65–74 years than in the other age groups (p = 0.016). The mortality rate of the patients overall was 74.3%, and while there was an increase in fatality in the older age group, the difference between the groups was not statistically significant. The cause of death in patients overall was severe ARDS, and acute cardiac complications were not the primary cause of mortality (Table 1).
All laboratory parameters, except for LDH, were statistically similar between the groups. However, there were significant differences in LDH levels between the groups (p = 0.023). In the post-hoc pairwise comparisons, we found a statistically significant difference in LDH levels between the group aged 75–84 years and the group aged ≥ 85 years (p = 0.024), (Table 2).CRP was a statistically significant predictor of mortality for each age group and for the patients overall (p = 0.001, p = 0.008, p = 0.008, and p < 0.001, respectively). Additionally, ferritin was a statistically significant predictor of mortality for those aged 65–74 years and for the patients overall (p = 0.002 and p = 0.016, respectively). However, neither Troponin Iicu nor Troponin Idiff was a statistically significant predictor of mortality for any of the age groups or for the patients overall (Table 3).
We also analyzed other laboratory parameters, such as LDH, D-dimer, NLR, PCT, and fibrinogen, to predict mortality in the ICU. We found that LDH and NLR were statistically significant predictors of mortality for patients overall (AUC [95% CI]: 0.726 [0.610-0.823], p = 0.001 and 0.675 [0.556-0.779], p = 0.013, respectively), (data not shown).
Discussion
In our study, we evaluated the predictive value of troponin I levels, along with other laboratory parameters, at ICU admission for mortality in geriatric patients with COVID-19 requiring ICU treatment according to age group. The predictive value of Troponin Iicu levels and Troponin Idiff levels were both limited. Ferritin, LDH, NLR, and especially CRP performed better as predictive markers for mortality in this patient group.
COVID-19 infections are associated with higher levels of CRP, NLR, AST, direct bilirubin, LDH, urea, creatinine, ferritin, D-dimer, and more profound lymphopenia than other viral infections. When secondary infections are present, PCT levels also increase [9,10]. Patients who require ICU treatment have higher levels of these parameters, along with higher levels of circulating cytokines, which are representative of the severity of acute lung injury and prognosis [10]. The majority of our patients had lymphocytopenia, leukocytosis, and elevated NLR, CRP, LDH, ferritin, fibrinogen, and D-dimer levels at ICU admission. When these parameters were compared across age groups, only LDH levels showed significant differences. LDH is found in many tissues, including the myocardium, reticuloendothelial system, lungs, kidneys, pancreas, liver, and striated muscles in the form of different isoenzymes and is released with tissue damage resulting from severe infections. LDH levels are expected to be elevated in patients with COVID-19 infections with severe interstitial pneumonia, which often results in ARDS, and increase with the severity of disease independent of age [11]. In our study, however, LDH levels were not higher in elderly patients compared to other age groups. This difference in LDH could have been caused by the less frequent observation of bilateral widespread pneumonia in the advanced age groups compared to other age groups in our study.
Bilateral pulmonary infiltrations (bilateral widespread ground-glass opacities on CT) were present in 89.2% of our patients, and although statistically insignificant, the frequency decreased with increasing age. All study patients had severe ARDS with a PO2/FiO2 < 200. The MV requirement and mortality were not significantly lower in patients aged < 75 years compared to the other age groups. Advanced age is independently associated with worse prognosis due to pathophysiological changes in the respiratory system. Higher mortality rates are reported for patients aged > 80 years compared with younger patients [5]. In the general population, 5% of COVID-19 cases develop severe pneumonia requiring ICU treatment. Approximately 42%–100% of these patients progress to ARDS, which requires invasive MV and is associated with a 50%–60% mortality rate [12,13]. Bozal et al. reported a 94.7% mortality rate in geriatric COVID-19 patients admitted to the ICU [14]. The time between onset of symptoms and ICU admission was shorter with increasing age. Although not statistically significant, this finding showed faster deterioration with increasing age. Among the patients in our study, overall, 87.8% required invasive MV during their ICU stay, and the mortality rate was 74.3%, with a higher rate in patients aged ≥ 85 years.
There is a potential relationship between disease severity and cardiac injury in patients with COVID-19 infection. Elevated troponin levels, indicative cardiac injury may be due to direct myocardial infiltration or non-ischemic causes, such as hypoxia, sepsis, or the cytokine storm associated with elevated inflammatory biomarkers [15,16]. Zhon et al. have associated leukocytosis, high levels of ALT, LDH, creatine kinase, D-dimer, ferritin, PCT, and interleukin-6, as well as highly sensitive cardiac troponin I, with worse prognosis and mortality [17]. Santoso et al. have shown that higher troponin levels are associated with increased mortality, a higher rate of ICU admissions, and more severe COVID-19 infection [7]. We observed an increase in troponin I levels with clinical worsening and transfer to the ICU from the general wards. While there were no significant differences in troponin I or creatinine kinase levels at ICU admission between the different age groups, these parameters were higher in patients aged ≥ 75 years. The need for inotropic support within the first 24 h of ICU admission was notably higher with increasing age. When troponin I levels and mortality were analyzed, Troponin Iicu levels and Troponin Idiff levels did not significantly predict mortality.
Arrhythmias can arise from the myocardial effects of severe COVID-19 infection [18]. Chen et al. reported that sinus tachycardia, not associated with body temperature or oxygen saturation, was the most frequent type of arrhythmia, especially in severe cases, and ventricular tachycardia, atrioventricular block, and atrial fibrillation were also associated with clinical worsening [19]. Consistent with previous studies, the most frequent arrhythmia found in our patients was sinus tachycardia. Atrial fibrillation and ventricular tachyarrhythmias were more frequent in patients aged ≥ 85 years.
Levels of CRP, which is an acute-phase reactant, increase with the severity of infection [20]. Arslan et al. have demonstrated that high CRP levels are indicative of worse prognosis and mortality in geriatric patients with sepsis [21]. Liu et al. found that higher CRP levels in geriatric patients compared to young and middle-aged patients were consistent with a worsening prognosis with age [22]. In their study on COVID-19 patients aged 61-75 years, Pan et al. found that SpO2, lymphocyte count, PCT, D-dimer, LDH, and CRP levels were predictive of prognosis in critically ill patients [12]. In our study, we observed that Ferritin, LDH, NLR, and especially CRP may be a more significant parameter than Troponin I in the prediction of mortality in geriatric patients upon admission to the intensive care unit.
There are some limitations to our study. First, due to the lack of data, we could not evaluate the relationship between trends in troponin I levels over the course of a patient’s ICU stay and outcomes. Therefore, our study did not include an analysis of changes in troponin levels as a predictor of mortality. Second, the number of patients was limited due to the retrospective nature of the study and the focus on a specific patient group. This may help explain why differences between the age groups did not reach statistical significance.
In conclusion, geriatric patients admitted to the ICU with severe COVID-19 pneumonia have a worse course of pulmonary disease, more frequent hemodynamic instability, and a worse prognosis with increasing age. For these patients, troponin I levels at the time of first admission to the ICU are not sufficient to predict mortality alone and should be evaluated together with other parameters.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Öznur Demiroluk, Yıldız Yiğit, Süheyla Abitağaoğlu, Zeynep Bayhan Arı, Arzu Yıldırım Ar. The predictive role of troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia. Ann Clin Anal Med 2022;13(2):200-205
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Effects of adding midazolam to ketamine and fentanyl combination in a burn wound dressing in adults
Osman Esen 1, Canan Balcı 2
1 Department of Anesthesiology And Reanimation, Istinye University Vocational School of Health, Istanbul, 2 Department of Anesthesiology And Reanimation, Faculty of Medicine, Kütahya Health Sciences University, Kütahya, Turkey
DOI: 10.4328/ACAM.20920 Received: 2021-10-24 Accepted: 2021-11-24 Published Online: 2021-12-02 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):206-209
Corresponding Author: Osman Esen, Zümrütevler Mah. Handegül Sokak, No:98/16, Maltepe, İstanbul, Turkey. E-mail: drosmanesen@gmail.com P: +90 505 677 13 85 Fax: +90 216 457 38 00 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6280-5064
Aim: It was aimed to investigate the effects and side effects of adding midazolam to ketamine and fentanyl combination on sedation, hemodynamic stability and recovery rate during burn debridement and dressing in adult patients.
Material and Methods: ASA I-II group, adult patients aged between 18-70 years, who were going to undergo therapeutic procedures such as change of burn dressings and debridement, were included in the study. The cases were randomly divided into two groups. The ketamine/fentanyl group (Group KF) received 1 mg/kg ketamine i.v and 1 mcgr/kg fentanyl just before the dressing. In the ketamine+midazolam/fentanyl group (Group MKF), 0.03 mg/kg midazolam was additionally administered 10 minutes before the procedure. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), peripheral oxygen saturation (sPO2), respiratory rate (RR) were monitored and recorded every 5 minutes. The results were evaluated at the 95% confidence interval and the significance level was p<0.05.
Results: Fifty-nine patients aged between 15-56 years (29.98±9.22 years) were included in the study. Six patients (10.2%) were female and 53 (89.8%) were male. There was no statistically significant difference between the KF-MKF groups in terms of age, weight and gender, burn rate, ASA distribution, dressing time, and additional dose requirement values (p>0.05). SBP0, SBP5, SBP10, SBP15 values, DBP0, DBP5 values and HR0, HR5 values of the subjects in the KF group were found to be statistically significantly higher than the values of subjects in the MKF group (p<0.05).
Discussion: Combinations of midazolam-ketamine/fentanyl and ketamine/fentanyl provide effective sedation in burn debridement and dressing in adult patients. It was concluded that the addition of midazolam to the ketamine/fentanyl combination provides better hemodynamic stability.
Keywords: Midazolam, Ketamine, Dressing, Burn
Introduction
Burn injury is a serious insult, and burn pain is considered by patients to be the most severe form of acute pain experienced. Burn-related pain occurs following burn insult as acute pain is closely related to the extent and extent of the injury. In addition to the burn injury, it can continue with repetitive treatment applications such as dressing changes, surgeries and physiotherapy applications during the treatment process, and in some cases, it turns into chronic pain. Burn pain also shows personal differences, and a person’s psychosocial environment makes pain more complex. Effective pain control is an important problem in burn units and its treatment requires a multidisciplinary approach [1, 2].
Burn patients, unlike other insults, often experience recurring situations that can cause serious pain such as dressing and debridement. Although many methods have been reported to relieve pain arising during these therapeutic applications, there is no consensus as to which method is best in this regard. Different agents are used in different centers. Generally, ketamine is the preferred agent for burn dressings and debridements. Ketamine has a sedative and analgesic effect, does not cause respiratory depression, and can also be administered alone or in combination with intravenous/inhalation anesthetics. It has been reported that even at subanesthetic doses, ketamine produces sufficient analgesia for burn dressing and burn wound debridement [3]. However, it has side effects such as hallucination on awakening, a rapid development of tolerance, a long recovery period and nausea. The addition of midazolam to ketamine has been reported to reduce the undesirable psychomimetic effects of ketamine [ 4 ].
In our study, it was aimed to investigate the effects and side effects of adding midazolam to ketamine and fentanyl combination during burn debridement and dressing in adult patients on sedation, hemodynamic stability and recovery rate, using the Ramsey sedation scale and modified Aldrete recovery score.
Material and Methods
With the approval of Kocaeli University Clinical Research Ethics Committee (KOÜ KAEK 2013/95), therapeutic procedures such as changing burn dressings and debridement will be performed, 59 adult patients aged between 18-70 years with ASA I-II group, 10-40% burns, 2nd and 3rd-degree burns and no burns in areas that could interact with the airway were included in the study. Pregnant, opioid allergy patients, and patients with significant psychiatric, cardiovascular, renal or hepatic disease were excluded from the study.
The cases were randomly divided into two equal groups considering the burn group and the percentage. The ketamine+midazolam/fentanyl group (Group MKF) received 0.03mg/kg midazolam 10 minutes before the procedure, and 1 mg/kg ketamine i.v. and 1 mcgr/kg fentanyl just before the dressing. In the ketamine/fentanyl group (Group KF), 1 mg/kg ketamine i.v. and 1mcgr/kg fentanyl were administered just before the dressing.
In the patients who were taken to the operating room, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), peripheral oxygen saturation (sPO2), respiratory rate (RR) were monitored from the appropriate arm or leg and recorded every 5 minutes. When SBP was <80 mmHg, 10 ml/kg of saline 0.9% was administered. When the patient developed respiratory apnea, the Ambu mask was used. Hemodynamic changes (tachycardia, bradycardia), number of patients requiring additional ketamine, sedation score, dressing time, recovery times, and adverse effects such as nausea, vomiting, hypotension, hypertension, apnea, if any, were recorded. The Ramsey Sedation Score (RSS) was aimed to be >4 during the procedure.
Ketamine (0.5-1 mg/kg i.v.) was administered as rescue analgesia in cases of insufficient analgesia such as grimacing, movement in the extremities, and an increase in systolic blood pressure more than 25% above the baseline value. After sedation, patients with a modified Aldrete recovery score of 11 and above were taken to the service from the recovery room.
Statistical analysis
While evaluating the findings obtained in the study, statistical analyses were performed using IBM SPSS Statistics 22. The Mann-Whitney U test, Independent-Samples T-test, Paired Samples T-test and the Wilcoxon test were used for numerical data, and the Chi-Square test was used to analyze discrete variables. The results were evaluated at the 95% confidence interval and the significance level was p<0.05.
Results
Fifty-nine patients aged between 15-56 years (29.98±9.22 years) were included in the study. Six patients (10.2%) were female and 53 (89.8%) were male. There was no statistically significant difference between the KF-MKF groups in terms of age, weight and gender, burn rate, ASA distribution, dressing time and additional dose requirement values (p>0.05) (Table 1).
It was determined that the SBP0, SBP5, SBP10 and SBP15 values of the subjects in the KF group were statistically significantly higher than the values of the subjects in the MKF group (p<0.05) (Table 2).
The DBP0 and DBP5 values of the subjects in the KF group were found to be statistically significantly higher than the values of the subjects in the MKF group (p<0.05). It was determined that the HR0 and HR5 values of the subjects in the KF group were statistically significantly higher than the values of the subjects in the MKF group (p<0.05) (Table 2).
It was determined that the SS0, SS5 and SS10 values of the subjects in the KF group were statistically significantly higher than the values of the subjects in the MKF group (p<0.05). It was determined that the SPO225 value of the subjects in the KF group was statistically significantly higher than the values of the subjects in the MKF group (p<0.05) (Table 3).
Discussion
Burn insult is a painful trauma with long-term physical and psychological negative effects on patients, and patients are exposed to pain due to treatments such as burn dressing and physiotherapy during the treatment process. Burn-related pain first appears as acute pain. Dressing change, wound debridement and other interventional procedures applied to the patient increase pain formation and in some cases turn into chronic pain. Therefore, effective pain control is important in burn centers and the solution of this problem requires a multidisciplinary approach. Pain relief in burn patients should begin in the acute phase with insult and continue until the end of treatment. After the patient’s acute pain has passed, the severity of the pain may increase depending on the treatment methods applied in the future, the presence of infection, rehabilitation applications, regeneration of damaged nerves and the psychosocial environment in which the person is located [1,5,6].
Burn pain can range from mild to severe, depending on the surface area and grade of the burn. Some studies have reported that the patient’s pain at rest is partially mild, but the pain increases significantly during procedures such as dressing changes and physiotherapy [7].
Ketamine is the analogue of angel dust, and it is the closest drug to full anesthetic with its wide safety margin, providing amnesia, unconsciousness and analgesia. It disconnects the thalamus from the limbic cortex and provides clinically dissociative anesthesia. Unlike other IV anesthetics, it is preferred for sedation because it has fewer adverse effects on the cardiovascular and respiratory systems. [8] In addition to these positive effects, the patient may become agitated and hallucinate upon returning from the dissociative process. Hallucination is a common unwanted side effect of ketamine. In order to prevent this side effect, ketamine is often combined with an agent such as midazolam [9]. Midazolam is a frequently used agent in sedation due to its positive properties such as sedative, anxiolytic, sleep-inducing, anticonvulsant and central muscle relaxant effects, rapid onset of action, wide safety margin, and short recovery time. However, besides these positive effects, there are also undesirable side effects such as lack of analgesic property, rapid and excessive IV doses causing respiratory depression, hiccups, nausea, vomiting, excessive sedation, headache, and cough. Midazolam can be used for premedication purposes (anxiolytic, sedative and amnesic effect), for surgical or diagnostic interventions under regional anesthesia to provide sedation (sedative and amnesic effect), to provide induction and maintenance of anesthesia, to prevent convulsions (anticonvulsant effect). [10] Respiratory depression with midazolam and dysphoric reactions (irritability, depression, etc.) with ketamine may occur when midazolam and ketamine are used alone. When midazolam is used with ketamine, faster analgesia, amnesia, and fewer side effects occur [11].
Ketamine and fentanyl were used as analgesics in both groups in the study. For this purpose, we used midazolam, a short-acting benzodiazepine, at a dose of 0.03 mg/kg IV, so that the patient would not be sedated for a long time when the application was finished. Bowdle et al. stated that since fear and anxiety may develop in burn cases, the addition of anxiolytic or hypnotics such as benzodiazepines to analgesic treatment eliminates anxiety and reduces the amount of the agent to be used for analgesia [12]. Dachs et al. suggested that the addition of midazolam to ketamine reduces ketamine-related undesirable effects such as unpleasant dreams and hallucinations [13]. We concluded that the addition of midazolam to the ketamine/fentanyl combination reduces the psychomimetic effects of ketamine.
The combination of midazolam with ketamine appears to be a good combination with short sedation and short recovery time. Aldrete or Modified Aldrete scoring is generally used during recovery in anesthesia applications. The modified Aldrete Score was used as the recovery score after dressing [14]. In our study, no statistically significant difference was found between the two groups in terms of recovery time, and the addition of midazolam to the ketamine/fentanyl combination did not prolong the recovery period.
Şentürk et al. investigated the effects of midazolam and ketamine combination and midazolam efficacy in oral premedication in children and their effects on possible hemodynamic and respiratory parameters, concluded that it can be used safely in pediatric premedication with its comfortable and easy application in children, providing effective sedation, facilitating anesthesia induction, and postoperative recovery [15]. Erk et al. reported that ketamine alone, with or without midazolam, provides a calm and safe anesthesia for pediatric patients in short-term procedures, and that the combination of ketamine and midazolam provides a better early postoperative period [16]. In our study, adequate sedation was achieved without midazolam, but adding midazolam provided better hemodynamics in terms of systolic blood pressure, diastolic blood pressure, and heart rate, especially in the early stages of the procedure.
Brecelj J et al. reported that the use of midazolam as a premedication before ketamine in pediatric patients is advantageous compared to the use of ketamine alone, as it reduces the occurrence of emergency reactions in the hospital [17]. In our study, the addition of midazolam reduced tachypnea in the early period in patients. Ghai B, et al. reported that oral midazolam alone and the combination of midazolam and ketamine provided equally effective anxiolysis and separation properties in children, however, the combination provided easy separation from their parents, providing a calmer and more relaxed state for the patient [18]. Dilli et al. concluded that the addition of midazolam to ketamine did not increase the frequency of side effects and that this combination was superior to ketamine alone in terms of sedation rate and parental satisfaction with sedation [19]. In our study, the addition of midazolam did not increase the dressing time and the need for additional doses. MacPherson et al. stated that the use of ketamine/midazolam is an effective pain control tool during burn dressings, and the incidence of side effects is low [20]. Our study supports these findings.
In conclusion, midazolam-ketamine/fentanyl and ketamine/fentanyl combinations provide effective sedation in burn debridement and dressing in adult patients. It was concluded that the addition of midazolam to the ketamine/fentanyl combination provides better hemodynamic stability.
Acknowledgment
We would like to thank Dr. Başar Erdivanlı for their kind help in the course of the study.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
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2. Pal SK, Cortiella J, Herndon D. Adjunctive methods of pain control in burns. Burns. 1997;23(5):404–12.
3. Warncke T, Stubhaug A, Jorum E. Ketamine, an NMDA receptor antagonist, suppresses spatial and temporal properties of burn-induced secondary hyperalgesia in man: a double-blind, cross-over comparison with morphine and placebo. Pain. 1997; 72(1-2):99-106.
4. Öner C, Borucu İ. Çocuklarda yanık yarası debridmanı ve pansumanında propofol-fentanil, propofol-ketamin sedasyonu. Türk Anest Rean Der Dergisi. 2011; 39:54-62 DOI:10.5222/JTAICS.2011.054
5. Ünlügenç, H. Yanık ve ağrı (Burn and pain). Galenos Aylık Tıp Dergisi. 1999; 33: 90-7
6. Yorgancı K, Geyik SG. Ciddi yanık hastasının izlem ve tedavisi (Follow-up and treatment of the severe burn patient). Hacettepe Tıp Dergisi. 2007;38:135-40
7. Szyfelbein SK, Osgood PF, Carr DB. The assesment of pain and plasma &-endorphin immunoactivity in burned children. Pain. 1985;22: 173-82.
8. Xu J, Lei H. Ketamine-an update on its clinical uses and abuses. CNS Neurosci Ther. 2014; 20(12): 1015-20.
9. Funk W, Jakob W, Riedl T, Taeger K. Oral preanaesthesic medication for children: double-blind randomized study of a combination of midazolam and ketamine vs midazolam or ketamine alone. Br J Anaesth. 2000;84(3):335-40.
10. Lau CE, Wang Y, Ma F: Pharmacokinetic-pharmacodynamic modeling of the coexistence of stimulatory and sedative components for midazolam. Eur J Pharmacol. 1998; 346(2-3): 131-44.
11. Parker RI, Mahan RA, Guigliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children. Pediatrics. 1997;99(3):427-31.
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13. Dachs RJ, Innes GM. Intravenous ketamine se¬dation of pediatric patients in the emergency department. Ann Emerg Med. 1997;29:146-50. DOI:10.1016/S0196-0644(97)70321-4
14. Dalal PG, Murray D, Cox T, McAllister J, Snider R. Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants: provider and pharmacologic considerations. Anesth Analg. 2006;103:863-8. DOI:10.1213/01.ane.0000237311. 15294.0e
15. Şentürk Z, Kuvaki B, Arkan A. Çocuklarda oral premedikasyonda midazolam ve midazolam-ketamin kombinasyonunun solunumsal ve hemodinamik etkilerinin karşılaştırılması (Comparison of the respiratory and hemodynamic effects of midazolam and midazolam-ketamine combination in oral premedication in children). SDÜ Tıp Fakültesi Dergisi. 1997; 4: 21-9.
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Osman Esen, Canan Balcı. Effects of adding midazolam to ketamine and fentanyl combination in a burn wound dressing in adults. Ann Clin Anal Med 2022;13(2):206-209
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To what extent are the appendicitis scoring systems effective in preventing negative appendectomy. Comparison of nine scoring systems
Baris Mantoglu 1, Emre Gonullu 1, Guner Cakmak 1, Mertcan Akcay 1, Merve Yigit 1, Guven Erdogrul 2, Kayhan Ozdemir 3, Fatih Altıntoprak 4
1 Department of General Surgery, Sakarya University Training and Research Hospital, Sakarya, 2 Department of General Surgery, Mersin City Training and Research Hospital, Mersin, 3 Department of General Surgery, Urgup State Hospital, Urgup, 4 Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
DOI: 10.4328/ACAM.20932 Received: 2021-11-01 Accepted: 2021-12-06 Published Online: 2021-12-10 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):210-214
Corresponding Author: Baris Mantoglu, Department of General Surgery, Sakarya Training and Research Hospital, Sakarya, Turkey. E-mail: barismantoglu@gmail.com P: +90 505 815 93 79 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2161-3629
Aim: Negative appendectomy is costly for both the patient and the health system; furthermore, it may introduce the patient to unnecessary surgical intervention and possible complications. This study aims to determine the most suitable one by comparing nine of the most popular appendicitis scoring systems.
Material and Methods: The study included 170 patients who were histopathologically diagnosed with appendicitis in the last year (Group 1), and 143 patients without appendicitis in the last five years (Group 2). The variables required to calculate scoring systems for the prediction of acute appendicitis were saved to the study datasheet, and each patient’s score was calculated for each scoring system with the formulated excel file automatically.
Results: Among all scoring systems, the Karaman score was most efficacious at predicting appendicitis. The positive predictive value of the Karaman score was 89.9%, whereas the negative predictive value was 57.9%. The Alvarado score performed the best among the scoring systems. This was associated with a positive predictive value of 89.5%, negative predictive value of 85.7%, and sensitivity and specificity of 67.6% and 84.1%, respectively.
Discussion: The use of suitable scoring systems with or without imaging modalities or may reduce negative appendectomy rates.
Keywords: Appendicitis, Appendectomy, Negative Appendectomy, Score
Introduction
Acute appendicitis (AA) is the most common diagnosis requiring emergency surgery worldwide, with a lifetime risk of 8.6% in males and 6.7% in females [1,2]. Despite developing laboratory and imaging methods, negative appendectomy rates vary between 3-25% in various publications [3–5]. The diagnosis of acute appendicitis is typically concluded by combining the patient’s history, physical examination findings, and laboratory parameters within imaging modalities, when necessary. Unfortunately, a patient encountered in the emergency unit may set the surgeon in a tricky circumstance due to the lack of physical examination, and laboratory findings do not fully corresponds to acute appendicitis.
In challenging cases, the use of ultrasonography (USG) and computed tomography (CT) promotes the diagnosis. In the literature, the overall sensitivity and specificity of US are 76% and 95%, respectively, and 99% and 84% for CT, respectively. However, these imaging methods may not be simply accessible, as well as leading to high costs.
A negative appendectomy (NA) is costly for both the patient and the health system [6]; furthermore, it may introduce the patient to unnecessary surgical intervention and possible complications. To date, clinical scoring systems (CSS) have been defined to assist the diagnosis of AA [6–14]. These clinical scoring systems generally aim to clarify the diagnosis of AA based on scaled parameters of patients’ examination findings and laboratory values. In the diagnosis of AA, the most precious of the CSSs should be the scoring system that reduces the rates of negative appendicitis as well as diagnosing positive appendicitis. Therefore, the study aims to determine the lowest rate of negative appendicitis among the nine popular scoring systems, as well as to reveal an effective scoring system that diagnoses positive appendicitis. Furthermore, the current study is the first in the literature to compare nine different CSSs.
Material and Methods
The current retrospective comparative study included 170 patients whose pathology was confirmed as acute appendicitis in the last year at our institute, and 143 patients in whom the pathology did not reveal acute appendicitis from 1314 appendectomies in the previous five years. The ethics committee of our university approved the study with ethics number E-71522473-050.01.04-47683-410. Patients <18 years of age, pregnant patients, patients with existing malignancy, patients using steroids for any reason, immunosuppressive patients, COVID-19 positive patients, were excluded from the study. Each patient was examined by a consultant surgeon within the first hour after admitting to the emergency department. Following the laboratory analyzes of each patient, abdominal USG was performed on all patients. In the case of doubt about the diagnosis, an abdominal CT was performed. Lack of appendicitis in pathology reports was considered negative appendectomy. The histological diagnosis of appendicitis was set according to the infiltration of muscularis propria with neutrophils granulocytes. Variables required to calculate scoring systems (Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis (Ripasa), Tzanakis, Appendicitis inflammatory response (AIR), Eskelinen, Ohmann, Lintula, Fenyo-Lindberg, and Karaman scoring systems) for the prediction of acute appendicitis were saved to the study datasheet, and each patient’s score was calculated for each scoring system with the formulated excel file automatically. The patients were divided into two groups as Group 1 positive appendicitis group and Group 2 as negative appendicitis group. Appendectomies were performed using conventional or laparoscopic methods. Statistical analysis was performed to compare the success of the scoring systems between groups.
Statistical analysis
Descriptive analyzes were performed to provide information on the general characteristics of the study population. The Kolmogorov-Smirnov test was used to evaluate whether the distributions of numerical variables were normal. Accordingly, the independent sample t-test and the Kruskal Wallis test were used to compare the numeric variables between groups. Numerical variables were presented as mean ± standard deviation. Categorical variables were compared using the Chi-Square test. Categorical variables were presented as a count and percentage. A p-value <0.05 was considered significant. Receiver operator characteristic (ROC) curve analysis was used to identify the best cut-off value and assess the performance of the test score for appendicitis. Analyses were performed using SPSS statistical software (IBM SPSS Statistics, Version 23.0. Armonk, NY: IBM Corp.)
Results
No difference was determined between the two groups included in the study in terms of age distribution. However, among laboratory parameters, white blood count (WBC), neutrophil percentage, PMNL rate were statistically high in Group 1 (Table 1). Total bilirubin value, on the other hand, was found to be high in group 2. Contrary to many studies, the C-reactive protein (CRP) value was high in group 1, but it did not reveal a statistically significant difference across group 2 (Table 1). Acute appendicitis was diagnosed in 82.9% of the patients who underwent USG. The consistency of male patients in group 1 and female patient distribution in group 2 is statistically significant. Abdominal pain severity was evaluated high in Group 1 at a rate of 31.2% and assessed as mild in Group 2 at a rate of 43%. The increase in pain created a significant difference in Group 2 compared to Group 1. Besides, the duration of symptoms of 24-48 hours is statistically high in Group 2. Hyperactive bowel sounds, moderate abdominal rigidity, tenderness, and absence of rebound are statistically significantly less in Group 2.
When the nine clinical scoring systems included in the study were compared, the Ohmann score had the highest sensitivity with a rate of 74% (Table 2). When the area under the curve (AUC) was evaluated, the Alvarado score was determined first, and the Ohmann score was in the second line (Figure 1).
Discussion
Despite advanced imaging methods, negative appendectomy rates have not decreased to the desired level in diagnosing appendicitis. Various examination and laboratory findings, including the female gender, are among the main reasons that make the diagnosis of appendicitis challenging. Unfortunately, many surgeons may face the dilemma of not performing unnecessary appendectomy or causing perforation due to delayed diagnosis in their professional practice. In the current study, our negative appendectomy rate was 10.88%, consistent with the literature.
The use of suitable scoring systems with or without imaging modalities or may reduce negative appendectomy rates. Furthermore, negative appendectomy can consequence in significant morbidity and mortality, such as prolonged hospital stay, postoperative surgical site infections, and even mortality [15]. On the other hand, diagnostic laparoscopy performed in suspicious cases also carries the risks of general anesthesia, and many surgeons eventually perform an appendectomy. The issue is that with or without inflammation of the appendix, postoperative complications are similar [16]. In this context, the described clinical scoring systems may effectively promote the diagnosis of appendicitis and reduce negative appendectomy rates in areas where imaging methods are difficult to access. Previous studies reveal that scoring systems reduce negative appendectomy rates [10,17–21]. The Alvarado score is the first of these scoring systems, and a score consisting of symptoms, signs, and laboratory parameters leads to diagnosis. In addition to similar parameters, different variables combined in the scoring systems defined later. Examples include gender in Fenyo-Lindberg, urinary symptoms in RIPASA and Ohmann scores, and the use of USG in the Tzanakis score. The Karaman score was the highest PPV value in the current study, and the RIPASA score had the highest NPV value. Moreover, Alvarado’s score was the most specific, while Ohmann’s score was the most sensitive (Figure 1). Based on AUC analysis, the Alvarado and Ohmann scores produced the highest AUC values among the nine scoring systems, while RIPASA and Lintula scores had the lowest AUC values (Figure 1). Considering the low valued AUC scoring systems, gender among the evaluation parameters draw attention. The inadequacy of this variable effects may be due to the presence or ratio of this parameter.
A significantly young female gender increases negative appendectomy rates due to numerous gynecological pathologies accompanying the differential diagnosis [22]. In addition, scoring systems are also affected by age and geographic population [23]. Unsurprisingly, in our study, the majority of group 2 consisted of the female gender.
Leukocytosis is the most critical laboratory value for the diagnosis of acute appendicitis so for scoring systems. In many studies, it has been stated that biochemical markers (C-Reactive Protein, bilirubin) may be helpful in the diagnosis of acute appendicitis. The fact that these markers differ in each study limits their routine use in diagnosing acute appendicitis; as expected, these values are not among the parameters in any scoring system. Our analysis has once again confirmed the influence of leukocytosis in acute appendicitis.
Although imaging modalities such as USG and CT are available to aid diagnosis and differential diagnosis, their utility is limited in accessibility, exposure to ionizing radiation, and cost-effectiveness. As evaluated in a previous study, negative appendectomy rates could not be reduced with the contribution of USG, but could be decreased at least by 8.3% with CT[24]. Precisely for this reason, it would not be off- target to state that the tomographic evaluation assists in the differential diagnosis further on the diagnosis of appendicitis. The USG was performed in all patients who were evaluated with a preliminary diagnosis of acute appendicitis. Patients still suspicious for appendicitis despite examination, laboratory data, and ultrasound had a CT scan. Despite this, unfortunately, our negative appendectomy rate was 10.88%.
From this point of view, combining CSS with ultrasound or tomography may reduce negative appendectomy rates. In the study conducted by Althoubaity et al., the higher rate of negative appendectomy detection (22%) using only USG in female patients showed that USG and scoring systems were more significant in females [24]. Likewise, in another recently published study, Ohmann, Lintula, and Ripasa reported that combining scoring systems with ultrasound could reduce the negative appendectomy rate up to 4% in female patients [25]. In addition, another study pointed out that, besides gender, age groups and geographic population also affect scoring systems in another study [23].
However, in hospitals where access to imaging methods is inconvenient or in cases where the cost cannot be condensed, CSS will significantly contribute to the diagnosis of appendicitis. In centers with no restrictions such as cost or accessibility in the usage of imaging methods, the combination of USG and/or CT with CSS may reduce negative appendectomy rates. In order to achieve the appropriate outcome, a CSS should be chosen as a result of studies carried out that minimize both gender, age, and other effects and can reduce negative appendectomy rates. In the current study, Alvarado and Ohmann score systems were the most effective scoring systems preventing negative appendectomy.
Study limitations
Among the limitations of our study, in addition retrospective analysis, clinical scoring systems were compared not among patients who presented to the emergency department with abdominal pain but between groups who had appendectomy.
In conclusion, the use of appropriate CSS where access to imaging modalities is difficult, or in suitable centers addition to these modalities, may reduce negative appendectomy rates in the diagnosis of appendicitis. According to our analysis, Alvarado’s and Ohmann score systems are the most relevant tests for this issue.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20932
Baris Mantoglu, Emre Gonullu, Guner Cakmak, Mertcan Akcay, Merve Yigit, Guven Erdogrul, Kayhan Ozdemir, Fatih Altıntoprak. To what extent are the appendicitis scoring systems effective in preventing negative appendectomy. Comparison of nine scoring systems. Ann Clin Anal Med 2022;13(2):210-214
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Efficacy of shear wave elastography in malignity assessment of thyroid nodules with atypia of undetermined significance and comparison with TI-RADS
Fatma Durmaz 1, Mesut Özgökçe 1, Sercan Özkaçmaz 1, İlyas Dündar 1, Murat Alay 2, Cemil Göya 1, Mehmet Çetin Kotan 3
1 Department of Radiology, 2 Department of Endocrinology and Metabolism, 3 Department of General Surgery, School of Medicine, Van Yuzuncu Yıl University, Van, Turkey
DOI: 10.4328/ACAM.20949 Received: 2021-11-14 Accepted: 2021-12-16 Published Online: 2022-01-25 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):215-219
Corresponding Author: Fatma Durmaz, Department of Radiology, School of Medicine, Van Yuzuncu Yıl University, Van, Turkey. E-mail: dr.fatmadrmz@gmail.com P: +90 432 215 04 70 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3089-7165
Aim: The aim of this study is to investigate the effectiveness of shear wave elastography (SWE) in the differentiation of benign-malignant thyroid nodules diagnosed with atypia of undetermined significance (AUS) and to compare with the American College of Radiology (ACR)-thyroid imaging reporting and data system (TIRADS).
Material and Methods: This monocentric study comprised 52 patients (9 males; 43 females) who were diagnosed with AUS by thyroid FNAB. All patients included in the study had gray scale ultrasound (US) and SWE images. The mean SWE value was calculated for each nodule, and TIRADS scores were determined based on the US. The obtained data were compared based on the histopathological result in patients who had undergone surgical treatment, and based on the cytology result in patients followed-up by FNAB, for the differentiation of benign and malignant nodules.
Results: Nineteen patients were found to have malignant nodules and 33 had benign nodules. The mean SWE was 2.89±0.51 (2.30–3.92) and 2.91±0.48 (2.16–3.79) in the malignant and benign cases, respectively. The results of independent T- tests between the two groups were insignificant (p=0.89). TIRADS 2-3 (total 29 patients) nodules were considered possibly benign, and TIRADS 4-5 (total 23 patients) possibly malign, the sensitivity, specificity, positive predictive and negative predictive value of TIRADS were identified 100%, 87.9%, 82.6% and 100%, respectively, when compared with the pathology results.
Discussion: There was no significant difference in SWE values in the differentiation of malignant-benign thyroid nodules with AUS. However, the ACR-TIRADS criteria still maintain their importance.
Keywords: Elastography, Thyroid nodule, Undetermined, TI-RADS, Ultrasonography
Introduction
Thyroid nodules are among the most frequently encountered pathologies in routine daily practice, both clinically and radiologically, and should be considered clinically important due to the roughly 5% risk of malignancy [1-3]. In this regard, the assessment of suspicious nodules is important to avoid unnecessary surgery. Fine needle aspiration biopsy (FNAB) has played a significant role in patient selection for surgery since it was accepted as the optimum approach for the differentiation of benign and malignant nodules [4-6]. However, a major limitation of FNAB is that it results in undetermined cytology in around 20–25% of cases [7, 8]. Although generally, a surgical approach is recommended for the treatment of such nodules, histological evaluation of this type of nodule in more than 70% of cases results in a benign pathology [4, 9]. Another approach is to follow-up such nodules with atypical cytology with FNAB, since most of them are benign [10]. Hence, the management of patients with undetermined cytology can be considered challenging. Considering these data, there is still a need to come up with better approaches to the preoperative diagnostic evaluation of patients with undetermined cytological findings in fine needle biopsy.
Ultrasound elastography is a newly developed technique that is gaining broader use day by day. Sonoelastography, based on the hardness of malignant tissues when compared to benign tissues, can be accepted as a sonographic equivalent of palpation as a common approach in physical examinations [11]. It is possible to be informed of the hardness of the organ or nodule from the superficial location of the thyroid gland. Strain wave elastography provides qualitative or semi-quantitative values and is operator dependent; while ARFI, transient and shear wave elastography present quantitative values, and is less operator dependent. Shear wave elastography (SWE) is a technique in which a pushing pulse is sent through the screening axis, advancing perpendicular to the screening axis, and which works based on the measurement of the velocity of the waves referred to as shear waves. Shear waves move faster through hard tissue, since velocity is associated with tissue stiffness [12-14]. It is possible to identify quantitatively the level of tissue stiffness based on the shear wave elastography. In this study, we aimed to compare the effectiveness of shear wave elastography technique in the differentiation of benign and malignant thyroid nodules diagnosed with atypia of undetermined significance by FNAB, and to compare it with the American College of Radiology (ACR)-thyroid imaging reporting and data system (TIRADS).
Material and Methods
Patients
Approval for the study was granted by the ethics committee of the institution, and written informed consent was obtained from all participating patients (2021/10-13). The records of 318 patients diagnosed with atypia of undetermined significance by thyroid FNAB in the interventional radiology clinic between January 2017 and August 2021 were screened retrospectively. Among these patients, those whose ultrasound and ultrasound elastography images were retrievable from the PACS (Picture Archiving Communication System) and who had a histopathological result or diagnosis of benign or malignant thyroid nodule during follow-up FNAB were included in the study. After the exclusion of 169 patients with missing ultrasound and ultrasound elastography images, 32 patients with a whole or partially cystic or calcified nodule, and 65 patients with missing follow-up FNAB or histopathological results, the study was completed with 52 patients matching the inclusion criteria.
Imaging
All patients included in the study had gray scale ultrasound and ultrasound elastography images obtained by the same radiologist with 13 years of experience prior to the FNAB. Ultrasound and elastography evaluations were performed using a Siemens ACUSON S2000™ (Siemens Healthcare, Erlangen, Germany) device. ARFI elastography evaluations were performed using a 4–9 MHz 9L4 linear probe and the Virtual Touch IQ (Virtual touch-operated IQ) option. First, a gray scale ultrasound evaluation was performed with the patient in the supine position. According to the TI-RADS system [15], five features of each nodule were evaluated, including (1) component (choose one): cystic or almost completely cystic 0; spongiform 0; mixed cystic and solid 1; solid or almost completely solid 2; (2) echogenicity (choose one): anechoic 0; hyperechoic or isoechoic 1; hypoechoic 2; very hypoechoic 3; (3) shape (choose one): wider-than-tall, 0; taller-than-wide, 3; (4) margin (choose one): smooth 0; Ill-defined 0; lobulated or irregular 2; extrathyroid extension 3; and (5) echogenic foci (choose one): none or large comet-tail artifact 0; macrocalcification 1; peripheral (rim) calcification 2; punctate echogenic foci 3. Each feature was assigned a corresponding score, and then the nodules were assigned to different TIRADS categories according to their total scores. Nodules with score 0 were classified as TI-RADS category 1 (malignancy risk of 2%, benign), score 2 was classified as TIRADS category 2 (malignancy risk of 2%, probably benign), score 3 was classified as TI-RADS category 3 (malignancy risk of 5%, mild suspicious malignancy), scores 4 to 6 were classified as TI-RADS category 4 (malignancy risk of 5–20%, moderate suspicious malignancy), and scores ≥7 were classified as TI-RADS category 5. Thereafter, elastography measurements were made using the SWE technique. The patients were told not to breathe deeply, cough, strain or move during the procedure. The linear probe was held as stable as possible, and gel was applied between the skin and the probe so as not to put pressure on the thyroid nodule. Two windows were opened on the screen using the dual key, and the borders of the nodule were drawn manually on the left-hand window (gray-scale US). The borders of the same nodule were produced automatically by the device on gray-scale color-coded elastography images (Figure 1-A). The ROI (region of interest), the dimensions of which were produced automatically by the device and which give the shear wave velocity at the nodule borders, were added to the right-hand image (elastography) (Figure 1-B). Although the number varies according to the size of the nodule, at least 5 ROIs were placed to obtain a more reliable mean value.
The mean of shear wave velocity was calculated for each nodule in m/sec, and the TIRADS scores were determined based on the gray-scale US properties. In nodules with atypia of undetermined significance, the obtained data were compared based on the histopathological result in patients who had undergone surgical treatment, and based on the cytology result in patients followed-up by FNAB, to differentiate between benign and malignant nodules.
Statistical Analysis
The descriptive statistics for continuous variables in the study included mean, standard deviation, and minimum and maximum, while categorical variables were expressed as numbers and percentages. An Independent samples t-test was performed to compare group means for continuous variables, and a Chi-square test was performed to determine the association between the groups and categorical variables. An independent sample T test was used to compare the mean shear wave values between malign and benign groups. Sensitivity, specificity, positive and negative predictive values were calculated using TI-RADS 2, 3 for benign lesions, and TI-RADS 4 and 5 for malignant lesions. The level of statistical significance was set at 5% in the calculations, and the SPSS software package was used for all statistical analyses.
Results
A total of 52 patients (9 males; 43 females) with atypia of undetermined significance in the thyroid nodule were included in the study. The diagnosis of 26 patients (10 benign, 16 malignant) was confirmed by histopathology, and of another 26 patients (23 benign, 3 malignant) with follow-up FNAB. According to the histopathology or follow-up FNAB, 19 patients (36.5%) were identified with malignant and 33 (63.5%) with benign nodules. Among patients with malignant nodules, five were male and 14 were female, with an average age of 47±10.6 years (age range: 33–75). Among patients with benign nodules, 4 were male and 29 were female, with an average age of 40±12.6 years (age range: 22–65).
The mean SWE was 2.89±0.51 (2.30–3.92) and 2.91±0.48 (2.16–3.79) in the malignant and benign cases, respectively. The results of independent T- tests between the two groups were not significant (p=0.89). According to the gray-scale US findings, 11 patents were classified as TIRADS 2, 18 as TIRADS 3, 17 as TIRADS 4 and 6 as TIRADS 5 (Figures 2, 3). All the TIRADS 2 and 3 nodules, identified from histopathology or follow-up FNAB, were benign; all the TIRADS 5 nodules were malignant, and four of the TIRADS 4 nodules were benign and 13 were malignant (Table 1). The nodules identified as TIRADS 2 and 3 (total 29 patients) were accepted as possibly benign, and the TIRADS 4 and 5 nodules (total 23 patients) were accepted as possibly malignant, and were compared with the histopathology results or follow-up FNAB results. Considering pathology (histopathology or cytology) results as the optimum approach to the determination of malignancy, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TIRADS were identified 100%, 87.9%, 82.6% and 100%, respectively.
Discussion
The main goal in the evaluation of the thyroid nodules is to determine precisely whether the nodule is benign or malignant, and thus decrease the need for unnecessary FNAB and surgery. Although fine needle aspiration biopsy is the most accurate approach to the characterization of thyroid nodules, the main limitation of this diagnostic approach is the possibility of a result of atypia of undetermined significance. Accordingly, a diagnostic approach that differentiates between benign and malignant nodules without the need for surgery in atypical nodules gains importance.
There have been various studies to date reporting equivocal results in the differentiation of malignant and benign thyroid nodules with atypia of undetermined significance. Malignant nodules have been found to have a statistically higher level of stiffness than benign nodules in a strain elastography studies of 270 (81 malignant and 189 benign) nodules [16], 140 (40 malignant and 100 benign) nodules [17] and 45 (13 malignant and 32 benign) nodules [18]. In a study performed using positron emission tomography (PET), multiparametric US (MPUS) and scintigraphy in 87 patients with atypia of undetermined significance that were histopathologically confirmed to be benign and malignant in 69 and 18 cases, respectively, the sensitivity, accuracy and negative predictive value (NPV) of PET were found to be significantly higher than that of MPUS and scintigraphy [19]. The strain elastography among the MPUS parameters, when evaluated alone, was found to have a suboptimal accuracy in differentiating between the malignant and benign character of thyroid nodules with atypia of undetermined significance. In another study [20], it was concluded that the preoperative strain elastography of thyroid nodules had low elasticity in most of the nodules, and was confirmed not to be so beneficial in the preoperative diagnosis of thyroid nodules with undetermined cytology, in contrast to the recent reports stating them to be beneficial. In contrast to previous studies of the strain elastography approach that revealed qualitative or semi-quantitative data, the SWE technique with quantitative values and less dependent on the operator was used in the present study. No statistical difference was found between benign and malignant nodules in the present study, which may be attributable to the low number of cases, and especially the low number of malignant cases. We also did not find a significant difference in elasticity in these nodules, which are not always cytologically distinguishable.
A significant difference was seen between strain elastography values recorded for benign and malignant nodules in a study [21] performed using both strain elastography and SWE on thyroid nodules with atypia of undetermined significance (P=0.05), while no significant difference was noted in the SWE values of the malignant and benign nodules (P=0.20). It has been suggested that SWE is of no value in differentiating between malignant and benign pathologies, with the nodules in the two groups being reported to have a similar degree of stiffness in a study of 131 thyroid nodules with atypia of undetermined significance [22]. In the present study, in which the applied SWE technique was similar to the studies mentioned above, no significant difference was found in the shear wave values of benign or malignant thyroid nodules with atypia of undetermined significance. Not all of the patients included in the present study had histopathological results, and the acceptance of the follow-up FNAB results as the reference value in some patients may have affected the results. Another SWE study involving a similar patient group reported no benefit of gray-scale US or doppler findings in diagnoses of malignancy, although SWE was reported to be of value in the evaluation of preoperative malignancy risk [23]. Contrary to this study, no significant difference was found in the SWE values in the present study, while the ACR-TIRADS criteria based on the gray-scale US were found to have a high sensitivity and high specificity in the benign and malignant differentiation of thyroid nodules with atypia of undetermined significance.
The main limitation of the present study was the lack of histopathological results of some patients, while a further limitation was the small sample size.
Conclusion
No significant difference was found in the SWE values of benign and malignant thyroid nodules with atypia of undetermined significance. However, the ACR-TIRADS criteria, based on gray-scale US findings, still maintain significance in the differentiation between benign and malignant nodules. Contradictory results have been recorded in the literature based on both SWE and strain elastography approaches to the differentiation of benign and malignant thyroid nodules with atypia of undetermined significance, therefore, further studies involving larger patient series are required. Elastography results should be evaluated concomitantly with gray-scale US findings, even if there are studies with significant results.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Download attachments: 10.4328:ACAM.20949
Fatma Durmaz, Mesut Özgökçe, Sercan Özkaçmaz, İlyas Dündar, Murat Alay, Cemil Göya, Mehmet Çetin Kotan. Efficacy of Shear Wave Elastography in Malignity Assessment of Thyroid Nodules with Atypia of Undetermined Significance and Comparison with TI-RADS. Ann Clin Anal Med 2022;13(2):215-219
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Comparison of tap block and epidural block in gynecologic oncology surgeries
Nevin Aydın 1, Osman Esen 2, Hatice Ateş 1
1 Department of Anesthesiology and Reanimation, University of Health Sciences, Kanuni Sultan SüleymanTraining and Research Hospital, 2 Department of Anesthesiology and Reanimation, Vocational School of Health, Istinye University, Istanbul, Turkey
DOI: 10.4328/ACAM.20971 Received: 2021-11-24 Accepted: 2021-12-31 Published Online: 2022-01-07 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):220-224
Corresponding Author: Nevin Aydın, Department of Anaesthesiology and Reanimation, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Atakent Mah., Turgut Özal Cad., No:1, Küçükçekmece, İstanbul Turkey. E-mail: nevinaydin4334@gmail.com P: +90 212 404 15 00 F: +90 212 571 47 90 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0189-5865
Aim: Transversus abdominis plane (TAP) block and epidural analgesia may be helpful in relieving pain after surgical procedures in gynecological malignancies. In this retrospective cohort study, it was aimed to compare the analgesic efficacy of TAP block and epidural block in patients operated for gynecological malignancy.
Material and Methods: Medical files of 74 patients who underwent surgery for gynecological malignancy were retrospectively reviewed. All patients underwent gynecologic surgeries. Group I (n=25) received epidural analgesia, Group II (n=25) TAP block, and Group III (n=24) received no additional analgesic procedures. Baseline descriptors, visual analog scale for pain, Ramsay sedation score, operation and ICU length of stay, need for additional medication, and gastrointestinal symptoms were compared between groups.
Results: The level of pain relief, hemodynamic and respiratory parameters in the 3 operated groups were mostly similar. In patients <55 years of age, the Ramsay sedation scale was significantly higher 12 hours after surgery. In these patients (<55 years), additional drug use was needed more at the 12th hour. VAS scores at the 1st (p=0.024) and 2nd (p=0.004) hours were also higher in patients with a body mass index of >25.
Discussion: Our results showed that TAP block and epidural analgesia provide safe and effective methods for postoperative analgesia in gynecological malignancies.
Keywords: Surgical Oncology, Epidural Analgesia, Postoperative Pain, Transversus Abdominis
Introduction
Dynamic analgesia is a critical factor for the success of enhanced recovery programs. There is a lack of consensus on the ideal analgesic technique after surgical procedures for gynecologic oncology [1]. Even though it was considered the gold standard, epidural analgesia is being replaced by other techniques with a better risk/benefit ratio. Transversus abdominis plane (TAP) blocks have gained popularity; however, they are unable to provide durable analgesia [2,3]. Another drawback with TAP blocks is their dermatomal limitation [4]. Recent studies demonstrated that patient-controlled epidural analgesia (PCEA) could decrease the total anesthetic need and reduce the workload of the medical staff. Maternal satisfaction was higher with PCEA than other techniques that did not involve patient participation. On the other hand, there is no consensus on patient selection criteria as well as the ideal route of delivery [5]. Epidural analgesia has been commonly used in anesthesiology practice except for patients with increased intracranial pressure, coagulation disorders, unwillingness for the procedure, uncompliance for intervention, local sepsis, and restricted experience. On the other hand, TAP block is a relatively novel mode that necessitates injection of the local anesthetic solution in the anterior abdominal wall [6]. Even though TAP is a technically challenging procedure, it is a less invasive intervention that provides maintenance of the sensory and motor function of the lower limb and the hemodynamic profile [7,8]. Patient-controlled analgesia is recommended for patients planned for gynecological surgery for postoperative analgesia, since it has a minor effect on respiration [6]. Effective management of postoperative pain is critical against chronic pain [9]. Unless relief of postoperative pain is possible, not only discharge from hospital is delayed, but also narcotic consumption and recovery time will be increased [10]. The purpose of the current study was to evaluate the efficacies of transversus abdominis plane block and epidural analgesia in patients operated for gynaecologic malignancies.
Material and Methods
This retrospective study was performed in the anesthesiology & reanimation and obstetrics & gynecology departments of a university hospital. Ethical approval was obtained from the institutional review board before the study. Adherence to the principles announced in the revised version of the Helsinki Declaration was provided.
Medical files of patients treated surgically for gynecologic malignancies were retrospectively reviewed. Patients deemed eligible for this study were ≥ 18 years of age and had an American Society of Anesthesiologists (ASA) status of 1-3. Exclusion criteria were drug allergy, chronic pain, diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease, coagulopathy or a surgical incision extending beyond the T10 dermatome. After an overnight fasting period, patients were premedicated with alprazolam 0.25 mg and ranitidine 150 mg orally the night before and 2 hours before surgery. Standard monitoring involved electrocardiogram, non-invasive arterial blood pressure, arterial oxygen saturation, and end-tidal carbon dioxide monitoring.
The regimen for epidural analgesia and TAP block was applied in the relevant literature [1]. Accordingly, a catheter was placed in the thoracic region at the level of T9–T11 before the operation in the epidural analgesia group. General anesthesia was induced with intravenous propofol (1.5–2 mg/kg) and fentanyl (1–2 µg/kg). In the TAP block group, general anesthesia was induced and maintained as described before using the same procedure as in the epidural group. At the end of the surgery, while the patient was still anaesthetized, the patient received a TAP block.
The median incision was performed routinely in all surgical procedures. All patients received tramadol HCl, dexketoprofen and paracetamol 5 minutes before the cessation of general anesthesia. Patient-controlled epidural analgesia (PCEA) was initiated half an hour before the end of the operation. Patient-controlled epidural analgesia was administered as follows: Bupivacaine (100 g) was diluted in 100 ml of isotonic saline yielding a dose of 1 mg/ml. The lock out time was 30 minutes and the infusion was set at a dose of 1.5 mg/hour. Therefore, the total dose per hour was adjusted to 3.5 mg. An anaesthesiologist who was not recruited in the clinical management of patients, prepared anesthetic solutions and scheduled the PCEA pump. For TAP block, 12.5 ml of bupivacaine and 2.5 ml of lidocaine were diluted with 20 ml of isotonic saline. In overweight and obese patients, TAP block was performed under ultrasonographic guidance.
Patients were allocated into three groups according to the care regimen: Group I (n=25) was composed of patients who had PCEA, Group II (n=25) underwent TAP block, whereas Group III (n=24) did not have any additional procedures. Variables under investigation included age, body-mass index (BMI), ASA score, comorbidities, durations of operation, hospitalization and intensive care unit stay, visual analog scale (VAS) for pain, gastrointestinal findings such as nausea, vomiting, and defecation were noted on 1st, 2nd, 3rd, 6th, 12th and 24th hours postoperatively. Furthermore, cardiovascular system indicators such as systolic and diastolic blood pressures, pulse rate and peripheral capillary oxygen saturation were recorded.
Statistical analysis
Descriptive data were expressed as mean, standard deviation, median, minimum and maximum values. Categorical variables were expressed as numbers and percentages. Comparison of groups was carried out via one-way analysis of variance (ANOVA) if parametric test assumptions were met, or performed with the Kruskal-Wallis test if parametric assumptions were not met. If a difference was determined between groups, comparisons were made to identify the group that causes the difference. The Chi-square test was used to assess categorical variables. The level of significance was set at a p-value <0.05. Data were analyzed using the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 21.
Results
Table 1 presents a comparative view of baseline descriptives and perioperative data in 3 groups. Three groups under investigation were similar regarding age (p=0.508), BMI (p=0.491), and ASA scores (p=0.797). In contrast, there were significant differences between the 3 groups concerning durations of operation (p=0.001) and recovery (p=0.028). The duration of operation and recovery were remarkably longer in Group I who had PCEA.
The most common diseases diagnosed were hypertension (n=26; 35.6%), cardiovascular system diseases such as deep venous thrombosis (n=13; 17.8%) and diabetes mellitus (n=6; 8.2%).
The measurements for systolic blood pressure at various time intervals indicated that there was no statistically significant difference between the 3 groups. Diastolic blood pressure values measured over 24 hours yielded that Group I had remarkably lower results on the 12th hour (p=0.011). The heart rates were measured in 3 groups, and there was no statisticallysignificant difference between groups at any periods under focus. Comparison of oxygen saturation values between 3 groups demonstrated that there were significant differences between 3 groups on 6th and 12th hours (p=0.022, and p=0.033, respectively). Group I displayed the highest values for oxygen saturation at these time intervals, while Group III had the lowest values (Figure 1).
The level of pain as reflected by VAS demonstrated that it was different between groups in the 3rd hour. It was lowest in Group II and highest in Group III (p=0.017). There was no significant difference between the 3 groups regarding Ramsey scores. Patients in Group III exhibited a more common rate of nausea and vomiting at the 2nd hour (p=0.030). There was no difference between the 3 groups concerning the return of defecation function.
Patients ≥55 years of age had higher ASA scores (p<0.001), more comorbidities (p<0.001) and longer stay in ICU (p=0.039). Durations of operation and hospitalization were also longer in patients ≥55 years (p=0.013; and p=0.012, respectively) (Table 2). Visual analog scale for pain was higher in patients younger than 55 years at 12 hours (p=0.003) and 24 hours (p=0.028). The Ramsay sedation scale in patients <55 years was notably higher at 12 hours after surgery (p=0.038). Additional drug use was needed more in these patients (<55 years) by the 12th hour (p=0.013). Systolic pressure at the 6th hour was remarkably higher in older patients (≥55 years). Patients with BMI ≥25 had higher ASA scores (p=0.008) and had a higher incidence of comorbidities (p=0.003). VAS scores on 1st (p=0.024) and 2nd (p=0.004) hours were also higher in these cases (Table 3).
Discussion
Insufficient relief of post-operative pain is associated with delayed recovery, increased health care costs and diminished patient satisfaction. Different adjuvants are utilized in regional anesthesia to facilitate and prolong local anesthetic analgesia and reduce opioid requirements and their side effects. Epidural analgesia may relieve both somatic (abdominal wall wound) and visceral (uterus) components of pain, while the TAP block is more likely to alleviate pain originating from the abdominal wall only [6,11].
The current trial was performed to investigate the efficacies of epidural analgesia and TAP block in patients operated for gynaecologic malignancies. Our results demonstrated that both of these methods provided effective relief of pain postoperatively, and sedation scores were similar between the groups receiving TAP block or epidural analgesia. The need for additional medications was more apparent, and nausea and vomiting were more evident in patients who did not undergo TAP block or epidural analgesia. Cardiovascular profiles and hemodynamic parameters were not adversely influenced by TAP block and epidural analgesia. Advanced age (≥55) was associated with prolonged hospital stay and longer duration of operation, while obesity (BMI≥25 kg/m2) was linked with higher ASA status and additional comorbidities.
The mode of anesthesia induction can affect the total anesthetic consumption with PCEA and the efficiency of analgesia [5]. The combination of an epidural opioid-local anesthetic provides good pain control during the first post-operative day, but is associated with nausea, vomiting, sedation, pruritus, urinary retention and respiratory depression [11].
The TAP block involves the sensory nerve supply of the anterior-lateral abdominal wall, in which the T7-12 intercostal nerves, the ilioinguinal and iliohypogastric nerves, and the lateral cutaneous branches of the dorsal rami of L1-3 are blocked. The efficacy of TAP block may be limited due to obesity, and ultrasonographic guidance may not be sufficient due to the difficulty of placement. The beneficial effects of the TAP block at the time of laparotomy and laparoscopy have been demonstrated in previous publications. Nevertheless, the additional time under anesthesia constitutes a disadvantage for the patient. The TAP block was found to be a safe method, which does not increase the likelihood of any adverse effects or increase in postoperative complications [10,12].
Improved pain management and quality of life as well as decreased costs due to prolonged hospitalization are the main advantages of procedures such as epidural analgesia and transversus abdominis plane block. Close collaboration between surgical and anesthesia pain management teams is necessary for the establishment of appropriate management [10].
Transversus abdominis plane block offers the advantage of providing analgesia without the addition of morphine PCA. It provides effective analgesia especially if the procedure is shifted to open surgery. TAP block is non-sedating and has minimal effect on the cardiovascular system, sparing the motor function of lower limbs. Compared with epidural analgesia, TAP analgesia does not disturb hemodynamic imbalance and is suitable for use in patients on anticoagulation medication. TAP block does not necessitate intensive nursing care. Thus, it avoids the side-effects of opioids administered by the intrathecal route, including urinary retention. Patients with epidural analgesia may need re-catheterization attributed to urinary retention. On the other hand, TAP analgesia does not alleviate visceral pain, and this can be a significant problem in some cases [1].
Epidural analgesia is supposed to be the most effective method for the relief of pain in labor. Our data support that PCEA may be a safe, convenient and effective analgesic option in the postoperative care of patients operated for gynecologic malignancies. It seems to significantly prolong the duration of operation and recovery. Owing to the systemic diseases to be encountered in a relatively elderly patient group, this point must be taken into account during planning the protocol for pain relief. Epidural analgesia not only diminishes the workload, but also reduces the number of interventions and improves the satisfaction of the patient [13]. In the literature, comparison of epidural versus TAP block for postoperative analgesia after abdominal surgery did not yield any differences concerning pain scores [14].
The main limitations of the current trial include retrospective design, small sample size, and data restricted to the experience of a single institution. Therefore, our results must be interpreted cautiously, and extrapolations to larger populations must be made carefully.
Conclusion
Results of the present study indicated that TAP block and epidural analgesia yield safe and effective modes for postoperative analgesia in gynaecologic malignancies. Close collaboration between surgical and anesthesia teams is mandatory for the appropriate selection of patients and the development of guidelines.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
References
1. Niraj G, Kelkar A, Hart E, Horst С, Malik В, Yeow С, et al. Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open-label, randomised, non-inferiority trial. Anaesthesia. 2014; 69(4):348-55.
2. Taylor R Jr, Pergolizzi JV, Sinclair A, Raffa RB, Aldington D, Plavin S, et al. Transversus abdominis block: clinical uses, side effects, and future perspectives. Pain Pract. 2013; 13(4):332–44.
3. Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia. 2011; 66(6):465–71.
4. Borglum J, Jensen K, Christensen A, Hoegberg LCG, Johansen SS, Lönnqvist PA, et al. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. Reg Anesth Pain Med. 2012; 37(3): 294–301.
5. Okutomi T, Saito M, Mochizuki J, Amano K, Hoka S. A double-blind randomized controlled trial of patient-controlled epidural analgesia with or without a background infusion following initial spinal analgesia for labor pain. Int J Obstet Anesth. 2009; 18(1):28-32.
6. Raghvendra KP, Thapa D, Mitra S, Ahuja V, Gombar S, Huria A. Postoperative pain relief following hysterectomy: A randomized controlled trial. J Midlife Health. 2016; 7(2): 65-8.
7. Bhattacharjee S, Ray M, Ghose T, Maitra S, Layek A. Analgesic efficacy of transversus abdominis plane block in providing effective perioperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2014; 30(3):391-6.
8. Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: A valuable option for postoperative analgesia? A topical review. Acta Anaesthesiol Scand. 2010; 54(5):529-35.
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11. Hefni AF, Mahmoud MS, Al Alim AA. Epidural dexamethasone for post-operative analgesia in patients undergoing abdominal hysterectomy: A dose ranging and safety evaluation study. Saudi J Anaesth. 2014; 8(3): 323-7.
12. Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesth. 2009; 102(1):143-4.
13. Vallejo MC, Ramesh V, Phelps AL, Sah N. Epidural labour analgesia: continuous infusion versus patient-controlled epidural analgesia with background versus without a background infusion. J Pain. 2007; 8: 970-5.
14. Rao Kadam V, Van Wijk RM, Moran JI, Miller D. Epidural versus continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesth Intensive Care. 2013; 41(4):476-81.
Download attachments: 10.4328:ACAM.20971
Nevin Aydın, Osman Esen, Hatice Ateş. Comparison of tap block and epidural block in gynecologic oncology surgeries. Ann Clin Anal Med 2022;13(2):220-224
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Association between NOS3 intron 4 VNTR variant and sports performance
Şaban Ünver 1, Tülin Atan 1, Ayşe Feyda Nursal 2, Serbülent Yiğit 3
1 Department of Coaching Education, Faculty of Sports Science, Ondokuz Mayıs University, Samsun, 2 Department of Medical Genetics, Faculty of Medicine, Hitit University, Çorum, 3 Department of Genetics, Faculty of Veterinary, Ondokuz Mayıs University, Samsun, Turkey
DOI: 10.4328/ACAM.20987 Received: 2021-12-09 Accepted: 2022-01-19 Published Online: 2022-01-25 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):225-229
Corresponding Author: Şaban Ünver, Faculty of Sports Sciences, Kurupelit Campus, Ondokuz Mayıs University, Atakum, Samsun, Turkey. E-mail: saban.unver@omu.edu.tr P: +90 506 276 98 51 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7378-596X
Aim: Evidence shows the involvement of Nitric oxide (NO) in glucose metabolism, which is glucose uptake in human skeletal muscle at the time of exercise, controlling function and structure of skeletal muscle, conversion of skeletal muscle fiber type, production of mitochondrial ATP, and uptake of oxygen in skeletal muscles, all necessary for anaerobic and aerobic performance. Endothelial nitric oxide synthase (NOS3) enzyme synthesizes NO. The main purpose of this study was to investigate whether the NOS3 gene variable number of tandem repeats (VNTR) variant affected athletic performance in the Turkish population.
Material and Methods: This is a prospective single-center cross-sectional study. One hundred thirty-six Turkish athletes and 150 sedentary individuals as controls were included in the study. The intron-4 27-bp VNTR variant of NOS3 genotype and allele frequencies were analyzed with polymerase chain reaction (PCR) analysis.
Results: There was a significant difference between the athletes and the control group in the genotype distribution of the NOS3 VNTR variant. We found that the NOS3 VNTR 4a/4a genotype significantly increased in athletes compared with controls (X2:10.862, p = 0.004). A statistically significant association was observed between the athletes and the controls in terms of 4b/4b + 4a/4b genotype vs 4a/4a genotypes (p = 0.011, 95% CI: 0.0366 – 0.7915). There was no significant difference between the groups in the NOS3 VNTR allele distribution (p>0.05).
Discussion: This study gives evidence of an association between the NOS3 variant and sports performance. More studies should focus on the genetic effect of increased performance to confirm these findings.
Keywords: Nitric Oxide, ENOS, Sports Performance, VNTR, PCR
Introduction
Study of sport sciences is faced with challenges of human athletic performance determinants. A significantly complex multifactorial phenomenon is sports performance, which is determined by various extrinsic factors such as nutrition, training, overall health conditions, development opportunities, and intrinsic factors such as psychological and physiological profile, motor behavior, genetics, and interaction [1]. As a gaseous free radical, nitric oxide (NO) functions as a multifunctional messenger [2]. Several studies show the involvement of NO in glucose metabolism, which is glucose uptake in human skeletal muscle at the time of exercise, controlling function and structure of skeletal muscle, conversion of skeletal muscle fiber type, production of mitochondrial ATP, and uptake of oxygen in skeletal muscles, all necessary for anaerobic and aerobic performance [3].
NO also helps repair and regenerate the myocardium and modulate consumption of oxygen in the myocardium [4]. Two NOS, i.e., nNOS and eNOS isoforms, have been found in skeletal muscle. The primary isoform found in skeletal muscle is nNOS, while eNOS, mainly expressed in endothelial cells, majorly helps control vascular tone. The NOS3 gene located on chromosome 7 (7q36) encodes NOS3 or eNOS as the endothelial nitric oxide synthase. The gene spans approximately 21 kb of genomic DNA and consists of 26 exons encoding a 1203 amino acids protein [5]. 4b/4a in intron 4, Glu298Asp (rs1799983) in exon 7, and T2786C (rs2070744) in the promoter region are regarded as polymorphisms found in the gene, which have been widely studied to see the relationship between the cardiovascular system functions in patients and healthy controls [6]. 4b/4a variant is placed in the minisatellite in intron 4 of the gene. Five VNTR alleles with 2–6 tandem 27-bp repeats (alleles 2–6) have been reported up to now. Alleles 4 and 5 are found in all investigated populations. Both genotype and allele frequencies of the VNTR show that there are interethnic variations [7]. Despite the lack of evidence on the exact molecular effects of this polymorphism, biochemical evidence shows the reduced expression of eNOS and enzymatic activity related to this NOS3 27-bp VNTR [6]. The intron 4 VNTR variant was reported to contribute to more than 25% of the phenotypic variation in the healthy Caucasian families with the observed NOS3 gene, where the minor allele a reduces the NO level [8].
Based on this data, the main purpose of this study was to investigate whether the NOS3 VNTR variant affected athletic performance in the Turkish population.
Material and Methods
Study population
The study group consisted of 136 athletes (34 females and 102 males) from different sports branches (football, basketball, volleyball, and wrestle) representing the Faculty of Sport Sciences, Ondokuz Mayıs University, Samsun, Turkey. The control group (43 females and 107 males) consisted of age-gender matched voluntary sedentary individuals studying at Ondokuz Mayıs University. The participants included both genders, were of Turkish descent and aged between 18 and 30 years. Informed written consent was obtained from all subjects before enrollment to the study, according to the Declaration of Helsinki’s ethical guidelines, and the study was approved by the Ondokuz Mayıs University Ethics Committee (2020/45).
Genotyping
Two ml of venous blood was taken from each participant (athletes and controls), and DNA was extracted from all the samples using the commercial kit, based on the manufacturer’s instructions. NOS3 VNTR variant was genotyped by the polymerase chain reaction (PCR) method described previously [9].
Statistical analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 20.0 for Windows (SPSS Inc., Chicago, IL). The mean and standard deviation were used for the presentation of continuous quantitative variables. Frequencies and percentages were used for categorical data. The NOS3 overall genotype distribution was compared using the chi-square (χ2) test, and the specific genotype and allele distributions were compared using Fisher’s exact test. The odds ratios (ORs) and 95 % confidence intervals (CIs) were used to determine the relationships between the NOS3 allelic and genotypic variants and their occurrence in the patients. The p-values below 0.05 were considered statistically significant.
Results
In the present study, 286 subjects, including 136 athletes and 150 controls, were genotyped for the NOS3 VNTR variant. The baseline demographic features of the subjects are shown in Table 1.
In Table 2, the descriptive information of the participants according to some variables is given.
The distribution of genotypes and allele frequencies of NOS3 VNTR between athletes and controls is shown in Table 3. There was a significant difference between the athletes and controls in terms of the intron 4 VNTR variant of the NOS3 gene. The NOS3 4b/4a genotype frequencies in elite athletes were 58.1%, 34.5%, and 7.4% for 4b/4b, 4b/4a, and 4a/4a, respectively, and 49.3%, 49.3%, and 1.4% in the control group for 4a/4a, 4a/4b, and 4b/4b, respectively. Genotype frequencies were significantly different between the groups (χ2=10.862, p=0.004). A statistically significant association was observed between the athletes and the controls in terms of 4b/4b + 4a/4b genotype vs 4a/4a genotypes (p = 0.01122, 95% CI: 0.03663 – 0.7915). We found no significant difference between the athletes and the controls in terms of the allelic frequencies of the NOS3 intron 4 VNTR variant.
Discussion
In this study on Turkish athletes and controls, an association was found between eNOS gene intron 4b/4a VNTR polymorphism and sports performance. The main finding in our study overrepresented the 4a/4a genotype among the Turkish athletes as compared with the ethnically-matched controls. A complex phenotype affected by several genetic and environmental factors is physical exercise. Adaptations for the production of coordinated movements involve changes in cells and tissue, which convey the expression of the gene. For example, skeletal muscles can have varying efficiency, and the cardiovascular system can be almost exposed to fatigue, which depends on the expression of genes. NO is produced by the endothelium as the most potent vasodilator, increasing physical activity and induces shear stress. This is modulated by a genetic predispositions to the expression of NOS3 [10]. NO is a potent vasodilator while helping control skeletal muscle glucose uptake at the time of exercise (3), mitochondrial ATP production (3), and skeletal muscle function (3), all modulating strength muscle. NO is also produced in the cerebral circulation, affecting neuronal activity, including dopamine release [11]. Thus, actions mediated by NO also affect cognition and behavior, motivation, and voluntary movement. The NOS3 gene explains individual variations in phenotypes related to health and exercise capacity as it encodes NOS3. NOS3 is the enzyme catalyzing the NO synthesis. This is a well-known molecule helping regulate important body functions and systems [12]. Since NO plays a potential role in regulating tolerance to physical exercise and recovery mechanisms, testing the NOS3 genetic variants has shown its association with different exercise or training response phenotypes such as cardiovascular hemodynamics features such as heart rate responses [13] and blood pressure [14]. NO directly regulates basal vascular tone and helps supply blood to tissues, including potentially working muscles, while contributing to myocardial respiration and cardioprotection [15]. Based on different candidate gene studies, there is an association between polymorphisms of NOS3 gene -786T/C, G894T and VNTR and several training, health/fitness, or exercise response phenotypes such as adapting heart rate responses [13], parasympathetic modulation response [16], cardiovascular traits such as athletes’ cardio-biochemical [17], aerobic capacity, and blood pressure [18].
Eynon et al. found that genotype distribution of NOS3 -786 T/C significantly differed between soccer players, controls, endurance, and power elite athletes [19]. Also, it was shown that the frequency of the NOS3 -786 T/C TT genotype was significantly higher in power athletes than that in the endurance or control group [12]. Drozdovs’ka et al. observed that NOS3 -786 T/C T-allele frequency was higher in athletes in speed and power sports than in the control group and group endurance sports [17]. Eider et al. (2014) reported a significant difference between control subjects and the power-oriented, mixed, endurance athletes in NOS3 G894T genotype and allele distributions [20]. Zmijewski et al. (2018) demonstrate the benefit of the G-T haplotype and T allele of the G894T and -786T/C polymorphisms for long-distance swimmers [21]. NOS3 promoter activity can be affected by the 27-bp VNTR as a cis-acting factor, inhibiting the expression of NOS3. Sparse evidence shows the impact of this polymorphism on the expression and activity of NOS3 [22]. Endothelial cells with the 4-repeat (4a) allele increase NOS3 mRNA level compared to the cells with the more common 5-repeat (4b) allele [23]. It has been reported that the “4a” allele is associated with some disorders [24, 25].
This study examined the NOS3 VNTR genotype distribution among 150 control individuals and 136 athletes. This is the first study to evaluate the association between the NOS3 VNTR variant and athletic performance in Turkey to the best of our knowledge. We observed that the NOS3 VNTR 4a/4a genotype was higher in athletes than in the controls (Table 3). In our study, the 4a/4a genotype in the athletes was 10.862 times as much as that in the controls. This has been interpreted as a contribution to predisposition. In addition, there was a significant difference between the athletes and the controls in terms of 4b/4b + 4a/4b genotype vs. 4a/4a genotypes.
However, the present case-control analysis has several limitations. First, our focus was on only one variant in the NOS3 pathway, and the mechanism may be affected by other regulatory genes in this family signaling pathway.Second, since the sample size was relatively small, the groups had low frequencies of some homozygous variants, reducing the statistical power. Third, individuals of the same race and geographical region were sampled.
Conclusıon
This study gives evidence of an association between the NOS3 variant and sports performance. More studies should focus on the genetic effect of increased performance to confirm these findings.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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9. Gonzalez-Ordonez A, Fernandez-Carreira JM, Franco AG, Sánchez LM, Alvarez MV, GarcÍa EC.Two expressive polymorphisms on the endothelial nitric oxide synthase gene (intron4, 27 bp repeat and -786 T/C) and the venous thromboembolism. Thrombosis Research. 2000; 99(6):563-6.
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Download attachments: 10.4328:ACAM.20987
Şaban Ünver, Tülin Atan, Ayşe Feyda Nursal, Serbülent Yiğit. Association between NOS3 intron 4 VNTR variant and sports performance. Ann Clin Anal Med 2022;13(2):225-229
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Microsatellite instability (MSI) in endometrial cancer; frequency and prognostic significance
Alptekin Küçük 1, Hacer Demir 2, Cigdem Ozdemir 3, Ismail Beypinar 4, Meltem Baykara 2, Dagıstan Tolga Arıoz 5
Department of Internal Medicine, Afyon Health Sciences University School of Medicine, Afyonkarahisar, 2 Department of Internal Medicine and Medical Oncology, Afyon Health Sciences University School of Medicine, Afyonkarahisar, 3 Department of Pathology, Afyon Health Sciences University School of Medicine, Afyonkarahisar, 4 Department of Internal Medicine and Medical Oncology, Eskişehir City Hospital, Eskişehir, 5 Department of Gynecological Oncology, Afyon Health Sciences University School of Medicine, Afyonkarahisar, Turkey
DOI: 10.4328/ACAM.20995 Received: 2021-12-14 Accepted: 2022-01-17 Published Online: 2022-01-25 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):230-235
Corresponding Author: Hacer Demir, Department of Internal Medicine and Medical Oncology, Afyon Health Sciences University School of Medicine, Afyonkarahisar, Turkey. E-mail: drhacerdemir@gmail.com P: +90 505 504 40 11 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1235-9363
Aim: In our study, we aimed to evaluate the frequency of MSI in endometrial cancer and its relationship with prognostic parameters and inflammatory indexes.
Material and Methods: MLH1, MSH2, MSH6, and PMS2 mutations were evaluated immunohistochemically in paraffin blocks of 74 patients diagnosed with endometrial cancer. If no staining was detected in any of these proteins, the tumor was considered microsatellite instable (MSI). Demographic and pathological data of the patients were obtained from the file records.
Results: MSI was detected in 21 (28.3%) of 74 patients; expression loss of MLH-1/PMS-2 (18.9%) in 14, PMS-2 (4.03%) in 3, MSH-2 (2.7%) in 2, MSH-6/PMS-2 (1.3%) in 1 and loss of expression of MSH-2/PMS-2 (1.3%) was observed in 1 of them. There was no significant difference between MSS and MSI groups in terms of age, grade, lymph node, stage, LVI, histological subtype. The 5-year survival rates were 73% in the MSS group and 46% in the MSI group, but this difference was not statistically significant (p=0.760).
Discussion: In conclusion, in this study, it was determined that MSI status did not affect the prognosis in endometrial cancers. With the widespread use of immunotherapies, the predictive role of knowledge of the MSI status in endometrial cancer comes to the forefront rather than its prognostic value. In addition, knowledge of the MSI status has gained importance in the new molecular classification of endometrial cancer.
Keywords: Microsatellite Instability (MSI), Endometrial Carcinoma, Prognosis
Introduction
Endometrial cancer is the most common gynecological malignancy in developed countries. It is the fourth most common cancer in women after breast, lung, and colorectal cancers. Despite its high incidence, mortality rates are low. Mortality rates are 4.1 per 100,000 women and 2.5% in cancer-related deaths [1].
Known risk factors for endometrial carcinoma are obesity, unopposed estrogen, chronic anovulation, diabetes, nulliparity, early menarche, late menopause, tamoxifen use, family history, and genetic predisposition [2].
There is no recommended screening test for endometrial carcinoma in asymptomatic patients. However, in patients with abnormal thickness increase, irregularity, and cystic degeneration in the endometrium on ultrasonography, an endometrial biopsy can help make the diagnosis. Abnormal uterine bleeding is present in 75-90% of patients diagnosed with endometrial cancer [3] .
Microsatellites are DNA base sequences consisting of 2-4 nucleotides and repeated 3-100 times sequentially. As the number of repeats increases, likelihood errors in the form of insertions or deletions during DNA replication increases. In a normal cell, these errors are recognized by MMR genes (Mismatch Repair Genes) and repaired. In one of the genes encoding proteins involved in mismatch repair (MLH1,MSH2, MSH6, PMS1, PMS2, MLH3, EXO1), any mutation or the development of epigenetic change causes dysfunction in related proteins [4]. In neoplastic lesions that develop due to the disruption of this mechanism, the number of microsatellite repeats in tumor tissues is different from that in normal tissues. This phenomenon is called Microsatellite instability (MSI) and is a marker of a DNA repair error that can lead to the accumulation of mutations in cells. MSI is closely associated with the carcinogenicity of hereditary tumors such as Lynch syndrome and was first identified in 1993 in sporadic and familial colon cancer. It is currently used as a secondary screening test for patients with suspected Lynch syndrome [5,6].
MSI is observed in 90% of colorectal cancers and 75% of endometrial cancers in Hereditary Nonpolyposis Colorectal Cancer (HNPCC) (7). MSI is observed in 12% of sporadic colorectal cancers and 25-30% of sporadic endometrial cancers [8] .
One of the clinical implications of the MSI test is in predicting the efficacy of anti-PDL1 therapy in MSI-associated endometrial cancers. The role of immunotherapy in many PDL1-expressing cancers is increasing. Clinical studies have shown that MSI-associated endometrial cancers respond better to anti-PDL1 therapy than microsatellite stable endometrial cancers. In the treatment of MSI-H endometrial cancers, the option of immunotherapy has taken its place in the treatment guidelines [9]. Therefore, routine evaluation of MSI status has become important.
However, the relationship between MSI status and prognosis is still unclear. Therefore, we planned to investigate the incidence of MSI and its relationship with prognosis and clinicopathological factors in patients with endometrial cancer followed in our clinic.
Material and Methods
The files of 150 patients diagnosed with endometrial carcinoma who applied to Afyonkarahisar Health Sciences University Medical Faculty Department of Medical Oncology between 01.01.2008 and 01.10.2020 were evaluated retrospectively. Patients who were older than 18 years of age, diagnosed with pathologically confirmed endometrial cancer, had sufficient file information and had regular follow-up data were included in the study. Seventy-six patients were excluded from the; because their pathological diagnosis was endometrial sarcoma, carcinosarcoma, or mixed histology, 5 patients due to insufficient follow-up data, and 6 patients because pathology blocks were not available in our center. The remaining 74 patients were included in the study. Information such as demographic data, tumor grade, lymph node status, tumor size of the patients was obtained retrospectively through file scanning or medical records in the hospital information system. The patient’s risk factors and treatments, relapse dates, last control dates or exitus dates were recorded.
Paraffin blocks of tumor tissue of the patients included in the study for MSI analysis were obtained from the archive of the Department of Pathology. Sections 1-1.5 mm thick were taken from the paraffin blocks with a microtome knife and placed on adhesive slides. Deparaffinization was performed at 60 °C for 30 minutes. A dewax solution was applied at 72 °C. Washing was done with alcohol. ER-2 solution was applied for 12 minutes. Bond Wash washing solution at 35 °C, then distilled water, Hematoxylin-eosin for 5 minutes, distilled water and finally washing water were applied, respectively.
Evaluation of all immunohistochemical stainings was carried out in accordance with the literature, using the method of Gark et al [10]. Accordingly, normal endometrial glandular structures, stromal cells, and lymphocytes were used as internal positive controls. Hyperplasia areas were excluded from the evaluation. The presence or absence of staining was detected in tumor cell nuclei. Any presence of nuclear staining was considered positive and evaluated as microsatellite stability (MSS). Total staining loss in tumor cell nuclei was evaluated as negative and considered as microsatellite instability (Figure 1).
Statistical analysis
Descriptive statistics for categorical variables are given with frequency and percentage values. In the comparisons between groups, an independent sample t-test was used for data conforming to normal distribution, and the Mann-Whitney U test was used for data not conforming to a normal distribution. Comparison of categorical variables between groups was determined using the Pearson Chi-square test, survival times and factors affecting survival time were determined using the Kaplan-Meier method. The log-rank test was used when comparing the survival times between groups. IBM SPSS 22.0 was used for statistical analysis, p<0.05 was considered statistically significant.
Ethical Approval
The study was started after the approval of the ethics committee with the decision numbered 2020/1 dated 03.01.2020 of the Clinical Research Ethics Committee of Afyonkarahisar Health Sciences University Faculty of Medicine.
Results
The median age of the diagnosed patients was 61±9.5 (37-85) years. Thirty (40.5%) of the patients were stage I, 21 (28.4%) were stage II, 14 (18.9%) were stage III, and 9 (12.2%) were stage IV. Pathological subtypes of the patients were endometrioid adenocarcinoma in 85.1% (62), serous carcinoma in 10.8% (8), and other histological subtypes in 4.3% (3), respectively. Of the patients, 16 (21.6%) had grade 1, 35 (47.3%) grade 2, and 23 (31.1%) grade 3 tumors. At the time of analysis, 15 (20.2%) of the cases were exitus, only 2 (2.7%) of the cases relapsed. The clinical and demographic data of the study group are summarized in Table 1.
Microsatellite instability was detected in 21 (28.3%) of 74 patients. Of these patients, 14 had MLH-1/PMS-2 (18.9%), 3 had PMS-2 (4.03%), 2 had MSH-2 (2.7%), 1 had MSH- 6/PMS-2(1.3%), 1 had loss of expression of MSH-2/PMS-2 (1.3%). Fifty-three patients with no loss of expression in any MSI marker were considered MSS.
There was no difference between the MSI and MSS groups in terms of age and lymph node metastasis (p=0.190). Lymph
node metastases were detected in 13 (17.8%) patients with MSI, while 7 (9.6%) did not have lymph node metastases. Myometrial invasion rates were different between MSI and MSS groups. While 95.2% of the patients in the MSI group had myometrial invasion, this rate was 73.6% in the MSS group and was statistically significant (p=0.031).
Both groups were found to be similar in terms of histological grade (p=0.230). It was determined that 2 (2.7%) of the patients with MSI were grade 1, 12 (16.4%) were grade 2, and 6 (8.2%) were grade 3. A summary of the evaluations made in terms of prognostic factors among the groups according to MSI status is given in Table 2.
The relationship between MSI and MSS patient groups and inflammation parameters was also evaluated in the study. NLR (neutrophil-lymphocyte ratio), SII (systemic immune inflammation index) parameters were used for inflammation parameters. Since no significant value could be obtained by ROC analysis for NLR and SII cut-off values, the median value was accepted as the cut-off value. When those below and above the median value in terms of NLR and SII were compared according to their MSI status, no statistically significant difference was observed (p=0.500 and p=0.303), respectively. Again, when the survival rates below and above the NLR and SII cut-off values were compared between the MSI and MSS groups, no significant difference was found between the groups (p=0.269 and p=0.164, respectively) (Figure 2). The median overall survival in the entire study group was 17 months, and disease-
free survival was 18.5 months. The 5-year survival rate was 73% in the MSS group, and 46% in the MSI group, and this difference was not statistically significant (p=0.760) (Figure 3).
Discussion
In our study, in which we evaluated the relationship between MSI status and prognostic factors in sporadic endometrial cancer, we found that there was no statistically significant difference in prognosis in MSI tumors compared to those with MSS tumors. In terms of 5-year survival rates, although survival seems to be shorter in MSI tumors than in MSS tumors (5-year OS 73% vs 43%), this difference was not statistically significant.
No statistically significant difference was found between MSI and MSS groups in terms of prognostic factors such as age, stage, grade, LVI, lymph node metastasis, and distant metastasis. The rate of myometrial invasion in MSI tumors was statistically significantly higher than in MSS tumors.
MSI is observed in hereditary non-colorectal polyposis coli (HNPCC) associated cancer syndromes, 90-95% of colorectal cancers, and 65-75% of endometrial cancers [11]. The discovery that the presence of MSI has a prognostic effect in colorectal cancers paved the way for its investigation in gynecological malignancies as well. However, there is no clear data on the prognostic significance of MSI status in endometrial cancer and the study results are confusing. The rate of MSI in endometrial cancer in sporadic cases is 25-30% [8]. Similarly, the rate of MSI was found to be 28.3% in our study. When we look at the studies on this subject in the world, it is seen that the rate of MSI is very variable. In a study conducted in the USA, the rate of MSI was found to be 20% in sporadic endometrial cancers [12]. In a study conducted in Pakistan, it was found to be 44% [13]. It is thought that the reasons for the different results may be related to the evaluation of small study groups quantitatively, retrospective analyzes, the use of different marker panels for MSI detection, not taking into account the effect of histological type, and racial characteristics.
In our study, the highest loss of MLH-1/PMS-2 expression (66%) was observed in patients with MSI. Similar to our study, in the study by Hashmi et al., the highest loss of MLH1/PMS-2 expression was observed (60%) in patients with MSI [13]. The presence of MSI in uterine sarcomas was less than 5% [14]. Considering this situation, cases with pathology subtype sarcoma were not included in our study.
In a large series of 1024 cases in the gynecology/oncology group, MMR defects were found to be associated with poor prognostic factors such as advanced stage (p=0.001), myometrial invasion (<0.001) (15). In the study by Sahinturk et al., 26.3% of MSI cases were stage I, 31.6% were stage II, 42.1% were stage III, and this relationship was statistically significant (p = 0.014) [16]. In our study, although myometrial invasion was statistically significantly higher in the group with MSI (p=0.008), there was no statistical difference in terms of disease stage (p=0.202). Here, it was seen that myometrial invasion may be associated with MSI. However, it can be thought that detection of the disease at an early stage may limit its effect on prognosis.
In the study by Arabi H et al., no statistically significant difference was found in survival (p=0.700) between patients with MSI and MSS, similar to the results of our study [17]. In the study by Kanopiene et al., MSI status was associated with better survival, early cancer stage, higher tumor differentiation, and endometrioid histology [18]. The Kaplan-Meier survival analysis did not show a statistically significant difference between patients with MSI-H and MSS tumors (p=0.400). In our study, there was no statistical difference in the overall survival analysis between cases with MSI tumors and MSS tumors (p=0.760), and this result was consistent with the literature.
Today, it is known that MSI is a marker that predicts the use of immunotherapies. Based on our study results, we think that MSI status may be a marker for Lynch syndrome screening and selection of patients for whom immunotherapies can be used, rather than prognosis.
The effect of systemic inflammation on cancer development has attracted great attention in recent years. Analysis of hematological inflammatory markers and their potential as prognostic factors have been investigated in various malignant tumors. In the study by Holub et al., pretreatment inflammatory markers (NLR ≥ 2.2, SII ≥ 1100) were found to be associated with worse survival outcomes in high-risk endometrial cancer patients who were surgically staged as FIGO I-III and treated with adjuvant EBRT (post-operative external radiotherapy) [19]. In our study, we evaluated the relationship between MSI status and inflammation parameters. However, we found the distribution of NLR and SII values in MSI and MSS subgroups to be similar (p=1,000 and p=0.600, respectively).
The prognostic value of the presence of MSI in endometrial cancer is still unclear. In our study, the effect of the presence of MSI on the prognosis could not be demonstrated. In our study, although there was a statistically significant difference between the presence of myometrial invasion and MSI (p=0.008), it was found that there was no effect on survival in accordance with the literature.
However, there are some limitations to our study. Our study is a retrospective study with a small number of patients and a short follow-up period. Another limitation is the lack of knowledge of other molecular factors that may have an impact on the prognosis of patients, such as P53, loss of PTEN, and POLE mutation.
Conclusion
In this study, it was determined that MSI status did not affect the prognosis in endometrial cancers. In order to have a clear understanding of the prognostic value of MSI in endometrial cancer, prospective, well-designed studies involving a large number of patients and examining other prognostic molecular markers other than MSI are needed. With the widespread use of immunotherapies, the predictive role of knowing the MSI status in endometrial cancer comes to the forefront rather than its prognostic value. In addition, knowledge of MSI status has gained importance in the new molecular classification of endometrial cancer.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding:
It was supported by the Afyonkarahisar Health Sciences University Research Projects Board Unit with project number 20.TUS.004.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Alptekin Küçük, Hacer Demir, Cigdem Ozdemir, Ismail Beypinar, Meltem Baykara, Dagıstan Tolga Arıoz. Microsatellite instability (MSI) in endometrial cancer; frequency and prognostic significance. Ann Clin Anal Med 2022;13(2):230-235
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Investigating thiol/disulfide homeostasis in acute migraine attack with aura
Bahriye Horasanli 1, Merve Aydin 2, Esra Sumlu 3, Zeynep Caliskan Sak 4, Aysun Ozsahin , Esra Firat Oguz 6, Ozcan Erel 6
1 Department of Neurology, Faculty of Medicine, KTO Karatay University, Konya, 2 Department of Medical Microbiology, Faculty of Medicine, KTO Karatay University, Konya, 3 Department of Pharmacology, Faculty of Medicine, KTO Karatay University, Konya, 4 Department of Physiology, Faculty of Medicine, KTO Karatay University, Konya, 5 Department of Neurology, Konya City Hospital, Konya, 6 Department of Medical Biochemistry, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
DOI: 10.4328/ACAM.21011 Received: 2021-12-20 Accepted: 2022-01-20 Published Online: 2022-01-20 Printed: 2022-02-01 Ann Clin Anal Med 2022;13(2):236-240
Corresponding Author: Bahriye Horasanli, Department of Neurology, Faculty of Medicine, KTO Karatay University, Konya, 42020, Turkey. E-mail: bahriye.horasanli@karatay.edu.tr P: +90 532 460 90 25 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3142-1011
Aim: This study investigates thiol-disulfide hemostasis, which plays a role in the pathophysiology of migraine and is a new marker for oxidative stress in migraine with aura and healthy controls.
Material and methods: The study included 53 healthy controls and 60 patients who presented to Konya City Hospital Neurology Outpatient Clinic with headache and were diagnosed migraine with aura. First, written informed consent was obtained from patients and controls. Then, dynamic thiol-disulfide homeostasis was investigated following the automated spectrophotometric method in serum samples of migraine with aura and controls. Native thiol (SH), total thiol (TT), disulfide (SS), ischemia-modified albumin (IMA), disulfide/native thiol (SS/SH), disulfide/total thiol (SS/TT), and native thiol/total thiol (SH/TT) ratios of patients and control groups were calculated.
Results: Seven (11.7%) males and 53 (88.3%) females made up 60 migraine patients, and 5 (9.4%) males and 48 (90.6%) females made up 53-person control group. The mean age was 35.3 ± 10.1 years in the patient group and 36.2 ± 13.9 years in the control group. Native thiol concentration was 481.6 ± 53.2 μmol/L in the migraine group and 448.8 ± 70.5 μmol/L in the control group. Furthermore, total thiol concentration was 523.0 ± 55.3 μmol/L in the migraine group and 488.7 ± 72.3 μmol/L in the control group. Statistically significant differences were found between the groups regarding native and total thiol levels (p < 0.001). However, disulfide, IMA levels, and SS/SH, SS/TT, and SH/TT ratios were similar, and statistical differences between groups were not significant (p>0.05).
Discussion: Our results suggested evidence of increment in oxidative stress in migraine. Further research with a larger number of patients is needed to support the presence of oxidative stress in migraine.
Keywords: Migraine With Aura, Thiol/Disulfide Homeostasis, Oxidative Stress, Ischemia-Modified Albumin
Introduction
Migraine is the most common neurological disease affecting a large population worldwide [1]. It is an episodic disease usually manifesting as nausea and/or recurrent severe headache with light and sound sensitivity [2]. The incidence of migraines in women is 2–3 times higher than in men [3]. In about one-third of individuals with migraines, transient neurological disorders called migraine aura sometimes or always persecute or accompany headaches [1, 3].
Although the pathophysiology of migraine is not well known, the most widely accepted theories are vascular, neurogenic, and cortically spreading depression hypotheses. In recent years, vascular and neuronal theories, which were combined into the neurovascular theory, have been accepted in the pathophysiology of migraine [4]. Additionally, recent studies on metabolism and mitochondrial dysfunction have suggested that migraine is partially due to an energy deficiency syndrome in the brain [5].
Reactive oxygen species (ROS), such as hydroxyl radicals, hydrogen peroxide, and superoxide radical anions, are produced as byproducts of normal metabolic processes, such as electron transport in mitochondria, host defense, or enzymatic reactions. Therefore, antioxidant defense systems in healthy organisms protect cells and tissues against these species [5, 6].
Oxidative stress causes an imbalance between the production of oxidants and their removal by antioxidants, producing oxidants to increase and accumulate in the body [6]. Oxidative stress is caused by excessive ROS production, mitochondrial dysfunction, impaired antioxidant system, or a combination of these factors [7]. When excessive ROS production exceeds the body’s antioxidant capacity, damage occurs in cellular components, such as proteins, lipids, carbohydrates, and DNA [6-8].
Thiols, which contain the sulfhydryl (-SH) group, are an important component of the antioxidant cascade, eliminating ROS and other free radicals with enzymatic and non-enzymatic mechanisms [5, 9, 10]. Thiols react with ROS oxidation, reducing them; thus, protecting the organism from oxidative damage [10]. When oxidative stress increases, the oxidative reaction of thiols through oxidants forms reversible disulfide bonds. However, when the oxidative stress ends, disulfide bond structures are reduced to thiol groups; thus, maintaining the dynamic thiol/disulfide balance [10-12].
Dynamic thiol/disulfide homeostasis is critical for many physiological mechanisms, such as antioxidant protection, detoxification, signal transmission, apoptosis, regulation of the activity of enzymes, transcription factors, and cellular signal transmission mechanisms [11, 12].
Ischemia-modified albumin (IMA) is caused by oxidative stress or ischemia, resulting in reduced bonding capacity of transition metals, such as cobalt, copper, and nickel in the amino-terminal (N-terminal) region of the album [13]. This reduced binding capacity occurs primarily in cases of ischemia, hypoxia, acidosis, oxidative stress, and free iron and copper exposure [14].
Serum IMA levels were significantly higher in patients with acute coronary syndrome, pulmonary embolism, stroke and brain hemorrhage, mesenteric ischemia, and peripheral vascular disease [15].
Oxidative stress and thiol/disulfide homeostasis may be a factor in the pathogenesis of migraines and may be associated with excessive ROS, which can damage DNA. Furthermore, data on thiol/disulfide homeostasis were reported in studies in patients with migraine, but the results were controversial [9, 11, 16-18]. Therefore, our study investigates thiol-disulfide homeostasis, a potential new marker for oxidative stress, which is assumed to play a role in the pathophysiology of migraine.
Material and Methods
The study was conducted in Konya City Hospital Neurology Outpatient Clinic, where migraine with aura were diagnosed; Patients ≥18 years and older, without any other known chronic diseases, 60 patients without smoking, alcohol, and substance use and 53 healthy control individuals were prospectively evaluated.
Patients with systemic diseases (cardiovascular and cerebrovascular disease, diabetes, etc.), history of malignancies, smoking, alcohol and drug use, pregnancy, breastfeeding and prophylactic treatment for migraines in the last 6 months or taking chronic drugs were excluded from the study. Written informed consent was obtained from the patients and controls. All researchers have approved the ethical standards described in the Helsinki Declaration. Ethical approval was obtained from KTO Karatay University Clinical Research Ethics Committee.
Venous blood samples taken into biochemistry and EDTA tubes from the patients and control groups participating in the study were used. Blood samples were centrifuged at 1500 rpm for 10 minutes within 30 minutes after collection. Separated serum and plasma samples were aliquoted and stored at −80 °C until use.
The demographic characteristics of the participants, including gender, age, and residence addresses, were recorded. By performing physical examinations of the individuals, hemogram, aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, sedimentation, and C-reactive protein (CRP) levels were determined.
Dynamic thiol-disulfide homeostasis in serum samples of migraine with aura and controls was investigated by automated spectrophotometric method developed by Erel and Neselioglu. Thiol/disulfide homeostasis tests were measured by the automated spectrophotometric method described by Erel and Neselioglu [12]. For short, disulfide bonds were first reduced to form free functional thiol groups with sodium borohydride. Unused reductant sodium borohydride was consumed and removed with formaldehyde to prevent reduction in DTNB (5,5’-dithiobis-(2-nitrobenzoic) acid), and all of the thiol groups, including reduced and native thiol groups were determined after reaction with DTNB. Half of the difference between the total and native thiols provides the dynamic disulfide amount. After the determination of native and total thiols, disulfide amounts, disulfide/total thiol percent ratios (SS/SH+SS), disulfide/native thiol percent ratios (SS/SH) and native thiol/total thiol percent ratios (SH/SH+) SS) were calculated.
The IMA levels were determined using the albumin cobalt binding test, a rapid colorimetric method developed by Bar-Or et al. [13], which is based on the binding ability of reduced cobalt ions (Co2+) of human serum albumin due to ischemia. Briefly, 50 mL of 0.1% cobalt (II) chloride (CoCl2) (Sigma-Aldrich, Germany) was added to the serum samples. After mixing, followed by 10 minutes of incubation to allow for albumin cobalt binding, 50 mL 1.5 mg/mL dithiothreitol was added. After mixing followed by 2 minutes of incubation, 1 mL of a 0.9% sodium chloride solution was added to reduce the binding capacity. The absorbance of samples was measured at 470 nm using a spectrophotometer. The results were expressed in absorbance units (ABSU) (kyn).
Hemoglobin (Hb), Hematocrit (Hct), Leukocyte (WBC), Platelet (PLT) values were studied on Sysmex XN-10™ Hematology System (Sysmex, Japan) automated blood count device. Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), creatinine (Kr) and CRP values were measured using Roche c702 chemistry autoanalyzer (Cobas 8000, Roche Diagnostics, Switzerland).
Sedimentation values were studied in Vision C autoanalyzer (Shenzhen YHLO Biotech, China). The value ranges of the tests were determined in accordance with the reference range of the Konya City Hospital Biochemistry laboratories where the measurements were made.
Statistical analysis
Statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) v.22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Results were presented as mean ± standard deviation, median, and minimum–maximum. Furthermore, the normality of the distribution of variables was confirmed with the Kolmogorov–Smirnov normality test. While comparing variables between groups, the Student’s t-test or Mann–Whitney U test was used, depending on whether the statistical hypotheses were fulfilled or not. A p-value < 0.05 was considered statistically significant.
Results
Of the 60 migraine with aura included in the study, 7 (11.7%) were males, and 53 (88.3%) were females; 5 (9.4%) of the 53 control group were males, and 48 (90.6%) were females. The mean age of migraine group was 35.3 ± 10.1 years, and the mean age of the control group was 36.2 ± 13.9 years. Also, gender and age distributions were similar between the groups (p = 0.767, p = 708, respectively).
Native thiol (SH), total thiol (TT), disulfide (SS), IMA, disulfide/native thiol (SS/SH), disulfide/total thiol (SS/TT), and data on native thiol/total thiol (SH/TT) ratios are shown in Table 1.
The native-thiol concentration was 481.6 ± 53.2 μmol/L in the migraine group and 448.8 ± 70.5 μmol/L in the control group. The native-thiol levels of the migraine group were significantly higher than the control group. Also, there was a statistically significant difference between the groups regarding native-thiol levels (p=0.007).
The total thiol concentration was 523.0 ± 55.3 μmol/L in the migraine group and 488.7 ± 72.3 μmol/L in the control group. Total thiol levels in the migraine group were significantly higher than the control group. Total thiol levels in the migraine group were significantly higher than the control group (p=0.006).
Disulfide levels were 20.5 ± 2.0 μmol/L in the migraine group and 20.1 ± 2.0 μmol/L in the control group. The disulfide level was similar in both groups, and there was no statistically significant difference between the groups (p=0.416).
The SS/SH ratio was 4.3 ± 0.6 in migraine with aura and 4.4 ± 0.7 in the control group. The SS/SH ratio was similar in both groups, and there was no statistically significant difference between the groups (p=0.585).
The SS/TT ratio was 4.0 ± 0.5 in migraine group and 4.1 ± 0.6 in the control group. The SS/TT ratio was similar in both groups, and there was no statistically significant difference between the patient and control groups (p = 0.599). The SH/TT ratio was 92.0 ± 1.1 in migraine group and 91.7 ± 1.4 in the control group. There was no statistically significant difference between patient and control groups regarding SH/TT ratio (p=0.258).
IMA levels were 0.790 ± 0.014 in the migraine group and 0.792 ± 0.013 in the control group. There was no statistically significant difference between the migraine and control groups regarding IMA level (p=0.524).
Discussion
Thiols are essential molecules that can trigger redox reactions in organisms and remove them from the environment by reducing the number of oxidant molecules. Thiol metabolism plays a key role in the physiology of many central nervous system functions by contributing to transporting and signal transmission in cells. It also supports proteins’ structural and functional integrity and normal enzyme activity [19, 20].
It has been suggested that some diseases, especially neurodegenerative diseases, such as Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis, are associated with abnormal thiol-disulfide homeostasis [21, 22].
Therefore, our study investigated the dynamic thiol-disulfide homeostasis in migraine with aura attacks. Compared with the data obtained from the migraine group and the data obtained from the control group, we found that native and total thiol levels were significantly higher in the migraine group compared to the control group.
Furthermore, there was no statistically significant difference between the groups regarding disulfide, IMA, disulfide/native thiol, disulfide/total thiol, native thiol/total thiol ratios.
Similar to our study, Gümüşyayla et al.’s [11] study conducted on 63 migraine (22 with and 41 without aura) and 50 healthy controls found that total and native-thiol levels were found in the migraine (497.11 ± 40.90; 462.10 ± 41.55 mmol/L) and control groups, respectively (477.51 ± 42.18; 437.39 ± 38.86 mmol/L) (p<0.001). There was no statistically significant difference between the two groups regarding disulfide, disulfide native-thiol ratio, disulfide total thiol ratio, and native thiol, total thiol ratio.
In 2020, Ersoy et al. [18] investigated IMA, total thiol, native thiol, and disulfide levels in 62 migraine and white matter lesions (with WML), 59 migraine and without white matter lesions (without WML), and 61 healthy controls. They found higher total and native-thiol levels in the non-WML group compared with the control and WML groups (p<0.001 for both). Disulfide levels were similar between the control and non-WML groups, whereas they were significantly lower in the WML group than the control and non-WML groups. They found that IMA levels were higher in the migraine group compared with the control group (p<0.001) and in the WML group compared with the non-WML groups (p<0.001). Furthermore, they did not find a significant relationship between thiol/disulfide, IMA levels, frequency and duration of attacks, pain severity, and migraine-related disability.
Contrary to our results, three more studies were conducted on thiol measurements in migraine, showing that total thiol levels were decreased in migraine compared with healthy volunteers. These results were attributed to the antioxidant properties of thiols [9, 16, 17].
A study by Eren et al. [9] in 141 migraine (77 with aura, 74 without aura) and 70 healthy controls in 2015 showed thiol levels to be significantly lower in migraine (604.2 ± 59.3 mmol/L) compared with healthy controls (670 ± 47.8) (p<0.001). However, there was no significant difference between migraine with aura (612.5 ± 56.3 mmol/L) and without aura (595.6 ± 61.4 mmol/L) (p=0.152).
Another study by Lucchesi et al. [16] showed 33 patients (30 females, 3 males) affected by chronic migraine and drug-overuse headache and 33 healthy controls. Also, they found statistically significantly lower total thiol groups in chronic migraine (0.26 ± 0.07) compared to controls (0.51 ± 0.08) (p<0.001).
A study by Gündüztepe et al. [17] investigated the effect of acupuncture on thiol-disulfide homeostasis and IMA levels in 22 migraine (with and without aura) and 25 healthy controls.
They found native-thiol levels to be significantly lower in the migraine group (327.16 ± 58.73 mmol/L) than in the control group (375.40 ± 45.20 mmol/L) (p<0.05). When migraine group before and after acupuncture were compared with the control group, there was a statistically significant difference in native-thiol levels between the groups (p<0.05). However, they found no significant difference in native-thiol levels before acupuncture compared with post-acupuncture in migraine group (p>0.05) [17].
They found that the total thiol levels in the migraine group (397.80 ± 56.40 mmol/L) were significantly lower than the control group (437.14 ± 49.70 mmol/L). In addition, they found statistically significant differences in total thiol levels in migraine group before and after acupuncture compared with the control group (p<0.05). However, they did not detect a significant difference between the post-acupuncture groups’ total thiol levels compared with the pre-acupuncture groups (p>0.05) [17].
Furthermore, they found that total thiol, native thiol, dynamic disulfide bond levels, and IMA levels were correlated with migraine attack frequency, pain severity, and migraine type. They suggested that thiol-disulfide homeostasis and IMA levels may play a role in the etiology and severity of migraine and that acupuncture treatment will reduce oxidative stress in migraine [17].
Studies have revealed that thiols are mostly antioxidant molecules, but they sometimes act as pro-oxidant molecules because they are affected by the organism’s physiological state [9, 24]. The high thiol levels detected in our study may be related to the pro-oxidant nature of thiols [11, 18]. Although thiols are the most important antioxidant molecules, in the case of oxidative stress, the concentration of sulfur-containing amino acids can change their structure and gain pro-oxidant properties according to the antioxidant properties of the proteins and enzymes involved in the structures. The oxidative stress level of the organism determines the antioxidant and pro-oxidant effects of thiols. This balance is dynamic and may change according to the organism’s state [11, 18, 23].
Pro-oxidant properties and increased homocysteine and cysteine levels of thiol-containing molecules have been reported in some studies. Additionally, homocysteine and cysteine levels increase in cardiovascular disease, cerebrovascular disease, and renal ischemia; oxidative stress plays a role in the pathogenesis of these diseases [11, 24].
Conclusion
We found increased total and natural thiol levels in migraine with aura attacks compared with healthy controls. These results support the idea that thiols affect the physiological state of an organism and, in this case, act as pro-oxidant molecules as they are dynamic molecules. Conclusively, oxidative stress plays a role in the pathogenesis of migraine. However, considering individual differences, further comprehensive studies with larger sample sizes are needed.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Funding: None
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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Bahriye Horasanli, Merve Aydin, Esra Sumlu, Zeynep Caliskan Sak, Aysun Ozsahin, Esra Firat Oguz, Ozcan Erel. Investigating thiol/disulfide homeostasis in acute migraine attack with aura. Ann Clin Anal Med 2022;13(2):236-240
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